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Klimke R, Ott A, Romero CS, Berendes A, Urman RD, Luedi MM, Ashok V. Transitional Pain Service: An Update. Curr Pain Headache Rep 2024; 28:457-464. [PMID: 38530574 PMCID: PMC11156754 DOI: 10.1007/s11916-024-01239-1] [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] [Accepted: 03/12/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE OF REVIEW Chronic Postsurgical Pain (CPSP) and the risk for long-term opioid dependency are known complications following major surgery. The idea of Transitional Pain Service (TPS) has been introduced as an interdisciplinary setting to manage pain in the perioperative continuum. We expand on the basic framework and principles of TPS and summarize the current evidence of the TPS and possible interventions to adress postoperative pain. Areas of future work in TPS-related research are discussed. RECENT FINDINGS Several studies support the effectiveness of TPS in reducing opioid consumption in the perioperative period and following discharge. Some studies also show an improvement in functional outcome with TPS with patients reporting lower pain severity and pain interference. The TPS aims to halt the progress of acute postoperative pain to CPSP by providing longitudinal support with patient-centered care. While some studies suggest a positive impact of TPS implementation in terms of reduction in postoperative opioid consumption and improvement of some functional outcomes, direct evidence in terms of reduction in the incidence of CPSP is still missing. The cost-effectiveness of TPS and the expansion of TPS through e-health services and digital applications also need to be evaluated.
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Affiliation(s)
- Ruben Klimke
- Department of Anaesthesiology Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Alexander Ott
- Department of Anaesthesiology Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Carolina S Romero
- Department of Anaesthesiology and Critical Care, Hospital General Universitario de Valencia, Valencia, Spain
- Research Methods Department, Universidad Europea de Valencia, Valencia, Spain
| | - Andrea Berendes
- Center for Palliative Care Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Richard D Urman
- Department of Anaesthesiology, College of Medicine, The Ohio State University, Columbus, OH, 43210, United States of America
| | - Markus M Luedi
- Department of Anaesthesiology Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Vighnesh Ashok
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Patel J, Snyder K, Brooks AK. Perioperative pain optimization in the age of the opioid epidemic. Curr Opin Anaesthesiol 2024; 37:279-284. [PMID: 38573179 DOI: 10.1097/aco.0000000000001370] [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: 04/05/2024]
Abstract
PURPOSE OF REVIEW The opioid epidemic remains a constant and increasing threat to our society with overdoses and overdose deaths rising significantly during the COVID-19 pandemic. Growing evidence suggests a link between perioperative opioid use, postoperative opioid prescribing, and the development of opioid use disorder (OUD). As a result, strategies to better optimize pain management during the perioperative period are urgently needed. The purpose of this review is to summarize the most recent multimodal analgesia (MMA) recommendations, summarize evidence for efficacy surrounding the increased utilization of Enhanced Recovery After Surgery (ERAS) protocols, and discuss the implications for rising use of buprenorphine for OUD patients who present for surgery. In addition, this review will explore opportunities to expand our treatment of complex patients via transitional pain services. RECENT FINDINGS There is ample evidence to support the benefits of MMA. However, optimal drug combinations remain understudied, presenting a target area for future research. ERAS protocols provide a more systematic and targeted approach for implementing MMA. ERAS protocols also allow for a more comprehensive approach to perioperative pain management by necessitating the involvement of surgical specialists. Increasingly, OUD patients taking buprenorphine are presenting for surgery. Recent guidance from a multisociety OUD working group recommends that buprenorphine not be routinely discontinued or tapered perioperatively. Lastly, there is emerging evidence to justify the use of transitional pain services for more comprehensive treatment of complex patients, like those with chronic pain, preoperative opioid tolerance, or substance use disorder. SUMMARY Perioperative physicians must be aware of the impact of the opioid epidemic and explore methods like MMA techniques, ERAS protocols, and transitional pain services to improve the perioperative pain experience and decrease the risks of opioid-related harm.
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Affiliation(s)
- Janki Patel
- Department of Anesthesiology, Section on Pain Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Liu O, Leon D, Gough E, Hanna M, Jaremko K. A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service. Br J Clin Pharmacol 2024. [PMID: 38817150 DOI: 10.1111/bcp.16118] [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: 01/10/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
AIMS To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). METHODS This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. RESULTS Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). CONCLUSIONS Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.
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Affiliation(s)
- Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Leon
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Gough
- Department of Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Buys MJ, Anderson Z, Bayless K, Zhang C, Presson AP, Hales J, Brooke BS. Postsurgical opioid prescribing among veterans using community care for orthopedic surgery at non-VA hospitals compared to a VA hospital with a transitional pain service: a retrospective cohort study. Reg Anesth Pain Med 2024:rapm-2023-105162. [PMID: 38677883 DOI: 10.1136/rapm-2023-105162] [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: 11/15/2023] [Accepted: 04/17/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The USA provides medical services to its military veterans through Veterans Health Administration (VHA) medical centers. Passage of recent legislation has increased the number of veterans having VHA-paid orthopedic surgery at non-VHA facilities. METHODS We conducted a retrospective cohort study among veterans who underwent orthopedic joint surgery paid for by the VHA either at the Salt Lake City VHA Medical Center (VAMC) or at non-VHA hospitals between January 2018 and December 2021. 562 patients were included in the study, of which 323 used a non-VHA hospital and 239 patients the VAMC. The number of opioid tablets prescribed at discharge, the total number prescribed by postdischarge day 90, and the number of patients still filling opioid prescriptions between 90 and 120 days after surgery were compared between groups. RESULTS Veterans who underwent orthopedic surgery at a non-VHA hospital were prescribed more opioid tablets at discharge (median (IQR)); (40 (30-60) non-VHA vs 30 (20-47.5) VAMC, p<0.001) and in the first 90 days after surgery than patients who had surgery at the Salt Lake City VAMC (60 (40-120) vs 35 (20-60), p<0.001). Patients who had surgery at Salt Lake City VAMC were also significantly less likely to fill opioid prescriptions past 90 days after hospital discharge (OR (95% CI) 0.06 (0.01 to 0.48), p=0.007). CONCLUSION These results suggest that veterans who have surgery at a veterans affairs hospital with a transitional pain service are at lower risk for larger opioid prescriptions both at discharge and within 90 days after surgery as well as persistent opioid use beyond 90 days after discharge than if they have surgery at a community hospital.
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Affiliation(s)
- Michael Jacob Buys
- Department of Anesthesiology, University of Utah Health Hospitals and Clinics, Salt Lake City, Utah, USA
- Anesthesiology, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Zachary Anderson
- Anesthesiology, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Kimberlee Bayless
- Anesthesiology, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Chong Zhang
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Angela P Presson
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Julie Hales
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
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Manoharan D, Xie A, Hsu YJ, Flynn HK, Beiene Z, Giagtzis A, Shechter R, McDonald E, Marsteller J, Hanna M, Speed TJ. Patient Experiences and Clinical Outcomes in a Multidisciplinary Perioperative Transitional Pain Service. J Pers Med 2023; 14:31. [PMID: 38248732 PMCID: PMC10821325 DOI: 10.3390/jpm14010031] [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: 12/01/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Siloed pain management across the perioperative period increases the risk of chronic opioid use and impedes postoperative recovery. Transitional perioperative pain services (TPSs) are innovative care models that coordinate multidisciplinary perioperative pain management to mitigate risks of chronic postoperative pain and opioid use. The objective of this study was to examine patients' experiences with and quality of recovery after participation in a TPS. Qualitative interviews were conducted with 26 patients from The Johns Hopkins Personalized Pain Program (PPP) an average of 33 months after their first PPP visit. A qualitative content analysis of the interview data showed that participants (1) valued pain expectation setting, individualized care, a trusting patient-physician relationship, and shared decision-making; (2) perceived psychiatric treatment of co-occurring depression, anxiety, and maladaptive behaviors as critical to recovery; and (3) successfully sustained opioid tapers and experienced improved functioning after PPP discharge. Areas for improved patient-centered care included increased patient education, specifically about the program, continuity of care with pain specialists while tapering opioids, and addressing the health determinants that impede access to pain care. The positive patient experiences and sustained clinical benefits for high-risk complex surgical patient support further efforts to implement and adapt similar models of perioperative pain care.
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Affiliation(s)
- Divya Manoharan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Hannah K. Flynn
- Loyola College of Arts & Sciences, Loyola University Maryland, Baltimore, MD 21210, USA
| | - Zodina Beiene
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Alexandros Giagtzis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Ronen Shechter
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Eileen McDonald
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jill Marsteller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Traci J. Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
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Admiraal M, Hermanides J, Meinsma SL, Wartenberg HCH, Rutten MVH, Heine Y, Kallewaard JW, Hollmann MW, Hermanns H. The effectiveness of a transitional pain service in patients undergoing surgery with an increased risk of developing chronic postsurgical pain (TRUSt study). A randomized clinical trial. J Clin Anesth 2023; 91:111262. [PMID: 37722149 DOI: 10.1016/j.jclinane.2023.111262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023]
Abstract
STUDY OBJECTIVE Poorly controlled acute postsurgical pain is associated with delayed recovery, chronic postsurgical pain (CPSP), chronic opioid use and impaired functioning in daily activities. The aim was to determine the effectiveness of a transitional pain service (TPS) to improve quality of recovery for patients at risk of CPSP. We hypothesized that a TPS improves the quality of recovery in patients at risk of CPSP. DESIGN Single-center, pragmatic, randomized, superiority trial. SETTING Tertiary hospital in the Netherlands. PATIENTS Assessed for eligibility if ≥18 years of age, undergoing elective surgery, and had an increased risk of developing CPSP. After being stratified for sex, 176 patients were included. INTERVENTION Patients were randomized to receive TPS or standard of care (SOC). TPS was a multidisciplinary intervention providing a patient-tailored perioperative pain management plan, throughout all phases of surgery. MEASUREMENTS The primary outcome was the difference in quality of recovery on the third postoperative day, measured by the Quality of Recovery (QoR)-15 questionnaire. Secondary outcomes include the between group differences in opioid consumption. MAIN RESULTS The primary outcome was available in 169 (96.0%) patients. No difference between groups was found in QoR-15 on the third postoperative day (mean difference 2.0, 95% CI -5.5 to 9.4, p = 0.607). A decrease in opioid usage (compared to baseline) was observed in chronic opioid users, the median [IQR] reduction in total daily oral morphine milligram equivalents (MME) for TPS was -30 [-60, 0] at three and - 29.3 [-65.6, 0] at six months, whereas SOC had a median reduction of 0 [-56, 0] at three, and 0 [-60, 7.5] at six months. CONCLUSIONS TPS did not significantly affect short-term quality of recovery but might improve long-term outcomes, such as the incidence of chronic pain, opioid consumption, and functioning in daily life. However, sample size in the present study was too small to provide solid evidence for this positive signal.
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Affiliation(s)
- Manouk Admiraal
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Soe L Meinsma
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hans C H Wartenberg
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Martin V H Rutten
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Yvonne Heine
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Willem Kallewaard
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Anaesthesiology, Rijnstate Hospital, Velp, the Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Henning Hermanns
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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McCauley JL, Ward RC, Taber DJ, Basco WT, Gebregziabher M, Reitman C, Moran WP, Cina RA, Lockett MA, Ball SJ. Surgical prescription opioid trajectories among state Medicaid enrollees. J Opioid Manag 2023; 19:465-488. [PMID: 38189189 DOI: 10.5055/jom.0832] [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: 01/09/2024]
Abstract
OBJECTIVE The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy. DESIGN Retrospective cohort. SETTING Administrative claims data. PATIENTS AND PARTICIPANTS Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017. INTERVENTIONS None. MAIN OUTCOME MEASURES Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period. RESULTS More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported. CONCLUSIONS Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.
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Affiliation(s)
- Jenna L McCauley
- Addiction Science Division, Department of Psychiatry, The Medical University of South Carolina, Charleston, South Carolina. ORCID: https://orcid.org/0000-0001-8406-2329
| | - Ralph C Ward
- Public Health Sciences, The Medical University of South Carolina, Charleston, South Carolina
| | - David J Taber
- The Medical University of South Carolina, Charleston, South Carolina
| | - William T Basco
- The Medical University of South Carolina, Charleston, South Carolina
| | - Mulugeta Gebregziabher
- Public Health Sciences, The Medical University of South Carolina, Charleston, South Carolina
| | - Charles Reitman
- Department of Orthopaedics and Physical Medicine, The Medical University of South Carolina, Charleston, South Carolina
| | - William P Moran
- College of Medicine, The Medical University of South Carolina, Charleston, South Carolina
| | - Robert A Cina
- The Medical University of South Carolina, Charleston, South Carolina
| | - Mark A Lockett
- The Medical University of South Carolina, Charleston, South Carolina
| | - Sarah J Ball
- College of Medicine, The Medical University of South Carolina, Charleston, South Carolina
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Al-Saidi I, Russell A, Dizdarevic A. The Acute Perioperative Pain Service: Impact, Organization, and Future Directions. Curr Pain Headache Rep 2023; 27:399-405. [PMID: 37354296 DOI: 10.1007/s11916-023-01133-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE OF REVIEW The Acute Perioperative Pain Service has been established as a relatively new but important concept and service in clinical patient care. Many surgical institutions have dedicated inpatient acute pain services with variable compositions. This review aims to investigate the purpose, clinical and economic implications, and future direction of the Acute Perioperative Pain Service (APPS). RECENT FINDINGS There is growing evidence of the multiple benefits of a dedicated APPS, especially pertaining to patients at higher risk of poorly controlled postoperative pain. Healthcare providers furthermore realize the importance of the perioperative pain management continuity of care, consisting of preoperative pain evaluations and post-discharge follow-up in an outpatient pain management setting, in coordination with the primary teams. The Transitional Pain Service (TPS) has emerged as the next step in this evolution and has been successfully implemented at various medical centers. With the growing number of surgical procedures and the increasing complexity of the patient population, effective management of acute postoperative pain continues to be challenging, despite ongoing advances in clinical care, analgesic modalities, and research. The APPS is becoming the clinical standard of care for managing postoperative pain, and its role continues to expand worldwide.
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Affiliation(s)
- Ibrahim Al-Saidi
- Columbia University Irving Medical Center, New York, USA.
- NewYork-Presbyterian/Columbia Univ Med Ctr, 622 W 168th St, NY, PH5-133 10032, New York, USA.
| | - Alex Russell
- Columbia University Irving Medical Center, New York, USA
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Azizoddin DR, Wilson JM, Flowers KM, Beck M, Chai P, Enzinger AC, Edwards R, Miaskowski C, Tulsky JA, Schreiber KL. Daily pain and opioid administration in hospitalized patients with cancer: the importance of psychological factors, recent surgery, and current opioid use. Pain 2023; 164:1820-1827. [PMID: 36893325 PMCID: PMC10363176 DOI: 10.1097/j.pain.0000000000002880] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/26/2023] [Indexed: 03/11/2023]
Abstract
ABSTRACT Pain is common and variable in its severity among hospitalized patients with cancer. Although biopsychosocial factors are well established as modulators of chronic pain, less is known about what patient-level factors are associated with worse pain outcomes among hospitalized cancer patients. This prospective cohort study included patients with active cancer presenting to the emergency department (ED) with pain severity of ≥4/10 and followed pain outcomes longitudinally throughout hospital admission. Baseline demographic, clinical, and psychological factors were assessed on ED presentation, and daily average clinical pain ratings and opioid consumption during hospitalization were abstracted. Univariable and multivariable generalized estimating equation analyses examined associations of candidate biopsychosocial, demographic, and clinical predictors with average daily pain and opioid administration. Among 113 hospitalized patients, 73% reported pain as the primary reason for presenting to the ED, 43% took outpatient opioids, and 27% had chronic pain that predated their cancer. Higher pain catastrophizing ( B = 0.1, P ≤ 0.001), more recent surgery ( B = -0.2, P ≤ 0.05), outpatient opioid use ( B = 1.4, P ≤ 0.001), and history of chronic pain before cancer diagnosis ( B = 0.8, P ≤ 0.05) were independently associated with greater average daily pain while admitted to the hospital. Higher pain catastrophizing ( B = 1.6, P ≤ 0.05), higher anxiety ( B = 3.7, P ≤ 0.05), lower depression ( B = -4.9, P ≤ 0.05), metastatic disease ( B = 16.2, P ≤ 0.05), and outpatient opioid use ( B = 32.8, P ≤ 0.001) were independently associated with higher daily opioid administration. Greater psychological distress, especially pain catastrophizing, as well as pain and opioid use history, predicted greater difficulty with pain management among hospitalized cancer patients, suggesting that early assessment of patient-level characteristics may help direct consultation for more intensive pharmacologic and nonpharmacologic interventions.
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Affiliation(s)
- Desiree R. Azizoddin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jenna M. Wilson
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kelsey Mikayla Flowers
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
| | - Meghan Beck
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
| | - Peter Chai
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Fenway Health, Boston, MA
| | - Andrea C. Enzinger
- Harvard Medical School, Boston, MA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Edwards
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Christine Miaskowski
- Schools of Nursing and Medicine, University of California San Francisco, San Francisco, CA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kristin L. Schreiber
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Pasqualini I, Rullán PJ, Deren M, Krebs VE, Molloy RM, Nystrom LM, Piuzzi NS. Team Approach: Use of Opioids in Orthopaedic Practice. JBJS Rev 2023; 11:01874474-202303000-00008. [PMID: 36972360 DOI: 10.2106/jbjs.rvw.22.00209] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
» The opioid epidemic represents a serious health burden on patients across the United States. » This epidemic is particularly pertinent to the field of orthopaedics because it is one of the fields providing the highest volume of opioid prescriptions. » The use of opioids before orthopaedic surgery has been associated with decreased patient-reported outcomes, increased surgery-related complications, and chronic opioid use. » Several patient-level factors, such as preoperative opioid consumption and musculoskeletal and mental health conditions, contribute to the prolonged use of opioids after surgery, and various screening tools for identifying high-risk drug use patterns are available. » The identification of these high-risk patients should be followed by strategies aimed at mitigating opioid misuse, including patient education, opioid use optimization, and a collaborative approach between health care providers.
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Affiliation(s)
- Ignacio Pasqualini
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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11
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Buys MJ, Anderson Z, Bayless K, Zhang C, Presson AP, Hales J, Brooke BS. Postsurgical Opioid Use Among Veterans Discharged to Skilled Care Facilities Compared to Veterans Discharged to Home After Orthopedic Surgery. J Am Med Dir Assoc 2023; 24:258-262.e1. [PMID: 36436669 DOI: 10.1016/j.jamda.2022.10.016] [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: 08/18/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To compare opioid use patterns among Veterans who were discharged to a skilled care facility vs home after orthopedic surgery at a VA hospital. DESIGN We conducted a retrospective cohort study of Veterans who had orthopedic surgery at the Salt Lake City VA Medical Center (VAMC) between January 2018 and December 2021 and were followed by a transitional pain service. The principal outcome of interest was the time to stop opioid use after discharge from the hospital. SETTING AND PARTICIPANTS Veterans not already on chronic opioid therapy who had orthopedic surgery at the Salt Lake City VAMC and were followed by a transitional pain service. METHODS 448 patients were included in the study, of which 371 (83%) were discharged to home and 77 (17%) were discharged to a skilled care facility. Median days to opioid cessation were estimated using the Kaplan-Meier method with 95% CIs and compared with discharge disposition using a log-rank test. Time to opioid cessation following hospital discharge was compared to baseline characteristics using univariable and multivariable Cox proportional hazards models. RESULTS Patients who were discharged to a skilled care facility used opioids for twice as long as those who were discharged home [median days (interquartile range)]: 22 (19, 26) vs 11 (10, 12), P < .001, respectively. When controlling for baseline characteristics in the multivariable analysis, discharge to a skilled care facility was significantly associated with continued opioid use at all time points [hazard ratio 0.63 (95% CI 0.44, 0.89), P = .009]. CONCLUSIONS AND IMPLICATIONS Veterans discharged to a skilled care facility after orthopedic surgery used opioids for twice as long as those who were discharged to home. As postsurgical pain management guidelines change to focus on nonopioid pain modalities and opioid reduction, skilled care providers should adapt those strategies for their facilities.
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Affiliation(s)
- Michael J Buys
- Department of Anesthesiology, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Salt Lake City, UT, USA; Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Zachary Anderson
- Department of Anesthesiology, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Salt Lake City, UT, USA
| | - Kimberlee Bayless
- Department of Anesthesiology, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Salt Lake City, UT, USA
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, UT, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, UT, USA
| | - Julie Hales
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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Geller JS, Milner JE, Pandya S, Mohile NV, Massel DH, Eismont FJ, Maaieh MA. The Impact of the Florida Law HB21 on Opioid Prescribing Patterns After Spine Surgery. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2023; 14:100202. [PMID: 36970062 PMCID: PMC10034149 DOI: 10.1016/j.xnsj.2023.100202] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/18/2023]
Abstract
Background The opioid epidemic represents a major public health issue in the United States and has led to significant morbidity and mortality. On July 1 2018, Florida implemented state-law House Bill 21 (HB21), limiting opioid prescriptions to a 3-day supply for acute pain or 7 days if an exception is documented. The purpose of this study is to evaluate the effects of HB21 on opioid prescribing patterns after spine surgery. Methods Patients 18 years and older who underwent spine surgery between January 2017 and January 2021 were eligible for inclusion. Information including demographics, pills, days, and morphine milligram equivalents (MMEs) was obtained via retrospective chart review using the Florida Prescription Drug Monitoring Program and Epic Chart Review. Student's t tests and Fisher's exact tests were used for comparison of continuous variables. Multiple logistic regression was utilized to determine which variables were associated with postoperative opioid prescriptions. p<.05 was considered significant. Results We reviewed 114 patients who underwent spine surgery from January 2017 to July 2018 and 264 patients from July 2018 to January 21. There were no significant differences between the groups in age, sex, ethnicity, body mass index, number of levels fused, or preoperative opioid use. The average number of MMEs, pills prescribed and days in the first postoperative prescription decreased significantly after HB21. Multiple logistic regression revealed that the variable most predictive of MMEs and number of pills in the first postoperative prescription was postlaw status (p=.002, p=.50). Conclusions Florida law HB21 was successful in decreasing postoperative opioid prescriptions after spine surgery, however, the need for additional progress remains. Legislation should be combined with multimodal pain regimens, as well as patient and provider education in order to further decrease postoperative opioid requirements. Future studies should include a larger number of patients treated by multiple spine surgeons across multiple institutions in order to further evaluate the effects of HB21 on postoperative opioid prescriptions.
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Affiliation(s)
| | - Jacob E. Milner
- Corresponding author. 801 South Miami Ave, Unit 1901, Miami, FL 33130, USA. Tel.: (203) 927-7339.
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