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Allen BF, Jablonski PM, McEvoy MD, Ehrenfeld JM, Shi H, King AB, Wanderer JP. Implementation of an Enhanced Recovery Protocol (ERP) is associated with an increase in the perioperative use of non-opioid multimodal analgesia for non-ERP patients. J Clin Anesth 2020; 62:109694. [DOI: 10.1016/j.jclinane.2019.109694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/24/2019] [Accepted: 12/14/2019] [Indexed: 01/13/2023]
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102
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Kim CH, Lefkowits C, Holschneider C, Bixel K, Pothuri B. Managing opioid use in the acute surgical setting: A society of gynecologic oncology clinical practice statement. Gynecol Oncol 2020; 157:563-569. [DOI: 10.1016/j.ygyno.2020.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 12/22/2022]
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103
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Huynh V, Rojas K, Ahrendt G, Murphy C, Jaiswal K, Cumbler E, Christian N, Tevis S. Reassessing Opioid Use in Breast Surgery. J Surg Res 2020; 254:232-241. [PMID: 32474196 DOI: 10.1016/j.jss.2020.04.030] [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: 12/10/2019] [Revised: 04/11/2020] [Accepted: 04/17/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study aims to assess multimodal pain management and opioid prescribing practices in patients undergoing breast surgery. METHODS A retrospective review of patients undergoing breast surgery at an academic medical center between April 1, 2018 and September 30, 2019, was performed. Patients with a history of recent opioid use or conditions precluding use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (APAP) were excluded. Opioid-sparing pain regimens were assessed. Opioids prescribed on discharge were recorded as oral morphine equivalents (OMEs) and concordance with the Opioid Prescribing Engagement Network (OPEN) determined. RESULTS The total study population consisted of 518 patients. 358 patients underwent minor outpatient procedures (sentinel lymph node biopsy, lumpectomy, and excisional biopsy), 10-40% of whom were appropriately prescribed as per the OPEN. Perioperatively, 53.9% of patients received APAP, 24.6% NSAIDs, 20.4% gabapentin, and 0.3% blocks; intraoperatively, 95.8% received local anesthetic and 25.7% ketorolac. For mastectomy without reconstruction, 63-88% of prescriptions were concordant with the OPEN. For mastectomy with reconstruction, discharge opioids ranged from 25 to 400 OMEs with a mean of 134.4 OMEs; 25% of patients received a refill. Of all patients undergoing mastectomy ± reconstruction, 62.5% received APAP, 18.8% NSAIDs, 38.8% pregabalin, and 20.6% locoregional block perioperatively; 37.5% received local anesthetic and 15.6% ketorolac intraoperatively. Of 143 inpatient stays, 89% received APAP, 38% NSAID, and 29% benzodiazepines; 29 patients received no opioids inpatient but were still prescribed 25-200 OMEs on discharge. CONCLUSIONS There is need for a multidisciplinary approach to pain management with the use of enhanced recovery after surgery protocols as potential means to standardize perioperative regimens and mitigate opioid overprescription.
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Affiliation(s)
- Victoria Huynh
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Gretchen Ahrendt
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Colleen Murphy
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kshama Jaiswal
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ethan Cumbler
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Nicole Christian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sarah Tevis
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Basics and Best Practices of Multimodal Pain Management for the Plastic Surgeon. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2833. [PMID: 33154874 PMCID: PMC7605865 DOI: 10.1097/gox.0000000000002833] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/17/2020] [Indexed: 12/18/2022]
Abstract
Pain management is a central focus for the plastic surgeon’s perioperative planning, and it no longer represents a postoperative afterthought. Protocols that rely on opioid-only pain therapy are outdated and discouraged, as they do not achieve optimal pain relief, increase postoperative morbidity, and contribute to the growing opioid epidemic. A multimodal approach to pain management using non-opioid analgesic techniques is an integral component of enhanced recovery after surgery protocols. Careful perioperative planning for optimal pain management must be achieved in multidisciplinary collaboration with the perioperative care team including anesthesiology. This allows pain management interventions to occur at 3 critical opportunities—preoperative, intraoperative, and postoperative settings.
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105
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Delaney LD, Clauw DJ, Waljee JF. The Management of Acute Pain for Musculoskeletal Conditions: The Challenges of Opioids and Opportunities for the Future. J Bone Joint Surg Am 2020; 102 Suppl 1:3-9. [PMID: 32251126 PMCID: PMC8272973 DOI: 10.2106/jbjs.20.00228] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➢ Opioid use for chronic and acute musculoskeletal pain is common.➢ Orthopaedic surgeons are frequent opioid prescribers.➢ Opioids are commonly prescribed for acute pain, with high variation.➢ Opioid alternatives for acute pain are effective, and the incorporation of multimodal pain management in the perioperative period can decrease opioid use.➢ Although opioids are effective for the management of acute musculoskeletal pain, the morbidity and mortality related to opioid analgesics reinforce the need for robust, evidence-based guidelines.➢ Providers should evaluate patient risk preoperatively, should prescribe judiciously with multimodal pain management plans, and should integrate a preoperative discussion on opioid usage.➢ Future research should include procedure-specific pain management strategies, as well as the comparative efficacy of pharmacologic and nonpharmacologic methods of pain management.
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Affiliation(s)
- Lia D Delaney
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Daniel J Clauw
- Departments of Anesthesiology (D.J.C.), Internal Medicine (D.J.C.), Psychiatry (D.J.C.), and Surgery (J.F.W.), University of Michigan, Ann Arbor, Michigan
- Chronic Pain and Fatigue Research Center, Ann Arbor, Michigan
| | - Jennifer F Waljee
- Departments of Anesthesiology (D.J.C.), Internal Medicine (D.J.C.), Psychiatry (D.J.C.), and Surgery (J.F.W.), University of Michigan, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
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Abstract
Background
Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion.
Methods
A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein).
Results
The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (−3 h; 95% CI, −6, −0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (−11 h; 95% CI, −19, −6; P < 0.001) were shorter; opioid consumption was lower at day 1 (−57 mg; 95% CI, −130, −5; P = 0.030) without adversely affecting pain scores (−2; 95% CI, −3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037).
Conclusions
Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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107
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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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108
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Chincholkar M. Gabapentinoids: pharmacokinetics, pharmacodynamics and considerations for clinical practice. Br J Pain 2020; 14:104-114. [PMID: 32537149 DOI: 10.1177/2049463720912496] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The gabapentinoids are often recommended as first-line treatments for the management of neuropathic pain. The differing pharmacodynamic and pharmacokinetic profiles can have implications for clinical practice. This article has summarised these key differences. In addition to their use in managing neuropathic pain, gabapentinoids are increasingly being used for off-label conditions despite the lack of evidence. Prescription rates for off-label conditions have overtaken that for on-label use. Similarly, the use of gabapentinoids in the perioperative period is now embedded in clinical practice despite conflicting evidence. This article summarises the risks associated with this increasing use. There is increasing evidence of the potential to cause harm in vulnerable populations such as the elderly and increasing prevalence of abuse. The risk of respiratory depression in combination with opioids is of particular concern in the context of the current opioid crisis. This article describes the practical considerations involved that might help guide appropriate prescribing practices.
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109
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Hernandez-Boussard T, Blayney DW, Brooks JD. Leveraging Digital Data to Inform and Improve Quality Cancer Care. Cancer Epidemiol Biomarkers Prev 2020; 29:816-822. [PMID: 32066619 DOI: 10.1158/1055-9965.epi-19-0873] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/03/2019] [Accepted: 02/12/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Efficient capture of routine clinical care and patient outcomes is needed at a population-level, as is evidence on important treatment-related side effects and their effect on well-being and clinical outcomes. The increasing availability of electronic health records (EHR) offers new opportunities to generate population-level patient-centered evidence on oncologic care that can better guide treatment decisions and patient-valued care. METHODS This study includes patients seeking care at an academic medical center, 2008 to 2018. Digital data sources are combined to address missingness, inaccuracy, and noise common to EHR data. Clinical concepts were identified and extracted from EHR unstructured data using natural language processing (NLP) and machine/deep learning techniques. All models are trained, tested, and validated on independent data samples using standard metrics. RESULTS We provide use cases for using EHR data to assess guideline adherence and quality measurements among patients with cancer. Pretreatment assessment was evaluated by guideline adherence and quality metrics for cancer staging metrics. Our studies in perioperative quality focused on medications administered and guideline adherence. Patient outcomes included treatment-related side effects and patient-reported outcomes. CONCLUSIONS Advanced technologies applied to EHRs present opportunities to advance population-level quality assessment, to learn from routinely collected clinical data for personalized treatment guidelines, and to augment epidemiologic and population health studies. The effective use of digital data can inform patient-valued care, quality initiatives, and policy guidelines. IMPACT A comprehensive set of health data analyzed with advanced technologies results in a unique resource that facilitates wide-ranging, innovative, and impactful research on prostate cancer. This work demonstrates new ways to use the EHRs and technology to advance epidemiologic studies and benefit oncologic care.See all articles in this CEBP Focus section, "Modernizing Population Science."
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Affiliation(s)
- Tina Hernandez-Boussard
- Department of Medicine, Stanford University, Stanford, California. .,Department of Biomedical Data Science, Stanford University, Stanford, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Douglas W Blayney
- Department of Medicine, Stanford University, Stanford, California.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - James D Brooks
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California.,Department of Urology, Stanford University School of Medicine, Stanford, California
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110
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Safety of Postoperative Opioid Alternatives in Plastic Surgery: A Systematic Review. Plast Reconstr Surg 2020; 144:991-999. [PMID: 31568318 DOI: 10.1097/prs.0000000000006074] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
With the growing opioid epidemic, plastic surgeons are being encouraged to transition away from reliance on postoperative opioids. However, many plastic surgeons hesitate to use nonopioid analgesics such as nonsteroidal antiinflammatory drugs and local anesthetic blocks because of concerns about their safety, particularly bleeding. The goal of this systematic review is to assess the validity of risks associated with nonopioid analgesic alternatives. A comprehensive literature search of the PubMed and MEDLINE databases was conducted regarding the safety of opioid alternatives in plastic surgery. Inclusion and exclusion criteria yielded 34 relevant articles. A systematic review was performed because of the variation between study indications, interventions, and complications. Thirty-four articles were reviewed that analyzed the safety of ibuprofen, ketorolac, celecoxib, intravenous acetaminophen, ketamine, gabapentin, liposomal bupivacaine, and local and continuous nerve blocks after plastic surgery procedures. There were no articles that showed statistically significant bleeding associated with ibuprofen, celecoxib, or ketorolac. Similarly, acetaminophen administered intravenously, ketamine, gabapentin, and liposomal bupivacaine did not have any significant increased risk of adverse events. Nerve and infusion blocks have a low risk of pneumothorax. Limitations of this study include small sample sizes, different dosing and control groups, and more than one medication being studied. Larger studies of nonopioid analgesics would therefore be valuable and may strengthen the conclusions of this review. As a preliminary investigation, this review showed that several opioid alternatives have a potential role in postoperative analgesia. Plastic surgeons have the responsibility to lead the reduction of postoperative opioid use by further developing multimodal analgesia.
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111
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St Clair CO, Golub NI, Ma Y, Song J, Winiecki SK, Menschik DL. Characteristics Associated With U.S. Outpatient Opioid Analgesic Prescribing and Gabapentinoid Co-Prescribing. Am J Prev Med 2020; 58:e11-e19. [PMID: 31862105 DOI: 10.1016/j.amepre.2019.08.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION A considerable burden of prescription and illicit opioid-related mortality and morbidity in the U.S. is attributable to potentially unnecessary or excessive opioid prescribing, and co-prescribing gabapentinoids may increase risk of harm. Data are needed regarding physician and patient characteristics associated with opioid analgesic and opioid analgesic-gabapentinoid co-prescriptions to elucidate targets for reducing preventable harm. METHODS Multiple logistic regression was utilized to examine patient and physician predictors of opioid analgesic prescriptions and opioid analgesic-gabapentinoid co-prescriptions in adult noncancer patients using the National Ambulatory Medical Care Survey 2015 public use data set. Potential predictors were selected based on literature review, clinical relevance, and random forest machine learning algorithms. RESULTS Among the 11.8% (95% CI=9.8%, 13.9%) of medical encounters with an opioid prescription, 16.2% (95% CI=12.6%, 19.8%) had a gabapentinoid co-prescription. Among all gabapentinoid encounters, 40.7% (95% CI=32.6%, 48.7%) had an opioid co-prescription. Predictors of opioid prescription included arthritis (OR=1.87, 95% CI=1.30, 2.69). Predictors of new opioid prescription included physician status as an independent contractor (OR=3.67, 95% CI=1.38, 9.81) or part owner of the practice (OR=3.34, 95% CI=1.74, 6.42). Predictors of opioid-gabapentinoid co-prescription included patient age (peaking at age 55-64 years; OR=35.67, 95% CI=4.32, 294.43). CONCLUSIONS Predictors of opioid analgesic prescriptions with and without gabapentinoid co-prescriptions were identified. These predictors can help inform and reinforce (e.g., educational) interventions seeking to reduce preventable harm, help identify populations for elucidating opioid-gabapentinoid risk-benefit profiles, and provide a baseline for evaluating subsequent public health measures.
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Affiliation(s)
- Christopher O St Clair
- Center for Drug Evaluation and Research, Food and Drug Administration, White Oak, Maryland
| | - Natalia I Golub
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yong Ma
- Center for Drug Evaluation and Research, Food and Drug Administration, White Oak, Maryland
| | - Jaejoon Song
- Center for Drug Evaluation and Research, Food and Drug Administration, White Oak, Maryland
| | - Scott K Winiecki
- Center for Drug Evaluation and Research, Food and Drug Administration, White Oak, Maryland
| | - David L Menschik
- Center for Drug Evaluation and Research, Food and Drug Administration, White Oak, Maryland.
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112
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Nelson DB, Niu J, Mitchell KG, Sepesi B, Hofstetter WL, Antonoff MB, Giordano SH, Mehran RJ, Rice DC. Persistent Opioid Use Among the Elderly After Lung Resection: A SEER-Medicare Study. Ann Thorac Surg 2020; 109:194-202. [DOI: 10.1016/j.athoracsur.2019.06.095] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 05/17/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
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113
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Quintero Garzola GC. Review: Does Gabapentin Relieve Opioids, Cannabis and Methamphetamines Addictions? REVISTA COLOMBIANA DE PSICOLOGÍA 2020. [DOI: 10.15446/.v29n1.75930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The study reviews the suitability of using Gabapentin for treating opioid, cannabis and methamphetamine use disorders. This revision consists of 61 biographical references based on a PubMed database search (January of 1983-May of 2018). Gabapentin displayed respectively 50% and 66.7% of success for treating methamphetamine dependence and opioid withdrawal symptoms. Furthermore, a few research studies have reported Gabapentin´s efficacy for alleviating cannabis dependence (two studies), and cannabis withdrawal symptoms (one study). Similarly, a single study reported Gabapentin reduction of opioid consumption during the detoxification process. Based on the revision, we can conclude that: (a) Gabapentin is useful for treating opioid withdrawal symptoms, (b) additional studies are necessary for elucidating the effectiveness of Gabapentin for treating methamphetamine dependence, cannabis dependence and its withdrawal symptoms, and (c) more studies are necessary to confirm the efficacy of Gabapentin in reducing opioid consumption during detoxification.
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114
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Abstract
This chapter describes recent clinical trials for opioid use disorder (OUD), an area that has rapidly accelerated in response to the opioid overdose crisis in the USA and newly appropriated funding. Trials involve a wide range of compounds including cannabinoids and psychedelics, new and existing compounds targeting domains emerging from addiction neuroscience, agents repurposed from other indications, and novel strategies including vaccines, enzymes, and other biologicals. In parallel, new formulations of existing compounds offer immediate promise, as do a variety of web-based interventions and smartphone-delivered apps. Trials focused on implementing existing effective interventions in mainstream healthcare settings, and others focused on special populations, e.g., adolescents, criminal justice, pregnant women, native Americans, etc., have the potential to vastly expand treatment in the near term. Given the range of ongoing and recent trials, this chapter is not intended to be an exhaustive review but rather to present an overview of approaches within the framework of the opioid treatment cascade and the context of current OUD pharmacotherapies.
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Affiliation(s)
- Esther Blessing
- Department of Psychiatry, NYU School of Medicine, New York, NY, USA.
| | - Sanya Virani
- Department of Psychiatry, Maimonides Medical Center, Brooklyn, NY, USA
| | - John Rotrosen
- Department of Psychiatry, NYU School of Medicine, New York, NY, USA
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115
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Chin KK, Carroll I, Desai K, Asch S, Seto T, McDonald KM, Curtin C, Hernandez-Boussard T. Integrating Adjuvant Analgesics into Perioperative Pain Practice: Results from an Academic Medical Center. PAIN MEDICINE 2020; 21:161-170. [PMID: 30933284 PMCID: PMC10147384 DOI: 10.1093/pm/pnz053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Opioid-sparing postoperative pain management therapies are important considering the opioid epidemic. Total knee arthroplasty (TKA) is a common and painful procedure accounting for a large number of opioid prescriptions. Adjuvant analgesics, nonopioid drugs with primary indications other than pain, have shown beneficial pain management and opioid-sparing effects following TKA in clinical trials. We evaluated the adjuvant analgesic gabapentin for its usage patterns and its effects on opioid use, pain, and readmissions. METHODS This retrospective, observational study included 4,046 patients who received primary TKA between 2009 and 2017 using electronic health records from an academic tertiary care medical institute. Descriptive statistics and multivariate modeling were used to estimate associations between inpatient gabapentin use and adverse pain outcomes as well as inpatient oral morphine equivalents per day (OME). RESULTS Overall, there was an 8.72% annual increase in gabapentin use (P < 0.001). Modeled estimates suggest that gabapentin is associated with a significant decrease in opioid consumption (estimate = 0.63, 95% confidence interval = 0.49-0.82, P < 0.001) when controlling for patient characteristics. Patients receiving gabapentin had similar discharge pain scores, follow-up pain scores, and 30-day unplanned readmission rates compared with patients receiving no adjuvant analgesics (P > 0.05). CONCLUSIONS When assessed in a real-world setting over a large cohort of TKA patients, gabapentin is an effective pain management therapy that is associated with reduced opioid consumption-a national priority in this time of opioid crisis-while maintaining the same quality of pain management.
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Affiliation(s)
| | - Ian Carroll
- Department of Medicine, Stanford University, Stanford, CA USA
| | - Karishma Desai
- Department of Medicine, Stanford University, Stanford, CA USA
| | - Steven Asch
- Department of Medicine, Stanford University, Stanford, CA USA.,VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA
| | - Tina Seto
- Stanford School of Medicine IRT Research Technology, Stanford, CA USA
| | - Kathryn M McDonald
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA USA
| | - Catherine Curtin
- Department of Surgery, VA Palo Alto Health Care System, Palo Alto, CA
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University, Stanford, CA USA.,VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA.,Department of Biomedical Data Science, Stanford University, Stanford, CA USA
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Talwar R, Xia L, Serna J, Ding J, Lee DJ, Ziemba JB, Guzzo TJ. Preventing Excess Narcotic Prescriptions in New Robotic Surgery Discharges: The PENN Prospective Cohort Quality Improvement Initiative. J Endourol 2020; 34:48-53. [DOI: 10.1089/end.2019.0362] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ruchika Talwar
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leilei Xia
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Juan Serna
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James Ding
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J. Lee
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justin B. Ziemba
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas J. Guzzo
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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117
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Nassif GJ, Miller TE. Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review. Curr Med Res Opin 2019; 35:2129-2136. [PMID: 31315466 DOI: 10.1080/03007995.2019.1646001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.
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Affiliation(s)
- George J Nassif
- AdventHealth Center of Colon and Rectal Surgery, Associate Professor of Surgery, University of Central Florida, Orlando, FL, USA
| | - Timothy E Miller
- Vascular and Transplant Anesthesia, Duke University School of Medicine, Durham, NC, USA
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118
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Burnett G, DeMaria S, Levine AI. Regional Anesthesia and Acute Pain Management. Otolaryngol Clin North Am 2019; 52:1065-1081. [DOI: 10.1016/j.otc.2019.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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119
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Berry DL, Blonquist TM, Halpenny B, Hong F, Morrison-Ma SC, McCullough MC, Carelli K, Dominici LS, King TA. The Jacki Jacket after mastectomy with reconstruction: a randomized pilot study. Breast Cancer Res Treat 2019; 179:377-385. [PMID: 31612292 DOI: 10.1007/s10549-019-05465-9] [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] [Received: 09/18/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Breast cancer patients undergoing mastectomy with reconstruction (TM + R) often experience post-operative discomfort from surgical drains. Despite a variety of garment options for use in the post-operative period, high-quality data assessing the impact of specific garments on post-operative pain are lacking. We report the results of a prospective randomized trial assessing the impact of the Jacki Jacket (JJ), a long-sleeve jacket with inner drain receptacle pockets, on post-discharge pain and quality of life (QOL) after TM + R. METHODS Breast cancer patients undergoing TM + R at a single institution were randomized post-operatively to receive a JJ or usual care (UC). Participant-reported demographics, pain intensity, and QOL were collected on post-operative day 1 (T1). Following discharge, participants completed a daily pain and medication dairy (T2); on day of drain(s) removal (T3), participants again completed pain and QOL questionnaires. Linear models were used to evaluate associations between JJ use, post-operative pain, and QOL. RESULTS From 3/8/17 to 12/20/17, 139 women were randomized. All participants completed T1 measures, 102 returned the T2 diary, and 118 (84.9%) completed T3 questionnaires. There was no significant difference in pain scores between JJ and UC arms at any timepoint. Adjusting for surgery type, age, marital status, depression, and obesity, participants randomized to JJ reported significantly better body image scores (estimate = 12.94, p = 0.009). There were no adverse events. CONCLUSIONS Although JJ garment use did not impact post-operative pain intensity scores, the significant impact of JJ use on body image supports consideration for inclusion of such garments in post-operative care for patients undergoing TM + R. CLINICAL TRIAL REGISTRATION INFORMATION Registered with ClinicalTrials.gov, NCT number NCT02976103, November 18, 2016.
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Affiliation(s)
- Donna L Berry
- Dana-Farber Cancer Institute, Boston, MA, USA. .,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg; Room T615A, Seattle, WA, 98195-7266, USA.
| | | | | | | | | | - Michele C McCullough
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Laura S Dominici
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
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Townsend M, Liou T, Kallogjeri D, Schoer M, Scott-Wittenborn N, Lindburg M, Bottros M, Jackson RS, Nussenbaum B, Piccirillo JF. Effect of Perioperative Gabapentin Use on Postsurgical Pain in Patients Undergoing Head and Neck Mucosal Surgery: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2019; 144:959-966. [PMID: 29710075 DOI: 10.1001/jamaoto.2018.0282] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Effective postoperative pain management increases patient satisfaction, reduces cost, reduces morbidity, and shortens hospitalizations. Previous studies investigating multimodal pain therapy in otolaryngology patients focused on homogenous patient groups with short postoperative follow-up times. Objective To investigate the effect of perioperative gabapentin treatment on postsurgical pain in patients undergoing head and neck mucosal surgery. Design, Setting, and Participants Adults undergoing head and neck mucosal surgery from July 25, 2016, through June 19, 2017, were included in this double-blinded, placebo-controlled randomized clinical trial and randomized to receive gabapentin, 300 mg twice daily, or placebo before surgery and up to 72 hours after surgery. Main Outcomes and Measures Primary outcome was hourly narcotic use calculated in morphine equivalents. Secondary outcomes included subjective visual analog scale pain scores captured for resting, coughing, and swallowing using a 0- to 100-mm scale (a 100-mm line anchored with no pain on the left end and worst possible pain on the right end). A change of 10 mm or more was deemed to be clinically meaningful. Additional secondary outcome measures included degree of pain control, patient satisfaction, and adverse effects. Results Of the 110 patients randomized to receive gabapentin or placebo, 11 and 10 withdrew from each group, respectively. Ninety patients were then analyzed: 44 in the gabapentin group (mean [SD] age, 61.1 [10.0] years; 33 [75%] male; 40 [91%] white) and 46 in the placebo group (mean [SD] age, 60.9 [11.3] years; 35 [78%] male; 43 [94%] white). Both groups had similar self-reported levels of preoperative pain and narcotic effectiveness. A median difference of 0.26 mg/h of morphine (95% CI, -0.27 to 0.94 mg/h) was found between groups. After controlling for comorbidity and self-reported baseline pain levels, mixed model analysis found the difference in marginal means of visual analog scale scores between groups to be lower in the gabapentin group compared with the placebo group for all categories (rest difference, 7.9 mm; 95% CI, -0.4 to 16.2 mm; cough difference, 8.9 mm; 95% CI, -0.5 to 18.3 mm; swallow difference, 9.4 mm; 95% CI, -1.2 to 20.0 mm). More patients in the gabapentin group reported that pain was always well controlled than in the placebo group (difference, 9.2%; 95% CI, -21% to 3%). Gabapentin and placebo groups reported similar levels of satisfaction with pain control (difference, 2%; 95% CI, -11% to 15%). There was no clinically meaningful difference in reported nausea between the 2 groups (difference, 6%; 95% CI, -14% to 26%). Conclusion and Relevance Perioperative gabapentin given 300 mg twice daily did not result in reduced narcotic use, but results were compatible with clinically meaningful reductions in pain scores. Satisfaction with pain control and adverse effects were similar between groups. Trial Registration ClinicalTrials.gov Identifier: NCT02926573.
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Affiliation(s)
- Melanie Townsend
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Tina Liou
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Morgan Schoer
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nicholas Scott-Wittenborn
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Miranda Lindburg
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael Bottros
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ryan S Jackson
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Brian Nussenbaum
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jay F Piccirillo
- Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri.,Editor
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Kumar AH, Habib AS. The role of gabapentinoids in acute and chronic pain after surgery. Curr Opin Anaesthesiol 2019; 32:629-634. [DOI: 10.1097/aco.0000000000000767] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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122
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Postoperative pain management in the era of ERAS: An overview. Best Pract Res Clin Anaesthesiol 2019; 33:259-267. [DOI: 10.1016/j.bpa.2019.07.016] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
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124
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Neuroimaging-based pain biomarkers: definitions, clinical and research applications, and evaluation frameworks to achieve personalized pain medicine. Pain Rep 2019; 4:e762. [PMID: 31579854 PMCID: PMC6727999 DOI: 10.1097/pr9.0000000000000762] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/28/2019] [Accepted: 05/15/2019] [Indexed: 12/22/2022] Open
Abstract
One of the key ambitions of neuroimaging-based pain biomarker research is to augment patient and clinician reporting of clinically relevant phenomena with neural measures for prediction, prognosis, and detection of pain. Despite years of productive research on the neuroimaging of pain, such applications have seen little advancement. However, recent developments in identifying brain-based biomarkers of pain through advances in technology and multivariate pattern analysis provide some optimism. Here, we (1) define and review the different types of potential neuroimaging-based biomarkers, their clinical and research applications, and their limitations and (2) describe frameworks for evaluation of pain biomarkers used in other fields (eg, genetics, cancer, cardiovascular disease, immune system disorders, and rare diseases) to achieve broad clinical and research utility and minimize the risks of misapplication of this emerging technology. To conclude, we discuss future directions for neuroimaging-based biomarker research to achieve the goal of personalized pain medicine.
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125
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Wu CL, King AB, Geiger TM, Grant MC, Grocott MPW, Gupta R, Hah JM, Miller TE, Shaw AD, Gan TJ, Thacker JKM, Mythen MG, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients. Anesth Analg 2019; 129:567-577. [PMID: 31082966 PMCID: PMC7261519 DOI: 10.1213/ane.0000000000004194] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.
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Affiliation(s)
- Christopher L. Wu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Adam B. King
- Department of Anesthesiology, Vanderbilt, Vanderbilt University School of Medicine and University Medical Center, Nashville, Tennessee
| | - Timothy M. Geiger
- Department of Surgery, Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michael P. W. Grocott
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Southampton National Institute of Health Research Biomedical Research Centre, University Hospital Southampton National Health Service (NHS) Foundation Trust/University of Southampton, Southampton, United Kingdom
| | - Ruchir Gupta
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Jennifer M. Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Andrew D. Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Julie K. M. Thacker
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Mythen
- University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, United Kingdom
| | - Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt, Vanderbilt University School of Medicine and University Medical Center, Nashville, Tennessee
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Edwards DA, Hedrick TL, Jayaram J, Argoff C, Gulur P, Holubar SD, Gan TJ, Mythen MG, Miller TE, Shaw AD, Thacker JKM, McEvoy MD, Geiger TM, Gordon DB, Grant MC, Grocott M, Gupta R, Hah JM, Hurley RW, Kent ML, King AB, Oderda GM, Sun E, Wu CL. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy. Anesth Analg 2019; 129:553-566. [DOI: 10.1213/ane.0000000000004018] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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127
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Zhao S, Chen F, Feng A, Han W, Zhang Y. Risk Factors and Prevention Strategies for Postoperative Opioid Abuse. Pain Res Manag 2019; 2019:7490801. [PMID: 31360271 PMCID: PMC6652031 DOI: 10.1155/2019/7490801] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 06/25/2019] [Indexed: 02/06/2023]
Abstract
Worldwide, 80% of patients who undergo surgery receive opioid analgesics as the fundamental agent for pain relief. However, the irrational use of opioids leads to excessive drug dependence and drug abuse, resulting in an increased mortality rate and huge economic loss. The crisis of opioid overuse remains a great challenge. In this review, we summarize several key factors in opioid abuse, including race, region, income, genetic factors, age and gender, smoking and alcohol abuse, history of chronic pain and analgesic drug abuse, surgery, neuropsychiatric illness, depression and antidepressant use, human factors, national policies, hospital regulations, and health insurance under treatment of pain. Furthermore, we present several prevention strategies, such as perioperative measures, opioid substitutes, treatment of the primary illness, emotional regulation, use of opioid antagonists, efforts of the state, hospitals, doctors and pharmacy benefit managers, gene therapy, and vaccines. Greater understanding and better assessment are required of the risks associated with opioid abuse to ensure the safety and analgesic effects of pain treatment after surgery.
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Affiliation(s)
- Shuai Zhao
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
| | - Fan Chen
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Anqi Feng
- Department of Anesthesiology, Second Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wei Han
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
| | - Yuan Zhang
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
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128
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Creighton DW, Kumar AH, Grant SA. Perioperative Multimodal Pain Management: an Evidence-Based Update. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00340-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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129
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Wilson RB. Morpheus and the Underworld-Interventions to Reduce the Risks of Opioid Use After Surgery: ORADEs, Dependence, Cancer Progression, and Anastomotic Leakage. J Gastrointest Surg 2019; 23:1240-1249. [PMID: 30937715 DOI: 10.1007/s11605-019-04167-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perioperative pain management is a key element of enhanced recovery after surgery (ERAS) programs. A multimodal approach to analgesia as part of a coordinated ERAS includes the reduction of opioid use. This review aims to discuss opioid-related adverse events, strategies to reduce opioid use after surgery, and the relevance to the present "opioid crisis" in North America. METHODS A literature review of the pharmacology of opioid drugs, perioperative opioid reduction strategies, and the potential public health benefit was performed. This included current ERAS guidelines on multimodal analgesia, randomized controlled trials on perioperative analgesia, and intervention studies to decrease opioid use, misuse, and diversion in North America. RESULTS Reduction of perioperative opioid usage has been endorsed by joint clinical practice guidelines on the management of postoperative pain from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists. Interventions as part of an "opioid bundle" that can be incorporated into ERAS protocols include multimodal analgesia, regional anesthesia, opioid sparing drugs, carbon dioxide humidification during laparoscopy, changing opioid prescription practices, patient and physician education, and proper disposal of unused opioid medications. CONCLUSION There are substantial benefits in incorporating opioid reduction strategies into ERAS and clinical practice guidelines. These include faster return of function and mobility, and decreased opioid-related adverse drug events (ORADEs), postoperative morbidity and mortality, and length of hospital stay. Improved oncological outcomes after cancer surgery may be an additional benefit. Evidence-based interventions can also reduce opioid abuse and diversion in the community.
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Affiliation(s)
- Robert Beaumont Wilson
- Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Suite 6, Level 2, 171 Bigge St, Liverpool, Sydney, NSW, 2170, Australia.
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130
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Campsen J, Call T, Allen CM, Presson AP, Martinez E, Rofaiel G, Kim RD. Prospective, double-blind, randomized clinical trial comparing an ERAS pathway with ketorolac and pregabalin versus standard of care plus placebo during live donor nephrectomy for kidney transplant. Am J Transplant 2019; 19:1777-1781. [PMID: 30589514 DOI: 10.1111/ajt.15242] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/28/2018] [Accepted: 12/14/2018] [Indexed: 01/25/2023]
Abstract
Opioid exposure is a concern after live donation for kidney transplant. We theorized that an enhanced recovery after surgery pathway (ERAS) using pregabalin preoperatively to desensitize nerves followed by the nonsteroidal anti-inflammatory drug ketorolac, during and after surgery, can control pain, thus requiring less perioperative narcotics. The aim of this study was to determine if the use of a nonopioid analgesic ERAS protocol for donor nephrectomies could decrease the use of narcotics without an increase in complications compared with standard of care (SOC). This is a single-center, prospective, double-blind, randomized clinical trial involving a total of 62 patients undergoing nephrectomy for live donor kidney transplant. Length of hospital stay (LOS) was significantly reduced by 10% in the ERAS group versus the SOC-plus-placebo group. Morphine dose equivalents were significantly reduced by 40% in the study group versus the SOC-plus-placebo group. The use of this nonopioid analgesic ERAS pathway for donor nephrectomies decreased the use of narcotics without an increase in complications compared with SOC. There was significantly reduced LOS and less narcotic use in the study group versus the SOC-plus-placebo group. (ClinicalTrials.gov registration number: NCT03669081).
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Affiliation(s)
- Jeffrey Campsen
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, Salt Lake City, Utah
| | - Tyler Call
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chelsea McCarty Allen
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Angela P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Eryberto Martinez
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, Salt Lake City, Utah
| | - George Rofaiel
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, Salt Lake City, Utah
| | - Robin D Kim
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, Salt Lake City, Utah
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131
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Kibbe MR. JAMA Surgery-The Year in Review, 2018. JAMA Surg 2019; 154:377-379. [PMID: 30892655 DOI: 10.1001/jamasurg.2019.0274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Melina R Kibbe
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill.,Editor
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132
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Goode VM, Morgan B, Muckler VC, Cary MP, Zdeb CE, Zychowicz M. Multimodal Pain Management for Major Joint Replacement Surgery. Orthop Nurs 2019; 38:150-156. [PMID: 30768538 PMCID: PMC6727971 DOI: 10.1097/nor.0000000000000525] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Effective pain management for orthopaedic major joint replacement is key to achieving earlier recovery, better functioning, and high rates of patient satisfaction. In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques. To utilize this technique, a patient's history of and preoperative consumption of medications to treat pain impacts the success of this regimen. Multimodal pain management involves the use of nonsteroidal anti-inflammatory drugs, acetaminophen, N-methyl-D-aspartate antagonists, gabapentin, serotonin inhibitors, regional techniques, and opioids as needed. It is necessary for the nurse to understand the mechanism of pain and how the multimodal adjuncts target the pain response to benefit the patient's perioperative course as well as his or her postoperative and discharge management.
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Affiliation(s)
- Victoria M Goode
- Victoria M. Goode, PhD, CRNA, Duke University School of Nursing, Durham, NC. Brett Morgan, DNP, CRNA, Duke University School of Nursing, Durham, NC. Virginia C. Muckler, DNP, CRNA, CHSE, Duke University School of Nursing, Durham, NC. Michael P. Cary, Jr., PhD, RN, Duke University School of Nursing, Durham, NC. Christine E. Zdeb, BSN, RN, ONC, Duke University School of Nursing, Durham, NC. Michael Zychowicz, DNP, ANP, ONP, FAAN, FAANP, Duke University School of Nursing, Durham, NC
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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: 273] [Impact Index Per Article: 54.6] [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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134
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Soens MA, He J, Bateman BT. Anesthesia considerations and post-operative pain management in pregnant women with chronic opioid use. Semin Perinatol 2019; 43:149-161. [PMID: 30791974 DOI: 10.1053/j.semperi.2019.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of opioid use disorder in pregnancy has escalated markedly in recent years. Chronic opioid use during pregnancy poses several challenges for providing adequate analgesia and anesthesia in the peripartum period. These challenges include the potential for withdrawal, opioid tolerance and opioid-induced hyperalgesia. Here we discuss alterations in analgesic pharmacokinetics and pharmacodynamics that are associated with chronic opioid use. In addition, when treating pain in patients with opioid use disorder it is important to distinguish between different subgroups. In this review, we will discuss practical management strategies for parturients with (1) untreated opioid use disorder, (2) parturients on medication-assisted treatment (methadone, buprenorphine) and (3) patients recovering from opioid use disorder that are currently abstinent. Finally, we offer an overview of non-opioid strategies that may be utilized as part of a multimodal approach to providing optimal analgesia in this patient population.
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Affiliation(s)
- Mieke A Soens
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Jingui He
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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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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136
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Stokes SM, Wakeam E, Antonoff MB, Backhus LM, Meguid RA, Odell D, Varghese TK. Optimizing health before elective thoracic surgery: systematic review of modifiable risk factors and opportunities for health services research. J Thorac Dis 2019; 11:S537-S554. [PMID: 31032072 PMCID: PMC6465421 DOI: 10.21037/jtd.2019.01.06] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/31/2018] [Indexed: 12/20/2022]
Abstract
Despite progress in many different domains of surgical care, we are still striving toward practices which will consistently lead to the best care for an increasingly complex surgical population. Thoracic surgical patients, as a group, have multiple medical co-morbidities and are at increased risk for developing complications after surgical intervention. Our healthcare systems have been focused on treating complications as they occur in the hopes of minimizing their impact, as well as aiding in recovery. In recent years there has emerged a body of evidence outlining opportunities to optimize patients and likely prevent or decrease the impact of many complications. The purpose of this review article is to summarize four major domains-optimal pain control, nutritional status, functional fitness, and smoking cessation-all of which can have a substantial impact on the thoracic surgical patient's course in the hospital-as well as to describe opportunities for improvement, and areas for future research efforts.
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Affiliation(s)
- Sean M. Stokes
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Elliot Wakeam
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Mara B. Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson, Cancer Center, Houston, TX, USA
| | - Leah M. Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Robert A. Meguid
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - David Odell
- Division of Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Thomas K. Varghese
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
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137
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Hah JM, Cramer E, Hilmoe H, Schmidt P, McCue R, Trafton J, Clay D, Sharifzadeh Y, Ruchelli G, Goodman S, Huddleston J, Maloney WJ, Dirbas FM, Shrager J, Costouros JG, Curtin C, Mackey SC, Carroll I. Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery: Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2019; 2:e190168. [PMID: 30821824 PMCID: PMC6484627 DOI: 10.1001/jamanetworkopen.2019.0168] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/08/2019] [Indexed: 12/21/2022] Open
Abstract
Importance Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable. Objective To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes. Design, Setting, and Participants A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018. Interventions Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours. Main Outcomes and Measures A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery. Results Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P < .001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P < .001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P = .89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P = .008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P < .001), a history of alcohol or drug abuse treatment (ARR, 1.90; 95% CI, 1.42-2.53; P < .001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P = .03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P < .001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P < .001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P < .001). Conclusions and Relevance This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings. Trial Registration ClinicalTrials.gov Identifier: NCT01067144.
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Affiliation(s)
- Jennifer M. Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| | - Eric Cramer
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Heather Hilmoe
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Peter Schmidt
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Rebecca McCue
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Jodie Trafton
- Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
- Veterans Administration Program Evaluation and Resource Center, Veterans Health Administration Office of Mental Health Operations, Menlo Park, California
| | - Debra Clay
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Gabriela Ruchelli
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Stuart Goodman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Bioengineering (by courtesy), Stanford University, Redwood City, California
| | - James Huddleston
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - William J. Maloney
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | | | - Joseph Shrager
- Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University, Palo Alto, California
| | - John G. Costouros
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Catherine Curtin
- Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Sean C. Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| | - Ian Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
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Soffin EM, Wu CL. Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review. HSS J 2019; 15:57-65. [PMID: 30863234 PMCID: PMC6384219 DOI: 10.1007/s11420-018-9652-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Elective total joint arthroplasty may be a gateway to long-term opioid use. QUESTIONS/PURPOSE We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies. RESULTS Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA. CONCLUSIONS The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.
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Affiliation(s)
- Ellen M. Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD USA
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139
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Saigal AN, Jones HM. Interdisciplinary Mitigation of Opioid Misuse in Musculoskeletal Patients. HSS J 2019; 15:72-75. [PMID: 30863236 PMCID: PMC6384213 DOI: 10.1007/s11420-018-09656-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The opioid prescribing patterns of orthopedic surgeons have been shown to play a role in exacerbating rates of opioid misuse among post-surgical patients. Demonstrable success has been appreciated by combining policy-level approaches and clinical education-based strategies to inform patients of alternative modalities of post-operative analgesia. QUESTIONS/PURPOSES The purpose of this review was to address two questions: What are the most substantiated measures orthopedic surgeons can take to limit opioid misuse or addiction among their patients? What advantages are gained in orthopedic surgeons' collaborating with other healthcare professionals with influence over patients' post-operative opioid exposure? METHODS We searched two databases for articles on multidisciplinary policy-based solutions to mitigating the opioid overdose crisis among musculoskeletal patients. Articles produced from the search were searched for further evidence supporting the use of standardized clinical and administrative protocols in mitigating opioid misuse within this patient population. Successful approaches to mitigating misuse of opioids in this demographic were synthesized from recurring themes in the studies. RESULTS Multiple articles support orthopedic surgeons being aware of the risk factors for chronic opioid use among their patients, as well as multidisciplinary strategies involving orthopedic surgeons and other healthcare/governmental professionals to address the burden of the opioid crisis on surgical patients. CONCLUSIONS Addressing the misuse of opioids among orthopedic patients requires appropriate prescribing practices and long-term support of patients. Collaboration between surgeons and policymaking entities is recognized as an effective population-wide approach to preventing opioid dependence, misuse, and addiction.
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Affiliation(s)
- Ammar N. Saigal
- Department of Surgery, Weill Cornell Medicine, 1320 York Avenue, Apt. # 28A, New York, NY 10021 USA
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY USA
| | - Henderson M. Jones
- Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX USA
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CORR Insights®: The 2018 Chitranjan S. Ranawat, MD Award: Developing and Implementing a Novel Institutional Guideline Strategy Reduced Postoperative Opioid Prescribing After TKA and THA. Clin Orthop Relat Res 2019; 477:114-115. [PMID: 29698300 PMCID: PMC6345305 DOI: 10.1097/corr.0000000000000334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Scientific Surgery August 2018 BJS. Br J Surg 2018. [DOI: 10.1002/bjs.10947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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143
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Kawada T. Comment on: “All-Cause and Drug-Related Medical Events Associated with Overuse of Gabapentin and/or Opioid Medications: A Retrospective Cohort Analysis of a Commercially Insured US Population”. Drug Saf 2018; 41:641-642. [DOI: 10.1007/s40264-018-0670-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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144
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Authors’ Reply to: Tomoyuki Kawada’s Comment on: “All-Cause and Drug-Related Medical Events Associated with Overuse of Gabapentin and/or Opioid Medications: A Retrospective Cohort Analysis of a Commercially Insured US Population’’. Drug Saf 2018; 41:643-644. [DOI: 10.1007/s40264-018-0671-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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145
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Herzig SJ, Mosher HJ, Calcaterra SL, Jena AB, Nuckols TK. Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine. J Hosp Med 2018; 13:263-271. [PMID: 29624189 PMCID: PMC6278928 DOI: 10.12788/jhm.2980] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hospital-based clinicians frequently treat acute, noncancer pain. Although opioids may be beneficial in this setting, the benefits must be balanced with the risks of adverse events, including inadvertent overdose and prolonged opioid use, physical dependence, or development of opioid use disorder. In an era of epidemic opioid use and related harms, the Society of Hospital Medicine (SHM) convened a working group to develop a consensus statement on opioid use for adults hospitalized with acute, noncancer pain, outside of the palliative, end-of-life, and intensive care settings. The guidance is intended for clinicians practicing medicine in the inpatient setting (eg, hospitalists, primary care physicians, family physicians, nurse practitioners, and physician assistants). To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines, composed a draft Statement based on extracted recommendations, and obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies, and peer-reviewers. The iterative development process resulted in a final Consensus Statement consisting of 16 recommendations covering 1) whether to use opioids in the hospital, 2) how to improve the safety of opioid use during hospitalization, and 3) how to improve the safety of opioid prescribing at hospital discharge. As most guideline recommendations from which the Consensus Statement was derived were based on expert opinion alone, the working group identified key issues for future research to support evidence-based practice.
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Affiliation(s)
- Shoshana J Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Hilary J Mosher
- The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Susan L Calcaterra
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Anupam B Jena
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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