Non-Opioid Perioperative Pain Strategies for the Clinician: A Narrative Review

Methadone and Buprenorphine in the Perioperative Setting: A Review of the Literature

PURPOSE OF REVIEW

The purpose of this review is to highlight the most recent literature and guidelines regarding perioperative methadone and buprenorphine use.

RECENT FINDINGS

Surgical patients taking methadone and buprenorphine are being encountered more frequently in the perioperative period, and providers are becoming more familiar with their pharmacologic properties, benefits as well as precautions. Recommendations pertaining to buprenorphine therapy in the perioperative settings have changed in recent years, owing to more clinical and basic science research. In addition to their use in chronic pain and opioid use disorders, they can also be initiated for acute postoperative pain indications, in select patients and situations. Methadone and buprenorphine are being more commonly prescribed for pain management and opioid use disorder, and their continuation during the perioperative period is generally recommended, to reduce the risk of opioid withdrawal, relapse, or inadequately controlled pain. Additionally, both may be initiated safely and effectively for acute pain management during and after the operating room period.

Nonpharmacologic Therapies for Postoperative Pain in Cardiac Surgery: A Systematic Review

OBJECTIVES

To search for studies that address the efficacy of nonpharmacologic methods for pain relief in adults undergoing cardiac surgeries.

DESIGN

A systematic review registered in the International Prospective Register of Systematic Reviews (PROSPERO) under number CRD42020168681.

DATA SOURCE

PubMed, LILACS, CINAHL, the Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials.

REVIEW/ANALYSIS METHODS

The review used a PRISMA guideline that selected primary randomized controlled trials on the efficacy of nonpharmacologic pain relief therapies in patients undergoing cardiac surgery, with no time or language restrictions. The Joanna Briggs Institute Critical Appraisal Checklist for Randomized Clinical Trials was used to assess methodological rigor.

RESULTS

After screening, 23 of the 140 studies found in the databases were selected. The studies examined the efficacy of 13 different nonpharmacologic therapies, as well as a combination of therapies, with massage therapy being the most commonly examined, followed by musical intervention and hypnosis.

CONCLUSIONS

Some interventions, when combined with pharmacologic therapy, were effective in relieving postoperative pain after cardiac surgeries, according to the studies analyzed. However, most studies had significant methodological flaws, and further studies with high methodological quality are needed.

Analgesic effect of the ultrasound-guided thoracolumbar paravertebral block in patients undergoing robot-assisted laparoscopic nephrectomy: a randomized controlled trial

BACKGROUND

Paravertebral block has similar effect as epidural anesthesia, and has good somatic and visceral analgesic effect. Paravertebral block is widely used in thoracic surgery, but rarely used in abdominal surgery.

AIMS

This study aimed to evaluate the analgesic effect of thoracolumbar paravertebral block in patients undergoing robot-assisted laparoscopic nephrectomy.

METHODS

One hundred patients undergoing elective robot-assisted laparoscopic nephrectomy were included in this study. Based on whether the thoracolumbar paravertebral block was performed, the patients were randomly divided into the thoracolumbar paravertebral block combined with general anesthesia group (TL-PVB group) and simple general anesthesia group (NO-PVB group). Oxycodone was administered for patient-controlled intravenous analgesia (PCIA). The primary outcomes included the amount of remifentanil used during surgery, the amount of oxycodone used in 24 and 48 h after surgery. Secondary outcomes included the changes of heart rate (HR) and mean arterial pressure (MAP), time for the first analgesia administration, visual analog score (VAS) of pain during rest and movement, and time of postoperative recovery.

RESULTS

Compared to the NO-PVB group, the amount of remifentanil used during surgery in patients with TL-PVB group was significantly reduced (1.78 ± 0.37 mg vs. 3.09 ± 0.48 mg, p < 0.001), the amount of oxycodone used 24 h after surgery was significantly reduced (8.70 ± 1.70 mg vs. 13.79 ± 2.74 mg, p < 0.001), and the amount of oxycodone used 48 h after surgery was remarkably reduced (21.83 ± 4.28 mg vs. 27.27 ± 4.76 mg, p < 0.001). There were significant differences in the changes of HR and MAP between the two groups (p < 0.001). The first analgesic requirement time of TL-PVB group was significantly longer than that of NO-PVB group (468.56 ± 169.60 min vs. 113.48 ± 37.26 min, p < 0.001). The postoperative VAS during rest and movement of TL-PVB group were significantly lower than that of NO-PVB group (p < 0.01). Compared with NO-PVB group, patients in TL-PVB group needed shorter time to awaken from anesthesia, leave the operating room, anal exhaust, get out of bed, and had shorter length of postoperative hospital stay (p < 0.001). The incidence of postoperative adverse reactions were lower in the TL-PVB group than that in the NO-PVB group (p < 0.05).

CONCLUSIONS

Ultrasound-guided thoracolumbar paravertebral block significantly reduces intraoperative and postoperative opioid consumption, and provides better analgesia in patients undergoing robot-assisted laparoscopic nephrectomy, which is a recommendable combined anesthesia technique.

TRIAL REGISTRATION

ChiCTR2200061326, 21/06/2022.

Acute Pain Management Pearls: A Focused Review for the Hospital Clinician

Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.

Harnessing the benefits of yoga for myositis, muscle dystrophies, and other musculoskeletal disorders

The recent global increase in popularity of home-based yoga, an ancient Indian technique practiced for thousands of years, has translated into its use as a complementary therapy for a multitude of ailments. This review aims to examine the published literature regarding the effects of yoga therapy on systemic chronic diseases; in particular on the inflammatory myopathies (IMs) and other muscle disorders.

Despite the fact that the evidence base for yoga in inflammatory myositis is in its infancy, collateral results in other disorders such as muscular dystrophies are promising. A beneficial effect of yoga in chronic pain has been shown alongside an improvement in motor function and muscle strength. Patients with Duchenne muscular dystrophy with respiratory involvement may find improvement in lung function. Elderly patients may experience reduction in falls secondary to an improvement in balance while practicing long-term yoga therapy.

Further benefits are improving disorders of mental health such as depression and anxiety. A reported improvement in overall quality of life further suggests its efficacy in reducing morbidity in patients with chronic diseases, who often suffer co-existent psychological comorbidities.

The effectiveness of acupuncture point stimulation for the prevention of postoperative sore throat: A meta-analysis

BACKGROUND

Enhanced recovery pathways can be further improved for postoperative sore throat (POST) that occurs after surgery under general anesthesia. Medications have shown some effectiveness in preventing POST, but acupuncture or related techniques with better safety and lower cost can be used as an alternative or adjuvant therapy to treat perioperative symptoms by stimulating acupuncture point (acupoint). Therefore, we aimed to conduct a meta-analysis to assess whether acupoint stimulation helps patients prevent POST in adults undergoing tracheal intubation for general anesthesia.

METHODS

Publications in PubMed, the Cochrane Central Register, ScienceDirect, and ClinicalTrial.gov were surveyed from January 2000 through August 2020. Studies that compared interventions between true acupoint stimulation and no or sham acupoint stimulation were included. The primary outcomes were the incidence and severity of POST at 24h.

RESULTS

Four randomized control trials and 1 comparative study involving 1478 participants were included. Compared with the no or sham acupoint stimulation, the true acupoint stimulation was associated with a reduced incidence (risk ratio, 0.32; 95% confidence interval (CI), 0.18-0.55; P < .001) and decreased severity (standardized mean difference, -2.79; 95% CI, -4.59 to - 0.99; P = .002) of POST. There were no significant adverse events related to acupoint stimulation. The finding for POST was assured by subgroup, sensitivity, and trial sequential analyses.

CONCLUSIONS

Acupoint stimulation may reduce the occurrence of POST. It can be considered as one of nonpharmacological methods to prevent POST in enhanced recovery pathways. Further rigorous studies are needed to determine the effectiveness of acupoint stimulation.

Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis

Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers' capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives.

Comparative evaluation of analgesic efficacy of buprenorphine transdermal patch and fentanyl patch in management of postoperative pain after arthroscopic lower limb surgery: A randomized controlled trial

Background and Aims

Transdermal opioids are newer modality in use for the control of postoperative pain, because of its noninvasiveness, longer duration of action, sustained blood levels, and with minimal side effects. The study was aimed to evaluate the efficacy of analgesia of buprenorphine patch 10, 20 μg·h^-1 and fentanyl patch 25 μg·h^-1 for relief of pain in the postoperative period in patients undergoing arthroscopic lower limb surgeries.

Materials and Methods

It was a randomized, double-blinded, prospective study in which adult patients undergoing lower limb arthroscopic surgery were randomly segregated into three groups. In Group 1 (fentanyl patch 25 μg·h^-1), Group 2 (buprenorphine patch 10 μg·h^-1), and Group 3 (buprenorphine patch 20 μg·h^-1), transdermal patches were applied 12 h prior to surgery. Mean NRS score, total rescue analgesic requirement, drug-related adverse effects, and hemodynamic status were evaluated till 72 h in the postoperative period.

Results

Out of 175 screened patients, 150 patients were finally analyzed. Baseline characteristics were the same among all the three groups. Median NRS score was lowest in Group 3 [P value < 0.05 at 2, 4, 8, 12, and 24 h after surgery (Kruskal Wallis test). The total consumption of postoperative rescue analgesic diclofenac was the lowest in Group 3 as compared to other groups without any significant increase in adverse events.

Conclusions

In arthroscopic lower limb surgery, buprenorphine patch (20 μg·h^-1) applied 12 h prior to surgery is an effective postoperative analgesic and it is not associated with any significant adverse effects.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.