Analgesic Efficacy and Tolerability of Intravenous Morphine Versus Combined Intravenous Morphine and Oxycodone in a 2-Center, Randomized, Double-Blind, Pilot Trial of Patients With Moderate to Severe Pain After Total Hip Replacement

[Opioids in primary total joint arthroplasty: Interpretation of 2020 AAHKS/ASRA/AAOS/THS/TKS clinical practice guidelines]

In 2020, the American Association of Hip and Knee Surgeons (AAHKS), the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Orthopaedic Surgeons (AAOS), the American Hip Society (THS), the American Knee Society (TKS) have worked together to develop clinical practice guidelines on the use of Opioids in primary total joint arthroplasty (TJA). This clinical practice guideline formulates recommendations for common and important questions related to the efficacy and safety of Opioids in primary TJA. This article interprets the guideline to help doctors make clinical decisions.

PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations

The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.

The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BACKGROUND

Opioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.

METHODS

The MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids.

RESULTS

Preoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness.

CONCLUSION

Moderate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.

A Scoping Review of Intravenous Opioid Pain Protocols and Their Dose-Time Intervals in the Management of Acute Postoperative Pain in the Postanesthesia Care Unit

PURPOSE

This review aims to explore intravenous opioid pain protocols and their dose-time intervals in managing acute postoperative pain in adults in the postanesthesia care unit (PACU).

DESIGN

A scoping review using a systematic search strategy.

METHODS

Sixteen articles were identified from MEDLINE, CINAHL, PubMed, Embase, and Cochrane specific to the aims.

FINDINGS

The literature demonstrated several variations on dose-time intervals used for opioid pain protocol administration globally. Furthermore, opioid analgesic pain protocols in the PACU appear to be effective in postoperative pain management. However, the literature did not identify optimal time intervals related to dose administration within these protocols.

CONCLUSIONS

Literature gaps were identified regarding the significance of dose-time intervals when using opioid analgesic pain protocols in the PACU.

Effects of Adding Oxycodone to Ropivacaine on Labor Analgesia: A Randomized Controlled Trial

BACKGROUND

It has been reported that oxycodone is superior to the other opioids for the treatment of visceral pain. During the first stage of labor, pain is mainly caused by uterine contractions (visceral pain). It seems that oxycodone is more suitable for labor analgesia. During this study, we investigated the effects of adding oxycodone to ropivacaine on epidural analgesia during labor.

MATERIALS AND METHODS

Eighty nulliparous parturients were randomly divided into 2 groups. Group A received 0.2 mg/mL oxycodone plus 0.1% ropivacaine for epidural analgesia and group C (control group) received 0.1% ropivacaine alone for epidural analgesia. The onset time and duration of analgesia, duration of labor stages, delivery outcome, analgesic effect, Bromage scores, blood pressure, heart rate, and neonatal Apgar scores were recorded. Umbilical arterial blood was collected to analyze. Side effects, if any, were also recorded.

RESULTS

The visual analog scale of pain was lower at 2 and 4 hours after analgesia and 10 cm cervical dilatation in group A compared with group C (P=0.021, 0.018, and 0.009, respectively). The onset time of analgesia was shorter in group A than that in group C (13.3±2.8 vs. 14.9±3.6 min, P=0.032). There were no significant differences between the 2 groups in terms of the duration of labor stages, delivery outcome, Bromage score, neonatal Apgar score, or umbilical arterial blood pH. The duration of analgesia was significantly longer in group A than in group C (326.2±56.5 vs. 68.4±10.5 min, P=0.000), but the incidence of pruritus was higher in group A than in group C (10% vs. 0%, P=0.115).

CONCLUSIONS

This study demonstrates that epidural oxycodone may accelerate the onset of analgesia and obviously prolong the duration of analgesia during labor without increasing adverse effects associated with the neonate. However, it may cause a higher incidence of maternal pruritus (registration number: ChiCTR1800016483).

Sublingual, transdermal and intravenous patient-controlled analgesia for acute post-operative pain: systematic literature review and mixed treatment comparison

OBJECTIVE

To conduct a systematic literature review (SLR) and quantitative analysis to assess the comparative efficacy and safety of the sufentanil sublingual tablet system (SSTS) against other available patient controlled analgesia (PCA) options for post-operative analgesia.

METHODS

An SLR was conducted for studies published between 2004 and 2016. Due to study heterogeneity, subgroup analyses were conducted controlling for differences in imputation methods for missing values, baseline pain severity, and type of surgery. Where sufficient data was available, a mixed treatment comparison (MTC) was performed.

RESULTS

The MTC and subgroup analyses used 13 studies. In direct meta-analysis, there was a statistically significant difference in favor of SSTS compared with intravenous (IV) PCA (morphine) at 24 hours for the patient global assessment (PGA) scores of "good" or "excellent". For the Pain Intensity Score, there were numerical but not statistically significant differences in favor of the SSTS versus IV PCA (morphine) and the patient controlled transdermal system (PCTS) (fentanyl) in the MTC at 6 hours (standardized mean difference -0.27 [credible interval -2.78, 2.09] and -0.36 [-3.89, 3.03], respectively). The onset of pain relief was earlier with the SSTS versus IV PCA (morphine) as shown by the Pain Intensity Difference. Likewise, the onset was earlier compared with PCTS (fentanyl) where data was available. There was a significant difference in favor of SSTS compared with IV PCA (morphine) and with PCTS (fentanyl) for any adverse event, and numerical improvements for withdrawals due to adverse events.

CONCLUSIONS

This meta-analysis shows that SSTS is an option for non-invasive management of moderate-to-severe post-operative pain which can be more effective, faster in onset and better tolerated than IV PCA (morphine) and PCTS (fentanyl).

Population Pharmacokinetics of Morphine in Patients With Nonalcoholic Steatohepatitis (NASH) and Healthy Adults

Altered expression and function of transporters in nonalcoholic steatohepatitis (NASH) patients may affect the pharmacokinetics (PK), efficacy, and safety of substrate drugs. A population pharmacokinetic (PopPK) analysis was performed to assess differences in morphine and morphine-3-glucuronide (M3G) disposition in NASH and healthy subjects. A total of 315 serum and 42 urine samples from 21 subjects (14 healthy; 7 NASH) were analyzed using NONMEM. Morphine and M3G PK were described by three- and one-compartment models, respectively. After accounting for the effect of total body weight on all clearance and volume of distribution parameters using an allometric scaling approach, NASH severity score (NASF; combination of fibrosis and nonalcoholic fatty liver disease activity scores) was the most significant predictor of differences in M3G exposure. The model predicted a linear decrease in the clearance of M3G with increasing NASF scores on a natural logarithmic scale. These results may provide some insight into the potential effect of NASH on the disposition of hepatic transporter substrates.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Efficacy and safety of dual opioid therapy

There is some evidence for a partial opioid switching or an 'add on' approach to opioid dosing strategies. Preclinical and clinical findings suggest different activation profiles for the stimulation of the mu subtypes, raising the questions about what might occur with combinations of these substances. In the postoperative setting, it seems that the analgesic effect of the combination at equivalent doses is similar to that produced by the individual components, not adding particular advantages. However, adverse effects seem to be reduced with the combination of morphine/oxycodone, when given in doses equianalgesic to individual opioids. The reduction of opioid-induced postoperative adverse effects may have important clinical implications, given that adverse effects may prolong length of stay and hospitalization costs. Thus, in the acute postoperative setting, a reduction of adverse effects may be expected. In chronic pain, information is still in the infancy, but opioid combination therapy may have greater advantages in improving the opioid response. The possibility to clinically translate opioid combinations into practice, as demonstrated in some animal models, depends on a broad number of factors implicated in the pain process. More research is needed to better elucidate these issues in the near future.