1
|
Soni A. Estimating price elasticities of demand for pain relief drugs: evidence from Medicare Part D. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2024:10.1007/s10754-024-09382-3. [PMID: 39093341 DOI: 10.1007/s10754-024-09382-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 07/21/2024] [Indexed: 08/04/2024]
Abstract
Overdose deaths from prescription opioids remain elevated, and policymakers seek solutions to curb opioid misuse. Recent proposals call for price-based solutions, such as opioid taxes and removal of opioids from insurance formularies. However, there is limited evidence on how opioid consumption responds to price stimuli. This study addresses that gap by estimating the effects of prices on the utilization of opioids, as well as other prescription painkillers. I use nationally representative individual-level data on prescription drug purchases and exploit the introduction of Medicare Part D in 2006 as an exogenous change in out-of-pocket drug prices. I find that new users have a relatively high price elasticity of demand for prescription opioids, and that consumers treat over-the-counter painkillers as substitutes for prescription painkillers. My results suggest that increasing out-of-pocket prices of opioids, through formulary design or taxes, may be effective in reducing new opioid use.
Collapse
Affiliation(s)
- Aparna Soni
- Department of Health Policy and Management, Fairbanks School of Public Health, Indiana University-Indianapolis, 1050 Wishard Blvd, Indianapolis, IN, 46202, USA.
| |
Collapse
|
2
|
Kushner P, McCarberg BH, Wright WL, Aldoori W, Gao P, Iqbal A, Petruschke R. Ibuprofen/acetaminophen fixed-dose combination as an alternative to opioids in management of common pain types. Postgrad Med 2024:1-9. [PMID: 39068515 DOI: 10.1080/00325481.2024.2382671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Abstract
Opioids are frequently used first line to manage acute pain in a variety of settings; however, the use of nonprescription analgesics for acute pain is recognized by experts as a practical and effective opioid-sparing strategy. Variations in dosages and formulations and a lack of standardization in reporting clinical data hinder the awareness of nonprescription treatments and recommendation of their use before opioids and other prescription options. A fixed-dose combination (FDC) of two common nonprescription analgesics, ibuprofen (IBU) and acetaminophen (APAP), is an appealing alternative to opioids in acute pain settings with a range of potential benefits. This narrative review evaluates the evidence in support of IBU/APAP FDCs containing IBU (≤1200 mg/day) and APAP (≤4000 mg/day), the nonprescription maximum daily doses in Canada and the United States, as alternatives to opioids and as a means to reduce the need for rescue opioid medication in acute pain management. A literature search was performed to identify clinical studies that directly compared IBU/APAP FDCs with opioids or nonopioids and measured the need for opioid rescue therapy in acute pain. Across studies, IBU/APAP FDCs consistently demonstrated pain relief similar to or better than opioid and nonopioid comparators and reliably reduced the use of rescue opioids with fewer adverse events. Based on these data, healthcare clinicians should consider FDC nonprescription analgesics as a potential first-line option for the management of acute pain.
Collapse
Affiliation(s)
- Pam Kushner
- Kushner Wellness Center, Los Angeles, CA, USA
| | - Bill H McCarberg
- University of California at San Diego School of Medicine, La Jolla, CA, USA
| | | | | | | | | | | |
Collapse
|
3
|
Le AB, Shkembi A, Scott Earnest G, Garza E, Trout D, Choi SD. Nonpharmacological pain management approaches among U.S. construction workers: A cross-sectional pilot study. Am J Ind Med 2024. [PMID: 38899539 DOI: 10.1002/ajim.23630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/03/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND U.S. construction workers experience high rates of injury that can lead to chronic pain. This pilot study examined nonpharmacological (without medication prescribed by healthcare provider) and pharmacological (e.g., prescription opioids) pain management approaches used by construction workers. METHODS A convenience sample of U.S. construction workers was surveyed, in partnership with the U.S. National Institute for Occupational Safety and Health (NIOSH) Construction Sector Program. Differences in familiarity and use of nonpharmacological and pharmacological pain management approaches, by demographics, were assessed using logistic regression models. A boosted regression tree model examined the most influential factors related to pharmacological pain management use, and potential reductions in use were counterfactually modeled. RESULTS Of 166 (85%) of 195 participants reporting pain/discomfort in the last year, 72% reported using pharmacological pain management approaches, including 19% using opioids. There were significant differences in familiarity with nonpharmacological approaches by gender, education, work experience, and job title. Among 37 factors that predicted using pharmacological and non-pharmacological pain management approaches, training on the risks of opioids, job benefits for unpaid leave and paid disability, and familiarity with music therapy, meditation or mindful breathing, and body scans were among the most important predictors of potentially reducing use of pharmacological approaches. Providing these nonpharmacological approaches to workers could result in an estimated 23% (95% CI: 16%-30%) reduction in pharmacological pain management approaches. CONCLUSION This pilot study suggests specific factors related to training, job benefits, and worker familiarity with nonpharmacological pain management approaches influence use of these approaches.
Collapse
Affiliation(s)
- Aurora B Le
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, Texas, USA
- Department of Environmental Health Sciences, School of Public Heath, University of Michigan, Ann Arbor, Michigan, USA
| | - Abas Shkembi
- Department of Environmental Health Sciences, School of Public Heath, University of Michigan, Ann Arbor, Michigan, USA
| | - G Scott Earnest
- Office of the Director, National Institute for Occupational Safety and Health, Washington, District of Columbia, USA
| | - Elizabeth Garza
- Office of the Director, National Institute for Occupational Safety and Health, Washington, District of Columbia, USA
| | - Douglas Trout
- Office of the Director, National Institute for Occupational Safety and Health, Washington, District of Columbia, USA
| | - Sang D Choi
- Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia, USA
- Department of Occupational & Environmental Safety & Health, University of Wisconsin - Whitewater, Whitewater, Wisconsin, USA
| |
Collapse
|
4
|
McMullan JT, Droege CA, Chard KM, Otten EJ, Hart KW, Lindsell CJ, Strilka RJ. Out-of-Hospital Intranasal Ketamine as an Adjunct to Fentanyl for the Treatment of Acute Traumatic Pain: A Randomized Clinical Trial. Ann Emerg Med 2024:S0196-0644(24)00229-4. [PMID: 38864781 DOI: 10.1016/j.annemergmed.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/22/2024] [Accepted: 04/12/2024] [Indexed: 06/13/2024]
Abstract
STUDY OBJECTIVE To evaluate if out-of-hospital administration of fentanyl and intranasal ketamine, compared to fentanyl alone, improves early pain control after injury. METHODS We conducted an out-of-hospital randomized, placebo-controlled, blinded, parallel group clinical trial from October 2017 to December 2021. Participants were male, aged 18 to 65 years, receiving fentanyl to treat acute traumatic pain prior to hospital arrival, treated by an urban fire-based emergency medical services agency, and transported to the region's only adult Level I trauma center. Participants randomly received 50 mg intranasal ketamine or placebo. The primary outcome was the proportion with a minimum 2-point reduction in self-described pain on the verbal numerical rating scale 30 minutes after study drug administration assessed by 95% confidence interval overlap. Secondary outcomes were side effects, pain ratings, and additional pain medications through the first 3 hours of care. RESULTS Among the 192 participants enrolled, 89 (46%) were White, (median age, 36 years; interquartile range, 27 to 53 years), with 103 receiving ketamine and 89 receiving placebo. There was no difference in the proportion experiencing improved pain 30 minutes after treatment (46/103 [44.7%] ketamine versus 32/89 [36.0%] placebo; difference in proportions, 8.7%; 95% confidence interval, -5.1% to 22.5%; P=.22) or at any time point through 3 hours. There was no difference in secondary outcomes or side effects. CONCLUSION In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients.
Collapse
Affiliation(s)
- Jason T McMullan
- Division of EMS, Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH.
| | - Christopher A Droege
- Department of Pharmacy Services, UC Health, University of Cincinnati Medical Center, Cincinnati, OH; Division of Pharmacy Practice and Administration, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH
| | - Kathleen M Chard
- Cincinnati Department of Veterans Affairs Medical Center, Cincinnati, OH; Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Edward J Otten
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Kim Ward Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Richard J Strilka
- 711 HPW/USAFSAM, Center for Sustainment of Trauma and Readiness Skills, Wright-Patterson Air Force Base, OH; Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH
| |
Collapse
|
5
|
Sardi JP, Smith JS, Gum JL, Rocos B, Charalampidis A, Lenke LG, Shaffrey CI, Cheung KMC, Qiu Y, Matsuyama Y, Pellisé F, Polly DW, Sembrano JN, Dahl BT, Kelly MP, de Kleuver M, Spruit M, Alanay A, Berven SH, Lewis SJ. Opioid Use Prior to Adult Spine Deformity Correction Surgery is Associated With Worse Pre- and Postoperative Back Pain and Prolonged Opioid Demands. Global Spine J 2024:21925682241261662. [PMID: 38832400 DOI: 10.1177/21925682241261662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
STUDY DESIGN Prospective multicenter database post-hoc analysis. OBJECTIVES Opioids are frequently prescribed for painful spinal conditions to provide pain relief and to allow for functional improvement, both before and after spine surgery. Amidst a current opioid epidemic, it is important for providers to understand the impact of opioid use and its relationship with patient-reported outcomes. The purpose of this study was to evaluate pre-/postoperative opioid consumption surrounding ASD and assess patient-reported pain outcomes in older patients undergoing surgery for spinal deformity. METHODS Patients ≥60 years of age from 12 international centers undergoing spinal fusion of at least 5 levels and a minimum 2-year follow-up were included. Patient-reported outcome scores were collected using the Numeric Rating Scale for back and leg pain (NRS-B; NRS-L) at baseline and at 2 years following surgery. Opioid use, defined based on a specific question on case report forms and question 11 from the SRS-22r questionnaire, was assessed at baseline and at 2-year follow-up. RESULT Of the 219 patients who met inclusion criteria, 179 (81.7%) had 2-year data on opioid use. The percentages of patients reporting opioid use at baseline (n = 75, 34.2%) and 2 years after surgery (n = 55, 30.7%) were similar (P = .23). However, at last follow-up 39% of baseline opioid users (Opi) were no longer taking opioids, while 14% of initial non-users (No-Opi) reported opioid use. Regional pre- and postoperative opioid use was 5.8% and 7.7% in the Asian population, 58.3% and 53.1% in the European, and 50.5% and 40.2% in North American patients, respectively. Baseline opioid users reported more preoperative back pain than the No-Opi group (7.0 vs 5.7, P = .001), while NRS-Leg pain scores were comparable (4.8 vs 4, P = .159). Similarly, at last follow-up, patients in the Opi group had greater NRS-B scores than Non-Opi patients (3.2 vs 2.3, P = .012), but no differences in NRS-Leg pain scores (2.2 vs 2.4, P = .632) were observed. CONCLUSIONS In this study, almost one-third of surgical ASD patients were consuming opioids both pre- and postoperatively world-wide. There were marked international variations, with patients from Asia having a much lower usage rate, suggesting a cultural influence. Despite both opioid users and nonusers benefitting from surgery, preoperative opioid use was strongly associated with significantly more back pain at baseline that persisted at 2-year follow up, as well as persistent postoperative opioid needs.
Collapse
Affiliation(s)
- Juan P Sardi
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Brett Rocos
- Departments of Neurosurgery and Orthopedic Surgery, Duke University, Durham, NC, USA
| | - Anastasios Charalampidis
- Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINITEC), Karolinska Institutet, Stockholm, Sweden
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University, New York, NY, USA
| | | | - Kenneth M C Cheung
- Department of Orthopaedic & Traumatology, The University of HK, Hong Kong
- The HKU-Shenzhen Hospital, Shenzhen China
| | - Yong Qiu
- The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Ferran Pellisé
- Spine Surgery Unit, Vall d'Hebron Hospital, Barcelona, Spain
| | - David W Polly
- University of Minnesota, Minneapolis, MN, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Jonathan N Sembrano
- University of Minnesota, Minneapolis, MN, USA
- Texas Children's Hospital, Houston, TX, USA
| | | | | | - Marinus de Kleuver
- Department of Orthopedic Surgery, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | | | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydınlar University School of Medicine. Istambul, Turkey
| | - Sigurd H Berven
- University of California San Francisco Spinal Disorders Service, San Francisco, CA, USA
| | | |
Collapse
|
6
|
Fink PB, Wheeler AR, Smith WR, Brant-Zawadzki G, Lieberman JR, McIntosh SE, Van Tilburg C, Wedmore IS, Windsor JS, Hofmeyr R, Weber D. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness Environ Med 2024; 35:198-218. [PMID: 38651342 DOI: 10.1177/10806032241248422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.
Collapse
Affiliation(s)
- Patrick B Fink
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Albert R Wheeler
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | - William R Smith
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | | | | | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Ian S Wedmore
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Ross Hofmeyr
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - David Weber
- Mountain Rescue Collective, LLC, Park City, UT
| |
Collapse
|
7
|
Bazan HA, Bhattacharjee S, Reid MM, Jun B, Polk C, Strain M, St Pierre LA, Desai N, Daly PW, Cucinello-Ragland JA, Edwards S, Recio J, Alvarez-Builla J, Cai JJ, Bazan NG. Transcriptomic signature, bioactivity and safety of a non-hepatotoxic analgesic generating AM404 in the midbrain PAG region. Sci Rep 2024; 14:11103. [PMID: 38750093 PMCID: PMC11096368 DOI: 10.1038/s41598-024-61791-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024] Open
Abstract
Safe and effective pain management is a critical healthcare and societal need. The potential for acute liver injury from paracetamol (ApAP) overdose; nephrotoxicity and gastrointestinal damage from chronic non-steroidal anti-inflammatory drug (NSAID) use; and opioids' addiction are unresolved challenges. We developed SRP-001, a non-opioid and non-hepatotoxic small molecule that, unlike ApAP, does not produce the hepatotoxic metabolite N-acetyl-p-benzoquinone-imine (NAPQI) and preserves hepatic tight junction integrity at high doses. CD-1 mice exposed to SRP-001 showed no mortality, unlike a 70% mortality observed with increasing equimolar doses of ApAP within 72 h. SRP-001 and ApAP have comparable antinociceptive effects, including the complete Freund's adjuvant-induced inflammatory von Frey model. Both induce analgesia via N-arachidonoylphenolamine (AM404) formation in the midbrain periaqueductal grey (PAG) nociception region, with SRP-001 generating higher amounts of AM404 than ApAP. Single-cell transcriptomics of PAG uncovered that SRP-001 and ApAP also share modulation of pain-related gene expression and cell signaling pathways/networks, including endocannabinoid signaling, genes pertaining to mechanical nociception, and fatty acid amide hydrolase (FAAH). Both regulate the expression of key genes encoding FAAH, 2-arachidonoylglycerol (2-AG), cannabinoid receptor 1 (CNR1), CNR2, transient receptor potential vanilloid type 4 (TRPV4), and voltage-gated Ca2+ channel. Phase 1 trial (NCT05484414) (02/08/2022) demonstrates SRP-001's safety, tolerability, and favorable pharmacokinetics, including a half-life from 4.9 to 9.8 h. Given its non-hepatotoxicity and clinically validated analgesic mechanisms, SRP-001 offers a promising alternative to ApAP, NSAIDs, and opioids for safer pain treatment.
Collapse
Affiliation(s)
- Hernan A Bazan
- Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic, New Orleans, LA, 70118, USA.
| | - Surjyadipta Bhattacharjee
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Madigan M Reid
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Bokkyoo Jun
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Connor Polk
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Madeleine Strain
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Linsey A St Pierre
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Neehar Desai
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Patrick W Daly
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Jessica A Cucinello-Ragland
- Department of Physiology, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Scott Edwards
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
- Department of Physiology, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA
| | - Javier Recio
- Department of Organic Chemistry and IQAR, University of Alcala, 28805, Alcala de Henares, Madrid, Spain
| | - Julio Alvarez-Builla
- Department of Organic Chemistry and IQAR, University of Alcala, 28805, Alcala de Henares, Madrid, Spain
| | - James J Cai
- Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX, 77843, USA
- Department of Veterinary Integrative Biosciences, Texas A&M University, College Station, TX, 77843, USA
| | - Nicolas G Bazan
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, LA, 70112, USA.
| |
Collapse
|
8
|
Segebarth PB, Schallmo M, Odum S, Hietpas K, Michalek C, Chapman TM, Leas D, Milam RA, Hamid N. Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial. Clin Spine Surg 2024; 37:138-148. [PMID: 38553433 DOI: 10.1097/bsd.0000000000001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/28/2024] [Indexed: 05/07/2024]
Abstract
STUDY DESIGN Randomized controlled trial (RCT). OBJECTIVE Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures. SUMMARY OF BACKGROUND DATA Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures. METHODS This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC). RESULTS Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively. CONCLUSIONS A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.
Collapse
|
9
|
Müller D, Scholz SM, Thalmann NF, Trippolini MA, Wertli MM. Increased Use and Large Variation in Strong Opioids and Metamizole (Dipyrone) for Minor and Major Musculoskeletal Injuries Between 2008 and 2018: An Analysis of a Representative Sample of Swiss Workers. JOURNAL OF OCCUPATIONAL REHABILITATION 2024; 34:157-168. [PMID: 37040000 PMCID: PMC10899285 DOI: 10.1007/s10926-023-10115-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE Musculoskeletal (MSK) injuries are a major contributing factor for chronic pain. To date, little is known how pain medication use in MSK injuries has changed over time. We assessed pain medication prescription for MSK injuries in a representative sample of Swiss workers between 2008 and 2018. METHODS Retrospective analysis of the Swiss Accident Insurance Fund (Suva) data. We calculated annual pain medication use, treatment days, and costs associated with pain medication use in minor and major MSK injuries. RESULTS In total, 1,921,382 cases with MSK injuries with ≥ 1 pain medication were analyzed. Whereas MSK injuries with ≥ 1 pain medication increased by 9.4%, we observed a larger increase in metamizole (+ 254%), strong opioids (+ 88.4%), coxibs (+ 85.8%), and paracetamol (+ 28.1%). Strong opioids were increasingly used in minor (+ 91.4%) and major (+ 88.3%) injuries. The increase in metamizole (+ 390.6%) and coxibs (+ 115.5%) was larger in minor injuries compared to major injuries (+ 238.7% and + 80.6%, respectively). Medical expenses decreased in all medications except for strong opioids where a substantial increase was observed (+ 192.4% in minor; + 34% in major injuries). CONCLUSIONS We observed a disproportionate increase in metamizole, strong opioids, coxibs, and paracetamol prescriptions even in minor MSK injuries between 2008 and 2018. Whereas treatment costs decreased for all pain medications, there was a substantial increase in strong opioids. A more liberal prescription practice of opioids conflict with current evidence-based practice recommendations and need to be addressed by physicians and policy makers.
Collapse
Affiliation(s)
- Dominic Müller
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - Stefan M Scholz
- Department of Statistics, Suva (Swiss National Accident Insurance Fund), Lucerne, Switzerland
| | - Nicolas Fabrice Thalmann
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Maurizio Alen Trippolini
- Bern University of Applied Sciences, School of Health Professions, Murtenstrasse 10, 3008, Bern, Switzerland
- Institute of Physiotherapy, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
- Evidence-Based Insurance Medicine (EbIM), Division of Clinical Research, Department of Clinical Epidemiology, University Hospital Basel, University of Basel, Totengässlein 3, 4051, Basel, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
- Department of Internal Medicine, Kantonsspital Baden, Im Ergel 1, 5404, Baden, Switzerland
| |
Collapse
|
10
|
Nasr Isfahani M, Etesami H, Ahmadi O, Masoumi B. Comparing the efficacy of intravenous morphine versus ibuprofen or the combination of ibuprofen and acetaminophen in patients with closed limb fractures: a randomized clinical trial. BMC Emerg Med 2024; 24:15. [PMID: 38273252 PMCID: PMC10809472 DOI: 10.1186/s12873-024-00933-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION This study aims to investigate the effectiveness of intravenous ibuprofen or intravenous ibuprofen plus acetaminophen compared to intravenous morphine in patients with closed extremity fractures. METHODS A triple-blinded randomized clinical trial was conducted at a tertiary trauma center in Iran. Adult patients between 15 and 60 years old with closed, isolated limb fractures and a pain intensity of at least 6/10 on the visual analog scale (VAS) were eligible. Patients with specific conditions or contraindications were not included. Participants were randomly assigned to receive intravenous ibuprofen, intravenous ibuprofen plus acetaminophen, or intravenous morphine. Pain scores were assessed using the visual analog scale at baseline and 5, 15, 30, and 60 min after drug administration. The primary outcome measure was the pain score reduction after one hour. RESULTS Out of 388 trauma patients screened, 158 were included in the analysis. There were no significant differences in age or sex distribution among the three groups. The pain scores decreased significantly in all groups after 5 min, with the morphine group showing the lowest pain score at 15 min. The maximum effect of ibuprofen was observed after 30 min, while the ibuprofen-acetaminophen combination maintained its effect after 60 min. One hour after injection, pain score reduction in the ibuprofen-acetaminophen group was significantly more than in the other two groups, and pain score reduction in the ibuprofen group was significantly more than in the morphine group. CONCLUSION The study findings suggest that ibuprofen and its combination with acetaminophen have similar or better analgesic effects compared to morphine in patients with closed extremity fractures. Although morphine initially provided the greatest pain relief, its effect diminished over time. In contrast, ibuprofen and the ibuprofen-acetaminophen combination maintained their analgesic effects for a longer duration. The combination therapy demonstrated the most sustained pain reduction. The study highlights the potential of non-opioid analgesics in fracture pain management and emphasizes the importance of initiation of these medications as first line analgesic for patients with fractures. These findings support the growing trend of exploring non-opioid analgesics in pain management. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05630222 (Tue, Nov 29, 2022). The manuscript adheres to CONSORT guidelines.
Collapse
Affiliation(s)
- Mehdi Nasr Isfahani
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Trauma Data Registration Center, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Etesami
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Student Research Committee, Vice Chancellery for Research, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Ahmadi
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Babak Masoumi
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| |
Collapse
|
11
|
Le Cornec C, Le Pottier M, Broch H, Marguinaud Tixier A, Rousseau E, Laribi S, Janière C, Brenckmann V, Guillerm A, Deciron F, Kabbaj A, Jenvrin J, Péré M, Montassier E. Ketamine Compared With Morphine for Out-of-Hospital Analgesia for Patients With Traumatic Pain: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2352844. [PMID: 38285446 PMCID: PMC10825723 DOI: 10.1001/jamanetworkopen.2023.52844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024] Open
Abstract
Importance Pain is a common out-of-hospital symptom among patients, and opioids are often prescribed. Research suggests that overprescribing for acute traumatic pain is still prevalent, even when limits restricting opioid prescriptions have been implemented. Ketamine hydrochloride is an alternative to opioids in adults with out-of-hospital traumatic pain. Objective To assess the noninferiority of intravenous ketamine compared with intravenous morphine sulfate to provide pain relief in adults with out-of-hospital traumatic pain. Design, Setting, and Participants The Intravenous Subdissociative-Dose Ketamine Versus Morphine for Prehospital Analgesia (KETAMORPH) study was a multicenter, single-blind, noninferiority randomized clinical trial comparing ketamine hydrochloride (20 mg, followed by 10 mg every 5 minutes) with morphine sulfate (2 or 3 mg every 5 minutes) in adult patients with out-of-hospital trauma and a verbal pain score equal to or greater than 5. Enrollment occurred from November 23, 2017, to November 26, 2022, in 11 French out-of-hospital emergency medical units. Interventions Patients were randomly assigned to ketamine (n = 128) or morphine (n = 123). Main Outcomes and Measures The primary outcome was the between-group difference in mean change in verbal rating scale pain scores measured from the time before administration of the study drug to 30 minutes later. A noninferiority margin of 1.3 was chosen. Results A total of 251 patients were randomized (median age, 51 [IQR, 34-69] years; 111 women [44.9%] and 140 men [55.1%] among the 247 with data available) and were included in the intention-to-treat population. The mean pain score change was -3.7 (95% CI, -4.2 to -3.2) in the ketamine group compared with -3.8 (95% CI, -4.2 to -3.4) in the morphine group. The difference in mean pain score change was 0.1 (95% CI, -0.7 to 0.9) points. There were no clinically meaningful differences for vital signs between the 2 groups. The intravenous morphine group had 19 of 113 (16.8% [95% CI, 10.4%-25.0%]) adverse effects reported (most commonly nausea [12 of 113 (10.6%)]) compared with 49 of 120 (40.8% [95% CI, 32.0%-49.6%]) in the ketamine group (most commonly emergence phenomenon [24 of 120 (20.0%)]). No adverse events required intervention. Conclusions and Relevance In the KETAMORPH study of patients with out-of-hospital traumatic pain, the use of intravenous ketamine compared with morphine showed noninferiority for pain reduction. In the ongoing opioid crisis, ketamine administered alone is an alternative to opioids in adults with out-of-hospital traumatic pain. Trial Registration ClinicalTrials.gov Identifier: NCT03236805.
Collapse
Affiliation(s)
- Clément Le Cornec
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | | | - Hélène Broch
- Urgences Service Mobile d’Urgence et de Réanimation (SMUR), Centre Hospitalier Chateaubriant, Chateaubriant, France
| | - Alexandre Marguinaud Tixier
- Pôle Urgences Adultes–Service d’Aide Médicale Urgente (SAMU), Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | | | - Said Laribi
- Centre Hospitalier Régional et Universitaire Tours Urgences SAMU 37 SMUR de Tours, Tours, France
| | - Charles Janière
- SAMU85 Centre Hospitalier Départemental Vendée la Roche sur Yon, la Roche sur Yon, France
| | | | | | - Florence Deciron
- Centre Hospitalier Le Mans SAMU 72 SMUR du Mans, Le Mans, France
| | - Amine Kabbaj
- Centre Hospitalier Saint Nazaire Urgences SMUR de Saint Nazaire, Saint Nazaire, France
| | - Joël Jenvrin
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | - Morgane Péré
- Plateforme de Méthodologie et Biostatistique, CHU Nantes, Nantes, France
| | - Emmanuel Montassier
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
- Center for Research in Transplantation and Translational Immunology, Unité Mixte de Recherche 1064, Nantes Université, CHU Nantes, Institut National de la Santé et de la Recherche Médicale, Nantes, France
| |
Collapse
|
12
|
Feldman C, Fredericks-Younger J, Desjardins P, Malmstrom H, Miloro M, Warburton G, Ward B, Ziccardi V, Fine D, Greenberg P, Andrews T, Matheson P, Lu SE. The Opioid Analgesic Reduction Study (OARS) Pilot: A Double-Blind Randomized Multicenter Trial. JDR Clin Trans Res 2024; 9:72-84. [PMID: 36680313 PMCID: PMC10850879 DOI: 10.1177/23800844221144031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND With addiction rates and opioid deaths increasing, health care providers are obligated to help stem the opioid crisis. As limited studies examine the comparative effectiveness of fixed-dose combination nonopioid analgesia to opioid-containing analgesia, a comparative effectiveness study was planned and refined by conducting a pilot study. METHODS The Opioid Analgesic Reduction Study (OARS) pilot, a stratified, randomized, multisite, double-blind clinical trial, was designed to test technology and procedures to be used in the full OARS trial. Participants engaged in the full protocol, enabling the collection of OARS outcome data. Eligible participants reporting to 1 of 5 sites for partial or full bony impacted mandibular third molar extraction were stratified by biologic sex and randomized to 1 of 2 treatment groups, OPIOID or NONOPIOID. OPIOID participants were provided 20 doses of hydrocodone 5 mg/acetaminophen 300 mg. NONOPIOID participants were provided 20 doses of ibuprofen 400 mg/acetaminophen 500 mg. OARS outcomes data, including pain experience, adverse effects, sleep quality, pain interference, overall satisfaction, and remaining opioid tablets available for diversion, were collected via surveys, electronic medication bottles, eDiary, and activity/sleep monitor. RESULTS Fifty-three participants were randomized with 50 completing the OARS pilot protocol. Across all outcome pain domains, in all but 1 time period, NONOPIOID was better in managing pain than OPIOID (P < 0.05 level). Other outcomes suggest less pain interference, less adverse events, better sleep quality, better overall satisfaction, and fewer opioid-containing tablets available for diversion. DISCUSSION Results suggest patients requiring impacted mandibular third molar extraction would benefit from fixed-dose combination nonopioid analgesia. KNOWLEDGE TRANSFER STATEMENT Study results suggest fixed-dose nonopioid combination ibuprofen 400 mg/acetaminophen 500 mg is superior to opioid-containing analgesic (hydrocodone 5 mg/acetaminophen 500 mg). This knowledge should inform surgeons and patients in the selection of postsurgical analgesia.
Collapse
Affiliation(s)
- C.A. Feldman
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
- School of Public Health, Rutgers University, Newark, NJ, USA
| | | | - P.J. Desjardins
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - H. Malmstrom
- Eastman Institute for Oral Health, University of Rochester, Rochester, NY, USA
| | - M. Miloro
- College of Dentistry, University of Illinois, IL, USA
| | - G. Warburton
- School of Dentistry, University of Maryland, MD, USA
| | - B. Ward
- School of Dentistry, University of Michigan, MI, USA
| | - V. Ziccardi
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - D.H. Fine
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - P. Greenberg
- School of Public Health, Rutgers University, Newark, NJ, USA
| | - T. Andrews
- School of Public Health, Rutgers University, Newark, NJ, USA
| | - P.B. Matheson
- School of Dental Medicine, Rutgers University, Newark, NJ, USA
| | - S.-E. Lu
- School of Public Health, Rutgers University, Newark, NJ, USA
| |
Collapse
|
13
|
Andre A, Benichou M, Dym H. Post-Procedure Analgesic Management. Dent Clin North Am 2024; 68:213-225. [PMID: 37951635 DOI: 10.1016/j.cden.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
During the development of multimodal pain management protocols, practitioners need to consider the potential risks each treatment modality inherently carries in order to prevent or diminish harmful outcomes. As an example, the part dentists played in the early stages of the opioid epidemic in the United States of America should serve as a cautionary account. By understanding the roots of this crisis, as practitioners we are better equipped to implement the novel analgesic agents available today to optimize post-operative pain control while minimizing any risk of addiction and harm to our communities. It is therefore critical that our colleagues understand the variety of accessible options for pain management to assure that our profession is able to seek adequate and sustainable relief for our post-operative patients. This article will go in depth to explain the analgesic tools practitioners can implement for an effective low-risk protocol, including a combination of NSAIDS and acetaminophen approach, using long-acting local anesthetics such as Exparel, pregabalin, gabapentin, ketamine, dexmedetomidine, and corticosteroids, and enhanced recovery after surgery protocols.
Collapse
Affiliation(s)
- Amanda Andre
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA.
| | - Michael Benichou
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
| | - Harry Dym
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
| |
Collapse
|
14
|
Daoust R, Paquet J, Marquis M, Williamson D, Fontaine G, Chauny JM, Frégeau A, Orkin AM, Upadhye S, Lessard J, Cournoyer A. Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis. Acad Emerg Med 2023; 30:1253-1263. [PMID: 37607265 DOI: 10.1111/acem.14790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. METHODS MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. RESULTS From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). CONCLUSIONS For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.
Collapse
Affiliation(s)
- Raoul Daoust
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - Martin Marquis
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - David Williamson
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Guillaume Fontaine
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean-Marc Chauny
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Amélie Frégeau
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Aaron M Orkin
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Joseph's Health Centre, Unity Health, Toronto, Ontario, Canada
| | - Suneel Upadhye
- McMaster University, Division of Emergency Medicine, Hamilton, Ontario, Canada
| | - Justine Lessard
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Alexis Cournoyer
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| |
Collapse
|
15
|
Barrett TW, Rief K, Parisi F. The OPAL Trial Provides a Treasure of Evidence to Stop Using Opioids for Acute Neck and Back Pain: December 2023 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2023; 82:758-759. [PMID: 37993223 DOI: 10.1016/j.annemergmed.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
| | - Katherine Rief
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
| | - Frank Parisi
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
16
|
Shih YV, Kingsley D, Newman H, Hoque J, Gupta A, Lascelles BDX, Varghese S. Multi-Functional Small Molecule Alleviates Fracture Pain and Promotes Bone Healing. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2303567. [PMID: 37939302 PMCID: PMC10754086 DOI: 10.1002/advs.202303567] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/21/2023] [Indexed: 11/10/2023]
Abstract
Bone injuries such as fractures are one major cause of morbidities worldwide. A considerable number of fractures suffer from delayed healing, and the unresolved acute pain may transition to chronic and maladaptive pain. Current management of pain involves treatment with NSAIDs and opioids with substantial adverse effects. Herein, we tested the hypothesis that the purine molecule, adenosine, can simultaneously alleviate pain and promote healing in a mouse model of tibial fracture by targeting distinctive adenosine receptor subtypes in different cell populations. To achieve this, a biomaterial-assisted delivery of adenosine is utilized to localize and prolong its therapeutic effect at the injury site. The results demonstrate that local delivery of adenosine inhibited the nociceptive activity of peripheral neurons through activation of adenosine A1 receptor (ADORA1) and mitigated pain as demonstrated by weight bearing and open field movement tests. Concurrently, local delivery of adenosine at the fracture site promoted osteogenic differentiation of mesenchymal stromal cells through adenosine A2B receptor (ADORA2B) resulting in improved bone healing as shown by histological analyses and microCT imaging. This study demonstrates the dual role of adenosine and its material-assisted local delivery as a feasible therapeutic approach to treat bone trauma and associated pain.
Collapse
Affiliation(s)
- Yu‐Ru V. Shih
- Department of Orthopaedic SurgeryDuke University School of MedicineDurhamNC27710USA
| | - David Kingsley
- Department of Orthopaedic SurgeryDuke University School of MedicineDurhamNC27710USA
| | - Hunter Newman
- Department of Mechanical Engineering and Materials ScienceDuke UniversityDurhamNC27710USA
| | - Jiaul Hoque
- Department of Orthopaedic SurgeryDuke University School of MedicineDurhamNC27710USA
| | - Ankita Gupta
- Translational Research in Pain ProgramDepartment of Clinical SciencesCollege of Veterinary MedicineNorth Carolina State UniversityRaleighNC27607USA
| | - B. Duncan X. Lascelles
- Translational Research in Pain ProgramDepartment of Clinical SciencesCollege of Veterinary MedicineNorth Carolina State UniversityRaleighNC27607USA
- Thurston Arthritis CenterUniversity of North Carolina School of MedicineChapel HillNC27599USA
- Center for Translational Pain MedicineDepartment of AnesthesiologyDuke University School of MedicineDurhamNC27710USA
- Comparative Pain Research and Education CenterCollege of Veterinary MedicineNorth Carolina State UniversityRaleighNC27607USA
| | - Shyni Varghese
- Department of Orthopaedic SurgeryDuke University School of MedicineDurhamNC27710USA
- Department of Mechanical Engineering and Materials ScienceDuke UniversityDurhamNC27710USA
- Department of Biomedical EngineeringDuke UniversityDurhamNC27710USA
| |
Collapse
|
17
|
Theeuwen H, Kim AW. The Delineation of Another Standard for Postoperative Pain Management Following Thoracic Surgery. JAMA Surg 2023; 158:1263-1264. [PMID: 37878290 DOI: 10.1001/jamasurg.2023.5229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Hailey Theeuwen
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| |
Collapse
|
18
|
Elliott ZT, Mann DS, Fiorella M, Christopher V, Givens A, Martin AM, Zhan T, Curry J. Predictors of opioid requirement among patients receiving free flap reconstruction to the head and neck. Am J Otolaryngol 2023; 44:104000. [PMID: 37499343 DOI: 10.1016/j.amjoto.2023.104000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Opioids are a part of standard of care treatment of acute, severe postoperative pain. However, increased opioid requirements have been shown to be associated with increased postoperative complications, morbidity, and mortality. The aim of this study was to identify potential predictive factors associated with increased or decreased opioid requirements after free tissue transfer (FTT) to the head and neck. MATERIALS/METHODS A retrospective review was conducted on subjects who underwent head and neck reconstruction (HNR) from 2015 to 2021 at a single tertiary care center. Patients with inpatient stay over 10 days and those receiving fentanyl for sedation purposes were excluded due to EMR limitations and confounding, respectively. The total dose of opioid medication each patient received was calculated and summed using morphine milligram equivalents (MME). Statistical analysis was conducted using poisson regression and multivariable regression models. RESULTS Two hundred and ninety-one patients were included. The mean opioid requirement for all subjects was 228.6 (SD 250.0) MMEs during their entire postoperative stay and the mean length of stay was 6.0 (SD 1.7) days. An established opioid prescription prior to surgical resection was the greatest predictor of increased risk for opioid requirement according univariate and multivariate analysis 2.356 (2.321-2.392), p ≤ 0.0001 and 1.833 (1.802-1.863), p ≤ 0.0001, respectively. Fibula transfers were associated with higher opioid requirements while scapula transfers were associated with decreased opioid requirements compared to other free tissue transfer types. CONCLUSION Preoperative opioid use was associated with higher postoperative opioid requirements. Multimodal pain management (MMPM) was not associated with a decreased opioid requirement; however, further studies are needed to investigate the hierarchy, dosing, and timing of MMPM in relation to opioid requirements and pain control.
Collapse
Affiliation(s)
- Zachary T Elliott
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA.
| | - Derek S Mann
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Michele Fiorella
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Vanessa Christopher
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Alyssa Givens
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Ann Marie Martin
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA 191071, USA
| | - Joseph Curry
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| |
Collapse
|
19
|
Atherton SW, Massey MS, Nguyen T, Wang DW, Subramaniam K, Abdelwahid E, Bahnaswy A, Trostler MS, Lombardero M, Planinsic R, Abuelkasem E. Evaluating a unique enhanced recovery protocol in laparoscopic donor nephrectomy: A single center experience. Clin Transplant 2023; 37:e15051. [PMID: 37335310 DOI: 10.1111/ctr.15051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/24/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) protocols have been associated with a reduction in opioid consumption and a hastening in recovery in abdominal surgery. However, their impact on laparoscopic donor nephrectomy (LDN) has not been fully elucidated. The aim of this study is to evaluate opioid consumption and other relevant outcome measures before and after implementation of a unique LDN ERAS protocol. METHODS 244 LDN patients were included in this retrospective cohort study. Forty-six underwent LDN prior to implementation of ERAS, whereas 198 patients received ERAS perioperative care. The primary outcome was daily oral morphine equivalent (OME) consumption averaged over the entire postoperative stay. Due to removal of preoperative oral morphine from the protocol partway through the study period, the ERAS group was further subdivided into morphine recipients and non-recipients for subgroup analysis. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), length of stay, pain scores, and other relevant measures. RESULTS ERAS donors consumed significantly fewer average daily OMEs than Pre-ERAS donors (21.5 vs. 37.6, respectively; p < .0001). There were no statistically significant differences in OME consumption between morphine recipients and non-recipients. The ERAS group experienced less PONV (44.4% requiring one or more rescue antiemetic postoperatively, vs. 60.9% of Pre-ERAS donors; p = .008). CONCLUSIONS A protocol pairing lidocaine and ketamine with a comprehensive approach to preoperative PO intake, premedication, intraoperative fluid management and postoperative pain control is associated with reduced opioid consumption in LDN.
Collapse
Affiliation(s)
- Samuel W Atherton
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael S Massey
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tho Nguyen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David W Wang
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eman Abdelwahid
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ahmed Bahnaswy
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael S Trostler
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Manuel Lombardero
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Raymond Planinsic
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
20
|
Fong ISH, Yiu CH, Abelev MD, Allaf S, Begley DA, Bugeja BA, Khor KE, Rimington J, Penm J. Supply of opioids and information provided to patients after surgery in an Australian hospital: A cross-sectional study. Anaesth Intensive Care 2023; 51:340-347. [PMID: 37688434 PMCID: PMC10493037 DOI: 10.1177/0310057x231163890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Opioids are commonly prescribed to manage pain after surgery. However, excessive supply on discharge can increase patients' risk of persistent opioid use and contribute to the reservoir of unused opioids in the community that may be misused. This study aimed to evaluate the use of opioids in Australian surgical patients after discharge and patient satisfaction with the provision of opioid information after discharge. This prospective cohort study was conducted at a tertiary referral and teaching hospital. Surgical patients were called 7-28 days after discharge to identify their opioid use and the information that they received after discharge. In total, 66 patients responded. Most patients underwent orthopaedic surgery (45.5%; 30/66). The median days of opioids supplied on discharge was 5 (IQR 3-5). In total, 40.9% (27/66) of patients had >50% of their opioids remaining. Patients undergoing orthopaedic surgery were less likely to have >50% of their opioids remaining (P = 0.045), whilst patients undergoing urological or renal surgeries were significantly more likely (P = 0.009). Most patients recalled receiving information about their opioids (89.4%; 59/66). However, the majority (51.5%; 34/66) did not recall receiving any information about the signs of opioid toxicity and interactions between opioids and alcohol. In conclusion, around 40% of patients had more than half of their opioid supply remaining after they ceased taking their opioid. Although most patients recalled receiving information about their opioids, more than half did not recall receiving any information about the signs of opioid toxicity or interactions between opioids and alcohol.
Collapse
Affiliation(s)
- Ian SH Fong
- Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| | - Chin Hang Yiu
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Camperdown, Australia
| | - Matthew D Abelev
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Camperdown, Australia
| | - Sara Allaf
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Camperdown, Australia
| | - David A Begley
- Department of Pain Management. Prince of Wales Hospital, Randwick, Australia
| | - Bernadette A Bugeja
- Department of Pain Management. Prince of Wales Hospital, Randwick, Australia
| | - Kok Eng Khor
- Department of Pain Management. Prince of Wales Hospital, Randwick, Australia
| | - Joanne Rimington
- District Pharmacy Services, South Eastern Sydney Local Health District, Randwick, Australia
| | - Jonathan Penm
- Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Camperdown, Australia
| |
Collapse
|
21
|
Lavin RA, Yuspeh L, Kalia N, Tsourmas NF, Leung N, Hunt DL, Green-McKenzie J, Bernacki EJ, Tao XG. Dose Escalations Among Workers' Compensation Claimants Using Opioid Medications-An 8 Year Postinjury Follow up Study. J Occup Environ Med 2023; 65:e558-e564. [PMID: 37231640 DOI: 10.1097/jom.0000000000002893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE The aim of the study is to determine the morphine equivalent dose in milligrams (MED)/day escalation trend after initial utilization. METHODS A total of 25,108 lost time claims filed between 1998 and 2007 were followed for 8 years from injury date. Claims were stratified by initial MED/day at 3 months after injury into four groups (0, 1 to < 15, 15 to < 30, and ≥30 MED/day). The slopes in MED/year of opioid dose escalation were determined for each initial MED/day group. RESULTS The slopes of MED/day escalation by initial MED categories were similar ( P ≥ 0.05) ranging from 5.38 to 7.76 MED annually. On average, MED/day increased in a liner pattern with a slope at 6.28 MED/year ( P < 0.01). CONCLUSIONS Opioid MED/day increased in a linear pattern, regardless of initial MED/day dose.
Collapse
Affiliation(s)
- Robert A Lavin
- From the Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland (R.A.L., L.Y., N.K., N.F.T., N.L., E.J.B., X.G.T.); Strategy, Enterprise Risk, and Research, Louisiana Workers' Compensation Corporation, Baton Rouge, Louisiana (L.Y.); Texas Mutual, Workers' Compensation Insurance, Austin, Texas (N.F.T., N.L.); General Electric, Norwalk, Connecticut (N.K.); Corporate Administration Office, AF Group, Lansing, Michigan (D.L.H.); and University of Pennsylvania, Perelman School of Medicine, Division of Occupational Medicine, Philadelphia, Pennsylvania (J.G.-M.)
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Fu Y, Liu Q, Nie H. Efficacy of opioids for traumatic pain in the emergency department: a systematic review and Bayesian network meta-analysis. Front Pharmacol 2023; 14:1209131. [PMID: 37576822 PMCID: PMC10413574 DOI: 10.3389/fphar.2023.1209131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/06/2023] [Indexed: 08/15/2023] Open
Abstract
Aim: To systematically assess and rank the efficacy of opioid medications for traumatic pain in the emergency department in terms of pain relief, adverse events and rescue analgesia. Methods: Four databases were systematically searched until 26 September 2022: PubMed, Embase, Cochrane Library, and Web of Science. Outcomes were pain relief, adverse events (dizziness, hypotension, pruritus, sedation), and rescue analgesia. For each outcome, network plots were drawn to exhibit direct and indirect comparisons, and rank probabilities were utilized to rank the efficacy of different opioids. Results: Twenty studies of 3,040 patients were eligible for this network meta-analysis. According to the rank probabilities, the top three analgesic medications for pain relief may be sufentanil (78.29% probability of ranking first), buprenorphine (48.54% probability of ranking second) and fentanyl (53.25% probability of ranking third); buprenorphine (31.20%), fentanyl (20.14%) and sufentanil (21.55%) were least likely to cause dizziness; the top three analgesic medications which were least likely to cause hypotension were buprenorphine (81.64%), morphine (45.02%) and sufentanil (17.27%); butorphanol (40.56%), morphine (41.11%) and fentanyl (14.63%) were least likely to cause pruritus; the top three medications which were least likely to cause sedation were hydrocodone + acetaminophen (97.92%), morphine (61.85%) and butorphanol (55.24%); patients who received oxycodone (83.64%), butorphanol (38.31%) and fentanyl (25.91%) were least likely to need rescue analgesia in sequence. Conclusion: Sufentanil, buprenorphine and fentanyl may be superior to other opioid medications in terms of pain relief and the incidence of dizziness, hypotension and pruritus, which might be selected as opioid analgesics for traumatic pain in the emergency setting.
Collapse
Affiliation(s)
- Yawen Fu
- Department of Emergency, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Qiang Liu
- Department of Emergency, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hu Nie
- Department of Emergency, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- West China Xiamen Hospital of Sichuan University, Xiamen, Fujian, China
| |
Collapse
|
23
|
Fennell G, Jacobson M, Grol-Prokopczyk H. Predictors of Multiwave Opioid Use Among Older American Adults. Innov Aging 2023; 7:igad068. [PMID: 38094934 PMCID: PMC10714904 DOI: 10.1093/geroni/igad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Indexed: 02/01/2024] Open
Abstract
Background and Objectives Despite limited analgesic benefits, long-term opioid therapy (L-TOT) is common among older adults with chronic pain. Extended opioid use poses a threat to older adults as aging metabolisms retain opioids for longer, increasing the risk of injury, overdose, and other negative health outcomes. In contrast to predictors of general opioid use, predictors of L-TOT in older adults are not well documented. We aimed to identify such predictors using all available data on self-reported opioid use in the Health and Retirement Study. Research Design and Methods Using 5 waves of data, respondents (N = 10,713) aged 51 and older were identified as reporting no opioid use (n = 8,621), a single wave of use (n = 1,410), or multiple waves of use (n = 682). We conducted a multinomial logistic regression to predict both single- and multiwave opioid use relative to no use. Demographic, socioeconomic, geographic, health, and health care-related factors were included in our model. Results Multivariable findings show that, relative to nonusers, both single- and multiwave users were significantly more likely to be younger (relative risk ratio [RRR] = 1.33; RRR = 2.88); report lower household wealth (RRR = 1.47; RRR = 2.88); live in the U.S. Midwest (RRR = 1.29; RRR = 1.56), South (RRR = 1.34; RRR = 1.58), or West (RRR = 1.46; RRR = 2.34); experience interfering pain (RRR = 1.59; RRR = 3.39), back pain (RRR = 1.35; RRR = 1.53), or arthritic pain (RRR = 1.46; RRR = 2.32); and see the doctor frequently (RRR = 1.50; RRR = 2.02). Multiwave users were less likely to be Black (RRR = 0.69) or Hispanic (RRR = 0.45), and less likely to be never married (RRR = 0.52). Discussion and Implications We identified demographic, socioeconomic, geographic, and health care-related predictors of chronic multiyear opioid use. Our focus on individuals taking opioids for this extended duration is novel. Differences in opioid use by geographic region and frequency of doctor visits particularly warrant attention from policy-makers and researchers. We make additional recommendations based on a sensitivity analysis limited to 2016-2020 data.
Collapse
Affiliation(s)
- Gillian Fennell
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Mireille Jacobson
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, USA
| | | |
Collapse
|
24
|
Truong A, Yao L, Fleshner PR, Zaghiyan KN. Feasibility of opioid-free surgery for inflammatory bowel disease. Colorectal Dis 2023; 25:976-983. [PMID: 36718946 DOI: 10.1111/codi.16493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/16/2022] [Accepted: 01/01/2023] [Indexed: 02/01/2023]
Abstract
AIM Patients undergoing colorectal surgery or those with inflammatory bowel disease (IBD) are particularly at risk for opioid-related complications and progression to long-term opioid dependence. The aim of this work is to explore the real-world possibility of perioperative opioid avoidance in colorectal surgery and IBD. METHOD We conducted a retrospective analysis of patients aggregated from two prospective studies on multimodal postoperative pain control conducted at a single tertiary referral centre. All patients underwent major colorectal surgery with bowel resection. Patients with chronic preoperative opioid use were excluded. Opioid use was measured in oral morphine equivalents (OME) each postoperative day (POD) and cumulatively for the first 72 h. RESULTS Our cohort of 209 patients included 148 (71%) with IBD and 61 (29%) non-IBD patients. IBD patients required significantly more opioids cumulatively over the first 72 postoperative hours compared with non-IBD patients [median OME 77 mg (interquartile range 33-148 mg) vs. 4 mg (interquartile range 17-82 mg), respectively; p = 0.001]. Five percent of IBD patients achieved opioid-free postoperative pain control during the entire 72 h postoperative period compared with 12% of non-IBD patients. Only 7% of IBD patients avoided opioid use on POD 1 compared with 20% of non-IBD patients (p = 0.02); however the number of IBD patients increased to 16% on POD 2 then 40% on POD 3, closely resembling the non-IBD cohort at 49% (p = 0.22). CONCLUSION In the era of modern enhanced recovery protocols and minimally invasive techniques, we show that early postoperative opioid avoidance is feasible in a limited number of IBD patients after colorectal surgery.
Collapse
Affiliation(s)
- Adam Truong
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lucille Yao
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | |
Collapse
|
25
|
Ginsberg Z, Lindor RA, Campbell RL, Ghaith S, Buckner-Petty S, McElhinny ML. Return Rates for Opioid versus Nonopioid Management of Patients with Abdominal Pain in the Emergency Department. J Emerg Med 2023; 64:471-475. [PMID: 36997433 DOI: 10.1016/j.jemermed.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/27/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Research suggests that opioid treatment for abdominal pain, which comprises a large proportion of patients presenting to the emergency department (ED), may contribute to long-term opioid use without significant benefits with regard to symptom management. OBJECTIVES This study seeks to assess the association between opioid use for management of abdominal pain in the ED and return ED visits for abdominal pain within 30 days for patients discharged from the ED at initial presentation. METHODS We conducted a retrospective, multicenter observational study of adult patients presenting to and discharged from 21 EDs with a chief concern of abdominal pain between November 2018 and April 2020. The proportion of 30-day return visits to the ED for patients who received opioid analgesics was compared with a reference group of patients who only received acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or both. RESULTS Of the 4745 patients, 1304 (27.5%) received opioids and 1101 (23.2%) only received either acetaminophen, NSAIDs, or both. Among those given opioids, 287 (22.0%) returned to the ED for abdominal pain within 30 days, compared with 162 (14.7%) of those in the reference group (odds ratio 1.57, 95% confidence interval 1.27-1.95, p-value < 0.001). CONCLUSION Patients given opioids for abdominal pain in the ED had 57% increased odds of a return ED visit within 30 days compared with those given only acetaminophen or NSAIDs. This warrants further research on the use of nonopioid analgesics in the ED, especially in patients with anticipated discharge.
Collapse
Affiliation(s)
| | - Rachel A Lindor
- Department of Emergency Medicine, Mayo Clinic, Phoenix, Arizona
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Summer Ghaith
- Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Skye Buckner-Petty
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
| | - Megan L McElhinny
- Department of Emergency Medicine, Mayo Clinic, Phoenix, Arizona; Creighton University School of Medicine, Valleywise Medical Center, Phoenix, Arizona
| |
Collapse
|
26
|
Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022; 71:1-95. [PMID: 36327391 PMCID: PMC9639433 DOI: 10.15585/mmwr.rr7103a1] [Citation(s) in RCA: 438] [Impact Index Per Article: 219.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.
Collapse
|
27
|
Okun MM, Flamm A, Werley EB, Kirby JS. Hidradenitis Suppurativa: Diagnosis and Management in the Emergency Department. J Emerg Med 2022; 63:636-644. [PMID: 36243614 DOI: 10.1016/j.jemermed.2022.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 07/07/2022] [Accepted: 08/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hidradenitis suppurativa (HS) is a chronic immune-mediated inflammatory skin disease characterized by abscesses and inflammatory nodules, and occasionally tunnels and scars, in the axillae, groin, and inframammary areas. OBJECTIVE HS can be challenging to diagnose because it mimics localized soft-tissue infection. The process of differentiating HS from soft-tissue infection is discussed. Patients with HS frequently visit emergency departments (EDs) for acute management of pain and drainage from HS lesions. This review updates emergency and urgent care physicians on how to educate and initiate treatment for patients with HS, and to coordinate care with dermatologists and other physicians early in their disease course. DISCUSSION Recent updates on the epidemiology, diagnosis, and management of HS are reviewed. CONCLUSIONS Practice variations between how care for HS is provided in the ED setting and what HS treatment guidelines recommend are identified.
Collapse
Affiliation(s)
- Martin M Okun
- Department of Dermatology, Fort HealthCare, Fort Atkinson, Wisconsin
| | - Avram Flamm
- Department of Emergency Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Elizabeth Barrall Werley
- Department of Emergency Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Joslyn S Kirby
- Department of Dermatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| |
Collapse
|
28
|
Jones CMP, Lin CWC, Jamshidi M, Abdel Shaheed C, Maher CG, Harris IA, Patanwala AE, Dinh M, Mathieson S. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis. Ann Intern Med 2022; 175:1572-1581. [PMID: 36252245 DOI: 10.7326/m22-2162] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. PURPOSE To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. DATA SOURCES Electronic databases and registries from inception to 7 February 2022. STUDY SELECTION Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. DATA EXTRACTION Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. DATA SYNTHESIS Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics. LIMITATIONS Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. CONCLUSION The risk-benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit-risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42021275293).
Collapse
Affiliation(s)
- Caitlin M P Jones
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Masoud Jamshidi
- Department of Sports Physiology, University of Tehran, Tehran, Iran (M.J.)
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Sydney, New South Wales, Australia (I.A.H.)
| | - Asad E Patanwala
- Royal Prince Alfred Hospital, and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (A.E.P.)
| | - Michael Dinh
- Sydney Local Health District and The University of Sydney, Sydney, New South Wales, Australia (M.D.)
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| |
Collapse
|
29
|
Farkouh A, Hemetsberger M, Noe CR, Baumgärtel C. Interpreting the Benefit and Risk Data in Between-Drug Comparisons: Illustration of the Challenges Using the Example of Mefenamic Acid versus Ibuprofen. Pharmaceutics 2022; 14:pharmaceutics14102240. [PMID: 36297674 PMCID: PMC9609416 DOI: 10.3390/pharmaceutics14102240] [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: 09/14/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 12/02/2022] Open
Abstract
Evidence-based pain therapy should rely on precisely defined and personalized criteria. This includes balancing the benefits and risks not only of single drugs but often requires complex between-drug comparisons. Non-steroidal anti-inflammatory drugs (NSAIDs) have been available for several decades and their use is described in an abundance of guidelines. Most of these guidelines recommend that ‘the selection of a particular NSAID should be based on the benefit-risk balance for each patient’. However, head-to-head studies are often lacking or of poor quality, reflecting the lower standards for clinical research and regulatory approval at the time. The inconsistency of approved indications between countries due to national applications adds to the complexity. Finally, a fading research interest once drugs become generic points to a general deficit in the post-marketing evaluation of medicines. Far from claiming completeness, this narrative review aimed to illustrate the challenges that physicians encounter when trying to balance benefits and risks in a situation of incomplete and inconsistent data on longstanding treatment concepts. Ibuprofen and mefenamic acid, the most frequently sold NSAIDs in Austria, serve as examples. The illustrated principles are, however, not specific to these drugs and are generalizable to any comparison of older drugs in daily clinical practice.
Collapse
Affiliation(s)
- André Farkouh
- Department of Pharmaceutical Sciences, University of Vienna, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-664-3029922
| | | | - Christian R. Noe
- Department of Medicinal Chemistry, University of Vienna, 1090 Vienna, Austria
| | - Christoph Baumgärtel
- AGES Austrian Medicines and Medical Devices Agency, Austrian Federal Office for Safety in Health Care, 1200 Vienna, Austria
| |
Collapse
|
30
|
Abstract
Human feelings cannot be expressed on a numerical scale. There are no units of measurement for feelings. However, such data are extensively collected in the modern world—by governments, corporations, and international organizations. Why? Our study finds that a feelings integer (like my happiness is X out of 10) has more predictive power than a collection of socioeconomic influences. Moreover, there is a clear link between those feelings numbers and later get-me-out-of-here actions. Finally, the feelings-to-actions relationship appears replicable and not too far from linear. Remarkably, therefore, humans somehow manage to choose their numerical answers in a systematic way as though they sense within themselves—and can communicate—a reliable numerical scale for their feelings. How remains an unsolved puzzle. Human feelings measured in integers (my happiness is an 8 out of 10, my pain 2 out of 6) have no objective scientific basis. They are “made-up” numbers on a scale that does not exist. Yet such data are extensively collected—despite criticism from, especially, economists—by governments and international organizations. We examine this paradox. We draw upon longitudinal information on the feelings and decisions of tens of thousands of randomly sampled citizens followed through time over four decades in three countries (n = 700,000 approximately). First, we show that a single feelings integer has greater predictive power than does a combined set of economic and social variables. Second, there is a clear inverse relationship between feelings integers and subsequent get-me-out-of-here actions (in the domain of neighborhoods, partners, jobs, and hospital visits). Third, this feelings-to-actions relationship takes a generic form, is consistently replicable, and is fairly close to linear in structure. Therefore, it seems that human beings can successfully operationalize an integer scale for feelings even though there is no true scale. How individuals are able to achieve this is not currently known. The implied scientific puzzle—an inherently cross-disciplinary one—demands attention.
Collapse
|
31
|
Kay AB, White T, Baldwin M, Gardner S, Daley LM, Majercik S. Less Is More: A Multimodal Pain Management Strategy Is Associated With Reduced Opioid Use in Hospitalized Trauma Patients. J Surg Res 2022; 278:161-168. [DOI: 10.1016/j.jss.2022.04.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 03/22/2022] [Accepted: 04/13/2022] [Indexed: 01/09/2023]
|
32
|
Willingness to use nonpharmacologic treatments for musculoskeletal pain in the emergency department: a cross-sectional study. Pain Rep 2022; 7:e1027. [PMID: 35999902 PMCID: PMC9387978 DOI: 10.1097/pr9.0000000000001027] [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: 03/31/2022] [Revised: 06/06/2022] [Accepted: 06/25/2022] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Patients in emergency department with musculoskeletal pain report high willingness to try nonpharmacologic treatments, and health care provider encouragement correlated with greater nonpharmacologic treatment use. Objectives: Pain is an individual experience that should incorporate patient-centered care. This study seeks to incorporate patient perspectives toward expanding nonpharmacologic treatment options for pain from the emergency department (ED). Methods: In this cross-sectional study of adult patients in ED with musculoskeletal neck, back, or extremity pain, patient-reported outcomes were collected including willingness to try and prior use of various nonpharmacologic pain treatments, sociodemographics, clinical characteristics, functional outcomes, psychological distress, and nonmusculoskeletal symptoms. Least absolute shrinkage and selection operator regression identified variables associated with (1) willingness to try and (2) having previously tried nonpharmacologic treatments. Results: Responses were analyzed from 206 adults, with a mean age of 45.4 (SD 16.4) years. The majority (90.3%) of patients in ED were willing to try at least one form of nonpharmacologic pain treatment, with 70.4%, 81.6%, and 70.9% willing to try respective subcategories of active (eg, exercise), passive (eg, heat), and psychosocial (eg, prayer) modalities. Only 56.3% of patients had previously tried any, with 35.0%, 52.4%, and 41.3% having tried active, passive, and psychosocial modalities, respectively. Patient-level factors associated with willingness included pain in upper back, more severe pain-related symptoms, and functional impairments. The factor most consistently associated with treatment use was health care provider encouragement to do so. Conclusions: Patients in ED report high willingness to try nonpharmacologic treatments for pain. Higher pain severity and interference may indicate greater willingness, while health care provider encouragement correlated with treatment use. These findings may inform future strategies to increase the introduction of nonpharmacologic treatments from the ED.
Collapse
|
33
|
Ruskin D, Rasul R, McCann-Pineo M. Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults. Pediatr Emerg Care 2022; 38:e1409-e1416. [PMID: 35686972 PMCID: PMC9351695 DOI: 10.1097/pec.0000000000002777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE It is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach. METHODS We conducted a secondary analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2018. Visits where patients were aged 10 to 24 years were included. Predictors of ED-RX and DC-RX were identified via machine learning methods. Separate weighted logistic regressions were performed to determine the association between each predictor, and ED-RX and DC-RX, respectively. RESULTS There were 12,693 ED visits identified within the study time frame, with the majority being female (58.6%) and White (70.7%). Approximately 12.3% of all visits were administered an opioid during the ED visit, and 11.5% were prescribed one at discharge. For ED-RX, the strongest predictors were fracture injury (odds ratio [OR], 5.24; 95% confidence interval [CI], 3.73-7.35) and Southern geographic region (OR, 3.01; 95% CI, 2.14-4.22). The use of nonopioid analgesics significantly reduced the odds of ED-RX (OR, 0.46; 95% CI, 0.37-0.57). Fracture injury was also a strong predictor of DC-RX (OR, 5.91; 95% CI, 4.24-8.25), in addition to tooth pain (OR, 5.47; 95% CI, 3.84-7.69). CONCLUSIONS Machine learning methodologies were able to identify predictors of ED-RX and DC-RX, which can be used to inform ED prescribing guidelines and risk mitigation efforts among adolescents and young adults.
Collapse
|
34
|
De Cassai A, Zarantonello F, Geraldini F, Boscolo A, Pasin L, De Pinto S, Leardini G, Basile F, Disarò L, Sella N, Mariano ER, Pettenuzzo T, Navalesi P. Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis. Eur J Anaesthesiol 2022; 39:591-601. [PMID: 35759292 DOI: 10.1097/eja.0000000000001644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective. OBJECTIVES To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected. DESIGN Systematic review with network meta-analysis (PROSPERO:CRD42021250651). DATA SOURCE PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021). ELIGIBILITY CRITERIA All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction. RESULTS Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40). CONCLUSION All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone. TRIAL REGISTRATION PROSPERO (CRD4202125065).
Collapse
Affiliation(s)
- Alessandro De Cassai
- From the UOC Anesthesia and Intensive Care Unit, University Hospital of Padua (ADC, FZ, FG, AB, LP, TP, PN), UOC Anesthesia and Intensive Care Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy (SDP, GL, FB, LD, NS, PN), Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford (ERM) and Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA (ERM)
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Nichtopioidanalgetika im Notfall. Notf Rett Med 2022. [DOI: 10.1007/s10049-020-00822-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
36
|
Eidbo SA, Kropp Lopez AK, Hagedorn JD, Mathew V, Kaufman DE, Nichols SD, McCall KL, Piper BJ. Declines and regional variation in opioid distribution by U.S. hospitals. Pain 2022; 163:1186-1192. [PMID: 34510133 DOI: 10.1097/j.pain.0000000000002473] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/08/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT The United States is enduring a preventable opioid crisis, particularly involving a population being treated in a hospital setting, a subset of whom may escalate to illicit opioids. This project analyzed trends in distribution of opioids by hospitals in the United States. Opioids monitored included buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, powdered opium, remifentanil, and tapentadol. The Automation of Reports and Consolidated Orders System (ARCOS) reports on substances controlled by the Drug Enforcement Administration. National data from ARCOS reports 5 and 7 from 2000 to 2019 were used for an observational study on hospital opioid distribution. Morphine milligram equivalents (MMEs) were calculated using oral conversion factors. The MME per person per state was calculated to compare data from the peak year, 2012, with data from 2019. Opioid use peaked in 2012, with a -46.6% decline from 2012 to 2019. Half (25) of the states have seen a decrease of -50% or greater. Of the opioid compounds observed, buprenorphine has seen increased (+122.5%) hospital use from 2012 to 2019. All other opioids have been experiencing a decline (≥50%), particularly hydromorphone (-49.9%), oxymorphone (-57.7%), methadone (-58.7%), morphine (-66.9%), codeine (-67.5%), and meperidine (-77.6%). There was a 6-fold difference in population-corrected use of opioids in 2019 between the lowest (6.8 MME/person in New Jersey) and highest (Alaska = 39.6) states. This study demonstrates the considerable progress made thus far by hospitals in curbing the U.S. opioid crisis.
Collapse
Affiliation(s)
- Sarah A Eidbo
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | | | - Joseph D Hagedorn
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | - Varkey Mathew
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | - Daniel E Kaufman
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | | | | | - Brian J Piper
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States
- Center for Pharmacy Innovation and Outcomes, Forty Fort, PA, United States
| |
Collapse
|
37
|
Davis A, Fassassi C, Dove D, Drapkin J, Likourezos A, Gohel A, Favale P, Hossain R, Butt M, Gerges L, Motov S. Analgesic Efficacy of Oral Aspirin/Ketamine Combination for Management of Acute Musculoskeletal Pain in the Emergency Department - A Proof of Concept Pilot Study. J Emerg Med 2022; 62:750-759. [PMID: 35624056 DOI: 10.1016/j.jemermed.2022.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Musculoskeletal pain (MSK) affects one out of three adults and is the most common source of significant long-term pain, physical disability, and under-treatment in the emergency department (ED). OBJECTIVE We aimed to assess the analgesic efficacy of a combination of oral VTS-Aspirin® (Vitalis Analgesics, New York, NY) and ketamine in managing acute MSK pain in adult ED patients. METHODS This was a prospective, proof-of-concept, single-arm, pilot study evaluating the analgesic efficacy of a single dose of oral combination of VTS-Aspirin and ketamine in adult ED patients with acute moderate-to-severe MSK pain. The primary outcome included the difference in pain scores on an 11-point numeric pain rating scale at 60 min. Secondary outcomes included the need for rescue analgesia, the occurrence of adverse events at 60 min, and a change in pain scores at 120 min. RESULTS We enrolled 25 subjects in the study. The mean baseline pain score was 8.6 and the mean pain score at 60 min decreased to 4.8. The oral ketamine dose ranged from 24 mg to 50 mg, with a mean dose of 37.8 mg. No clinically concerning changes in vital signs were noted. No serious adverse events occurred in any of the subjects. Majority of adverse effects were transient and weak in intensity. CONCLUSION We demonstrated that administration of an oral combination of VTS-Aspirin and ketamine to adult ED patients with acute MSK pain resulted in clinically significant pain relief in 80% of enrolled subjects.
Collapse
Affiliation(s)
- Ashley Davis
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Catsim Fassassi
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Daniel Dove
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Jefferson Drapkin
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Antonios Likourezos
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Ankit Gohel
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, New York
| | - Patrizia Favale
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, New York
| | - Rukhsana Hossain
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Mahlaqa Butt
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Louis Gerges
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| |
Collapse
|
38
|
Medline A, Wham R, Kim G, Staley C, Steck A, Boissonneault A, Schenker ML. Opioid Prescribing Behavior in the Emergency Department During Routine Orthopedic Manipulations. Am Surg 2022:31348221091957. [PMID: 35522851 DOI: 10.1177/00031348221091957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The emergency department (ED) often represents the first exposure orthopedic trauma patients have to prescription opioids and thus a critical opportunity for prevention of potential long-term opioid use. This study will analyze the impact of opioid prescribing patterns among both ED providers and orthopedic surgery residents on the utilization of opioids during routine orthopedic trauma manipulations. MATERIALS AND METHODS This retrospective study reviewed opioid utilization among patients with an ankle or distal radius fracture at a large, urban, level 1 trauma center. Data on clinical providers, patient demographics, and injury severity score (ISS) were collected. Total opioid use was reported in oral morphine milligram equivalents (MME). Regression analyses were performed to determine how provider opioid prescribing intensity affected administered MME. RESULTS Five-hundred and ninety-five patients were included. The mean MME administered was 40.84 (SD 30.0) and was inversely associated with ISS (R = -.05; P = .40). Patients treated by a high-intensity ED prescriber had approximately three times higher odds of receiving over 40.84 MME (OR 2.8, 95% CI 1.33-5.90 P = .07). For those with an ISS score less than 15, the presence of a low-intensity orthopedic resident decreased the odds of receiving over 40.84 MME from 2.25 to 1.78 in the presence of a high-intensity ED prescriber. CONCLUSION For isolated orthopedic manipulations in the ED, involvement of a low-intensity prescribing orthopedic resident significantly decreased the quantity of opioids administered for those with lower ISS injuries, thus effectively mitigating the effect of high-intensity prescribing behavior prescriber.
Collapse
Affiliation(s)
- Alexandra Medline
- Department of Orthopaedics, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Robert Wham
- Department of Orthopaedics, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Grace Kim
- 160343Augusta University/ Medical College of Georgia, Atlanta, GA, USA
| | | | - Alaina Steck
- Department of Emergency Medicine, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Adam Boissonneault
- Department of Orthopaedics, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Mara L Schenker
- Department of Orthopaedics, 12239Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
39
|
Gerges L, Fassassi C, Barberan C, Correa S, Davis A, Drapkin J, Likourezos A, Silver M, Hossain R, Motov S. Oral VTS-Aspirin/ketamine versus oral ketamine for emergency department patients with acute musculoskeletal pain. Am J Emerg Med 2022; 58:298-304. [DOI: 10.1016/j.ajem.2022.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/12/2022] [Accepted: 05/15/2022] [Indexed: 11/25/2022] Open
|
40
|
Rech MA, Griggs C, Lovett S, Motov S. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med 2022; 58:57-65. [DOI: 10.1016/j.ajem.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 12/01/2022] Open
|
41
|
Warnecke T, Djuren O, Hinkelbein J, Mohrman C, Rosner B. Organisation und Durchführung der Schmerztherapie in deutschen Notaufnahmen – eine Onlineumfrage. Notf Rett Med 2022. [DOI: 10.1007/s10049-022-01030-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Einleitung
Obwohl Schmerzen der häufigste Grund für eine Vorstellung in der Notaufnahme sind, ist ihre Erfassung und Therapie sehr heterogen organisiert und wird vielfach von Patienten als unzureichend beschrieben. Eine spezielle Leitlinie existiert bislang nicht und so wird beispielsweise die Delegation an die Notfallpflege nach Standard Operating Procedure (SOP) sehr unterschiedlich gehandhabt.
Methode
Mithilfe einer Umfrage erfolgte eine Ist-Analyse zur Organisation und Durchführung der akuten Schmerztherapie in deutschen Notaufnahmen. 18 Fragen wurden onlinebasiert erstellt und über das Notaufnahmeverzeichnis der DGINA e. V. (Deutsche Gesellschaft für interdisziplinäre Notfall- und Akutmedizin) und DIVI e. V. (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) an die Leiter von 951 deutschen Notaufnahmen verschickt.
Ergebnis
Es konnten 166 vollständige Fragebögen ausgewertet werden. Die Erfassung der Schmerzen erfolgt bei 77,7 % der Notaufnahmen innerhalb der ersten 10 min nach Erstkontakt, meist mit der numerischen Rating-Skala (46,4 %). Obwohl 17,7 % nicht dauerhaft ärztlich besetzt sind, dürfen in insgesamt 32,5 % der Notaufnahmen Pflegekräfte keine eigenständige Schmerztherapie durchführen. Eine spezielle SOP gab es nur in 44,8 % der befragten Notaufnahmen. Die am häufigsten verwendeten Analgetika sind Piritramid und Morphin sowie Metamizol und Ibuprofen.
Schlussfolgerung
Eine entsprechende nationale Leitlinie könnte Handlungssicherheit geben und als Grundlage für angepasste, örtliche SOP helfen, Verzögerungen bei der akuten Schmerztherapie zu vermeiden.
Collapse
|
42
|
Abstract
Pain and related disability remain a major social and therapeutic problem. Comorbidities and therapies increase drug interactions and side effects making pain management more compounded especially in the elderly who are the fastest-growing pain population. Multimodal analgesia consists of using two or more drugs and/or techniques that target different sites of pain, increasing the level of analgesia and decreasing adverse events from treatment. Paracetamol enhances multimodal analgesia in experimental and clinical pain states. Strong preclinical evidence supports that paracetamol has additive and synergistic interactions with anti-inflammatory, opioid and anti-neuropathic drugs in rodent models of nociceptive and neuropathic pain. Clinical studies in young and adult elderly patients confirm the utility of paracetamol in multimodal, non-opioid or opioid-sparing, therapies for the treatment of acute and chronic pain.
Collapse
Affiliation(s)
- Ulderico Freo
- Anesthesiology & Intensive Medicine, Department of Medicine - DIMED, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| |
Collapse
|
43
|
Anne S, Mims JW, Tunkel D. In Response to: "Nonopioid Combination Formulations". Otolaryngol Head Neck Surg 2022; 166:791-792. [PMID: 35363585 DOI: 10.1177/01945998211027354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
44
|
Oliveira IS, Tomazoni SS, Vanin AA, Araujo AC, de Medeiros FC, Oshima RKA, Costa LOP, Costa LDCM. Management of acute low back pain in emergency departments in São Paulo, Brazil: a descriptive, cross-sectional analysis of baseline data from a prospective cohort study. BMJ Open 2022; 12:e059605. [PMID: 35365544 PMCID: PMC8977796 DOI: 10.1136/bmjopen-2021-059605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To describe management strategies used in public emergency departments in a middle-income country for patients with acute non-specific low back pain. DESIGN A descriptive, cross-sectional analysis of baseline data from a prospective cohort study. SETTING AND PARTICIPANTS A study with 600 patients with low back pain presenting in four public emergency departments from São Paulo, Brazil was conducted. OUTCOME MEASURES Diagnostic tests, pharmacological interventions, and/or referral to other healthcare professionals were collected. Descriptive analyses were used to report all outcomes. RESULTS Of all patients, 12.5% (n=75) underwent some diagnostic imaging tests. Medication was administered to 94.7% (n=568) of patients. The most common medications were non-steroidal anti-inflammatory drugs (71.3%; n=428), opioids (29%; n=174) and corticosteroids (22.5%; n=135). Only 7.5% (n=45) of patients were referred to another type of care. CONCLUSION There is a need for research data on low back pain from middle-income countries. There was an acceptable rate of prescription for diagnostic imaging tests. However, there were high medication prescriptions and small rates of referrals to other healthcare services. Our findings indicate that there is still a need to implement best practices in the management of acute low back pain at public emergency departments in Brazil.
Collapse
Affiliation(s)
- Indiara Soares Oliveira
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Shaiane Silva Tomazoni
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Adriane Aver Vanin
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Amanda Costa Araujo
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | | | | | | | | |
Collapse
|
45
|
Schaffer S, Bayat D, Biffl WL, Smith J, Schaffer KB, Dandan TH, Wang J, Snyder D, Nalick C, Dandan IS, Tominaga GT, Castelo MR. Pain management on a trauma service: a crisis reveals opportunities. Trauma Surg Acute Care Open 2022; 7:e000862. [PMID: 35402732 PMCID: PMC8948384 DOI: 10.1136/tsaco-2021-000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/08/2022] [Indexed: 11/07/2022] Open
Abstract
Objectives The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC). Methods Retrospective analysis of pain management at a level II trauma center for January–November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses. Results 208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin. Conclusions Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study. Level of evidence IV.
Collapse
Affiliation(s)
- Sabina Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Dunya Bayat
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jeffrey Smith
- Orthopedic Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Tala H Dandan
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jiayan Wang
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Deb Snyder
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Chris Nalick
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Imad S Dandan
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Gail T Tominaga
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Matthew R Castelo
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| |
Collapse
|
46
|
Chumpitazi CE, Chang C, Atanelov Z, Dietrich AM, Lam SH, Rose E, Ruttan T, Shahid S, Stoner MJ, Sulton C, Saidinejad M. Managing acute pain in children presenting to the emergency department without opioids. J Am Coll Emerg Physicians Open 2022; 3:e12664. [PMID: 35310402 PMCID: PMC8918119 DOI: 10.1002/emp2.12664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/12/2021] [Accepted: 01/03/2022] [Indexed: 02/06/2023] Open
Abstract
Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non‐pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.
Collapse
Affiliation(s)
- Corrie E. Chumpitazi
- Department of Pediatrics Division of Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital Houston Texas USA
| | - Cindy Chang
- Department of Pediatrics, Division of Emergency Medicine Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Zaza Atanelov
- North Florida Regional Medical Center Emergency Department HCA/University of Central Florida College of Medicine Consortium Florida USA
| | - Ann M. Dietrich
- Department of Pediatrics and Emergency Medicine University of South Carolina College of Medicine Greenville North Carolina USA
| | - Samuel Hiu‐Fung Lam
- Department of Emergency Medicine Sutter Medical Center Sacramento Sacramento California USA
| | - Emily Rose
- Keck School of Medicine of the University of Southern California Los Angeles California USA
| | - Tim Ruttan
- Dell Children's Medical Center, Department of Pediatrics The University of Texas at Austin Dell Medical School, US Acute Care Solutions Austin Texas USA
| | - Sam Shahid
- American College of Emergency Physicians Irving Texas USA
| | - Michael J. Stoner
- Nationwide Children's Hospital The Ohio State University College of Medicine Columbus Ohio USA
| | - Carmen Sulton
- Emory University School of Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Mohsen Saidinejad
- Department of Emergency Medicine Harbor UCLA Medical Center Torrance California USA
| | | |
Collapse
|
47
|
A Randomized, Placebo-Controlled Study of Intranasal Fentanyl as an Analgesic Adjunct For Incision and Drainage of Abscess. J Emerg Med 2022; 62:291-297. [PMID: 35067389 DOI: 10.1016/j.jemermed.2021.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/02/2021] [Accepted: 11/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Incision and drainage (I&D) of abscesses is one of the most painful procedures performed in emergency departments (EDs). OBJECTIVE We tested the following hypothesis: The addition of intranasal fentanyl to the standard practice of local infiltration with lidocaine would provide better pain control than lidocaine alone for adult ED patients undergoing I&D. METHODS This was a randomized, double-blind study. Participants received 2 μg/kg of intranasal fentanyl or a comparable amount of intranasal water in addition to local lidocaine infiltration. The primary outcome, which we assessed immediately after the I&D was completed, was a summary 0-10 pain score for which we asked study subjects to provide a number depicting their entire experience with the procedure. RESULTS During a 19-month enrollment period, we screened 176 patients for eligibility and enrolled 49; 25 received placebo and 24 received fentanyl. Baseline characteristics were comparable. Mean (standard deviation) summary pain scores were as follows: fentanyl 6.2 (3.3) and placebo 7.0 (3.2). The 95% confidence interval for a rounded between-group difference of 0.9 was -1.1 to 2.6. CONCLUSIONS In this small study, the addition of intranasal fentanyl did not substantially impact the pain scores of ED patients undergoing I&D.
Collapse
|
48
|
Sultan M, Hafez OM, Saleh MA. Quality assessment of lemon (Citrus aurantifolia, swingle) coated with self-healed multilayer films based on chitosan/carboxymethyl cellulose under cold storage conditions. Int J Biol Macromol 2022; 200:12-24. [PMID: 34973265 DOI: 10.1016/j.ijbiomac.2021.12.118] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/12/2021] [Accepted: 12/18/2021] [Indexed: 12/30/2022]
Abstract
The polyelectrolyte multilayer self-healing coating film of chitosan and carboxymethyl cellulose (PEM-SH) tended to maintain high sensory quality and control physiological and pathological decay of lemon fruits under cold storage. The PEM-SH film was characterized by ATR-IR, XRD, X-ray photoelectron spectroscopy, SEM analysis, swelling ratio, self-healing, and mechanical characteristics. The 3-layered film (3L) exhibited the optimum barrier properties; WVP: 3.32 ± 0.06 g. mm. k Pa-1.h-1.m-2 and GTR: 0.256 ± 0.032 cc.M-2.day-1. The moisture sorption isotherm data were fitted with BET, GAB, and Peleg models and three models showed applicability. The coated fruits exhibit superior features of fruit quality such as reduced weight loss %, respiration rate, and decay symptoms appearance. The 3L-coated fruit showed the lower pectinase enzyme activity (0.689 Ug-1 FW) up to 60 days. As well as, increased total soluble solids, keeping vitamin C of loss and decreasing percentage acidity of juice up to 60 days.
Collapse
Affiliation(s)
- Maha Sultan
- Packaging Materials, National Research Centre, 33 El Bohouth St. (former El Tahrir st.), Dokki, Giza P.O. 12622, Egypt
| | - Omaima M Hafez
- Pomology Departments, National Research Centre, 33 El Bohouth St. (former El Tahrir st.), Dokki, Giza P.O. 12622, Egypt
| | - Malaka A Saleh
- Pomology Departments, National Research Centre, 33 El Bohouth St. (former El Tahrir st.), Dokki, Giza P.O. 12622, Egypt
| |
Collapse
|
49
|
Feldman CA, Fredericks-Younger J, Lu SE, Desjardins PJ, Malmstrom H, Miloro M, Warburton G, Ward B, Ziccardi V, Fine D. The Opioid Analgesic Reduction Study (OARS)-a comparison of opioid vs. non-opioid combination analgesics for management of post-surgical pain: a double-blind randomized clinical trial. Trials 2022; 23:160. [PMID: 35177108 PMCID: PMC8851821 DOI: 10.1186/s13063-022-06064-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 01/29/2022] [Indexed: 12/01/2022] Open
Abstract
Background Everyday people die unnecessarily from opioid overdose-related addiction. Dentists are among the leading prescribers of opioid analgesics. Opioid-seeking behaviors have been linked to receipt of initial opioid prescriptions following the common dental procedure of third molar extraction. With each opioid prescription, a patient’s risk for opioid misuse or abuse increases. With an estimated 56 million tablets of 5 mg hydrocodone annually prescribed after third molar extractions in the USA, 3.5 million young adults may be unnecessarily exposed to opioids by dentists who are inadvertently increasing their patient’s risk for addiction. Methods A double-blind, stratified randomized, multi-center clinical trial has been designed to evaluate whether a combination of over-the-counter non-opioid-containing analgesics is not inferior to the most prescribed opioid analgesic. The impacted 3rd molar extraction model is being used due to the predictable severity of the post-operative pain and generalizability of results. Within each site/clinic and gender type (male/female), patients are randomized to receive either OPIOID (hydrocodone/acetaminophen 5/300 mg) or NON-OPIOID (ibuprofen/acetaminophen 400/500 mg). Outcome data include pain levels, adverse events, overall patient satisfaction, ability to sleep, and ability to perform daily functions. To develop clinical guidelines and a clinical decision-making tool, pain management, extraction difficulty, and the number of tablets taken are being collected, enabling an experimental decision-making tool to be developed. Discussion The proposed methods address the shortcomings of other analgesic studies. Although prior studies have tested short-term effects of single doses of pain medications, patients and their dentists are interested in managing pain for the entire post-operative period, not just the first 12 h. After surgery, patients expect to be able to perform normal daily functions without feeling nauseous or dizzy and they desire a restful sleep at night. Parents of young people are concerned with the risks of opioid use and misuse, related either to treatments received or to subsequent use of leftover pills. Upon successful completion of this clinical trial, dentists, patients, and their families will be better able to make informed decisions regarding post-operative pain management. Trial registration ClinicalTrials.govNCT04452344. Registered on June 20, 2020
Collapse
Affiliation(s)
- Cecile A Feldman
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA. .,School of Public Health, Rutgers University, 683 Hoes Lane, Piscataway, NJ, 08854, USA.
| | | | - Shou-En Lu
- School of Public Health, Rutgers University, 683 Hoes Lane, Piscataway, NJ, 08854, USA
| | - Paul J Desjardins
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
| | - Hans Malmstrom
- Eastman Institute for Oral Health, University of Rochester, 625 Elmwood Ave, Rochester, NY, 14620, USA
| | - Michael Miloro
- College of Dentistry, University of Illinois, 801 S Paulina St, Room 110 (MC 835), Chicago, IL, 60612, USA
| | - Gary Warburton
- School of Dentistry, University of Maryland, 650 W Baltimore St, Room 1209, Baltimore, MD, 2120, USA
| | - Brent Ward
- School of Dentistry, University of Michigan, 1515 E. Hospital Drive, Ann Arbor, MI, 48109, USA
| | - Vincent Ziccardi
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
| | - Daniel Fine
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
| |
Collapse
|
50
|
Atkins D, Bohnert ASB. The Work-Opioid Connection: What Do Construction Workers and Military Veterans Have in Common? Am J Public Health 2022; 112:S33-S35. [PMID: 35143275 PMCID: PMC8842203 DOI: 10.2105/ajph.2021.306663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 02/03/2023]
Affiliation(s)
- David Atkins
- David Atkins is with the Office of Research and Development, Department of Veterans Affairs, Washington, DC. Amy S. B. Bohnert is with the VA Center for Clinical Management Research, Ann Arbor, MI, and the Departments of Anesthesiology, Psychiatry, and Epidemiology, University of Michigan, Ann Arbor. Note. The opinions expressed in this editorial are those of the authors alone and do not reflect official policy of the Department of Veterans Affairs or any federal agency
| | - Amy S B Bohnert
- David Atkins is with the Office of Research and Development, Department of Veterans Affairs, Washington, DC. Amy S. B. Bohnert is with the VA Center for Clinical Management Research, Ann Arbor, MI, and the Departments of Anesthesiology, Psychiatry, and Epidemiology, University of Michigan, Ann Arbor. Note. The opinions expressed in this editorial are those of the authors alone and do not reflect official policy of the Department of Veterans Affairs or any federal agency
| |
Collapse
|