1
|
Wiesenberger R, Müller J, Kaufmann M, Weiß C, Ghezel-Ahmadi D, Hardt J, Reissfelder C, Herrle F. Influence of motivational interviewing on postoperative mobilization in the enhanced recovery after surgery (ERAS®) pathway in elective colorectal surgery - a randomized patient-blinded pilot study. Langenbecks Arch Surg 2024; 409:134. [PMID: 38644386 PMCID: PMC11033226 DOI: 10.1007/s00423-024-03321-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: 11/21/2023] [Accepted: 04/10/2024] [Indexed: 04/23/2024]
Abstract
PURPOSE Early mobilization is an essential component of the Enhanced Recovery after Surgery (ERAS®)-pathway. However, a large percentage of patients fail to achieve the ERAS® recommended goal (360 min out of bed from post-operative day 1/POD1). Motivational Interviewing (MI) is an evidence-based type of patient-centered consultation to promote intrinsic motivation. This study aims to evaluate if MI can improve postoperative mobilization. METHODS This two-arm, patient-blinded pilot randomized controlled trial included ERAS®-patients undergoing elective bowel resections. Conversations were validated by MI Treatment Integrity. Two validated motion sensors (movisens) and self-assessments were used to measure mobilization (POD1-POD3: Time out of bed, time on feet and step count). RESULTS 97 patients were screened, 60 finally included and randomized. Cumulatively across POD1-3, the intervention group (IG) was longer out of bed than the control group (CG) (median: 685 vs. 420 min; p=0.022). The IG achieved the ERAS®-goal of 360 min/day more frequently across POD1-3 (27.4% vs. 10.61%; p=0.013). Time on feet was 131.5 min/day (median per POD) in IG vs. 95.8 min/day in the CG (p=0.212), step count was 1347 in IG vs. 754 steps/day in CG (p=0.298). CONCLUSION MI could be conducted low threshold and was well accepted by patients. MI can improve mobilization in the context of ERAS®. Despite better performance, it should be noted that only 27.4% of the IG reached the ERAS®-compliance goal of 360 min/day. The findings of this pilot study stipulate to further test the promising perioperative effects of MI within a multicenter superiority trial. REGISTRATION This study was registered prospectively in the German Clinical Trials Register on 25.02.2022. Trial registration number is "DRKS00027863".
Collapse
Affiliation(s)
- Rico Wiesenberger
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Julian Müller
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Mario Kaufmann
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christel Weiß
- Institute for Medical Statistics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - David Ghezel-Ahmadi
- Department of Anaesthesiology and Critical Care Medicine, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Julia Hardt
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
| | - Florian Herrle
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| |
Collapse
|
2
|
Madden K, Pallapothu S, Young Shing D, Adili A, Bhandari M, Carlesso L, Khan M, Kleinlugtenbelt YV, Krsmanovic A, Nowakowski M, Packham T, Romeril E, Tarride JE, Thabane L, Tushinski DM, Wallace C, Winemaker M, Shanthanna H. Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty. Pilot Feasibility Stud 2024; 10:30. [PMID: 38360686 PMCID: PMC10868001 DOI: 10.1186/s40814-024-01457-9] [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: 01/26/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA. METHODS This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use. DISCUSSION The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making. TRIAL REGISTRATION Prospectively registered in Clinicaltrials.gov (NCT04968132).
Collapse
Affiliation(s)
- Kim Madden
- Department of Surgery, McMaster University, Hamilton, Canada.
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada.
- Department of Health Research Methods, McMaster University, Hamilton, Canada.
| | | | | | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Lisa Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Moin Khan
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Adrijana Krsmanovic
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Matilda Nowakowski
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Tara Packham
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Eric Romeril
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Jean-Eric Tarride
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
- Center for Health Economics and Policy Analyses, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Daniel M Tushinski
- Department of Surgery, McMaster University, Hamilton, Canada
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Christine Wallace
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Harsha Shanthanna
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
| |
Collapse
|
3
|
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.
Collapse
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.)
| |
Collapse
|
4
|
Hah JM, Vialard JDV, Efron B, Mackey SC, Carroll IR, Amanatullah DF, Narasimhan B, Hernandez-Boussard T. Preoperative Versus Perioperative Risk Factors for Delayed Pain and Opioid Cessation After Total Joint Arthroplasty: A Prospective Cohort Study. Pain Ther 2023; 12:1253-1269. [PMID: 37556071 PMCID: PMC10444739 DOI: 10.1007/s40122-023-00543-9] [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: 05/18/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION The evolution of pre- versus postoperative risk factors remains unknown in the development of persistent postoperative pain and opioid use. We identified preoperative versus comprehensive perioperative models of delayed pain and opioid cessation after total joint arthroplasty including time-varying postoperative changes in emotional distress. We hypothesized that time-varying longitudinal measures of postoperative psychological distress, as well as pre- and postoperative use of opioids would be the most significant risk factors for both outcomes. METHODS A prospective cohort of 188 patients undergoing total hip or knee arthroplasty at Stanford Hospital completed baseline pain, opioid use, and emotional distress assessments. After surgery, a modified Brief Pain Inventory was assessed daily for 3 months, weekly thereafter up to 6 months, and monthly thereafter up to 1 year. Emotional distress and pain catastrophizing were assessed weekly to 6 months, then monthly thereafter. Stepwise multivariate time-varying Cox regression modeled preoperative variables alone, followed by all perioperative variables (before and after surgery) with time to postoperative opioid and pain cessation. RESULTS The median time to opioid and pain cessation was 54 and 152 days, respectively. Preoperative total daily oral morphine equivalent use (hazard ratio-HR 0.97; 95% confidence interval-CI 0.96-0.98) was significantly associated with delayed postoperative opioid cessation in the perioperative model. In contrast, time-varying postoperative factors: elevated PROMIS (Patient-Reported Outcomes Measurement Information System) depression scores (HR 0.92; 95% CI 0.87-0.98), and higher Pain Catastrophizing Scale scores (HR 0.85; 95% CI 0.75-0.97) were independently associated with delayed postoperative pain resolution in the perioperative model. CONCLUSIONS These findings highlight preoperative opioid use as a key determinant of delayed postoperative opioid cessation, while postoperative elevations in depressive symptoms and pain catastrophizing are associated with persistent pain after total joint arthroplasty providing the rationale for continued risk stratification before and after surgery to identify patients at highest risk for these distinct outcomes. Interventions targeting these perioperative risk factors may prevent prolonged postoperative pain and opioid use.
Collapse
Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA.
- , 1070 Arastradero Rd., Suite 200, Palo Alto, CA, 94304, USA.
| | - Julien D Veron Vialard
- Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA
| | - Bradley Efron
- Departments of Statistics, Stanford University, Stanford, CA, USA
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Ian R Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | | | - Balasubramanian Narasimhan
- Departments of Statistics, Stanford University, Stanford, CA, USA
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Tina Hernandez-Boussard
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Department of Medicine, Stanford University, Stanford, CA, USA
- Department of Surgery, Stanford University, Stanford, CA, USA
| |
Collapse
|
5
|
Uhrbrand PG, Rasmussen MM, Haroutounian S, Nikolajsen L. An individualised tapering protocol reduces opioid use 1 year after spine surgery: A randomised controlled trial of patients with preoperative opioid use. Acta Anaesthesiol Scand 2023; 67:1085-1090. [PMID: 37203222 DOI: 10.1111/aas.14266] [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: 11/24/2022] [Revised: 04/01/2023] [Accepted: 04/28/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Persistent opioid use following surgery is common especially in patients with preoperative opioid use. This study aims to determine the long-term effect of an individualised opioid tapering plan versus standard of care in patients with a preoperative opioid use undergoing spine surgery at Aarhus University Hospital, Denmark. METHODS This is the 1-year follow-up of a prospective, single-centre, randomised trial of 110 patients who underwent elective spine surgery for degenerative disease. The intervention was an individualised tapering plan at discharge and telephone counselling 1 week after discharge, compared to standard of care. Postoperative outcomes after 1 year include opioid use, reasons for opioid use and pain intensity. RESULTS The overall response rate to the 1-year follow-up questionnaire was 94% (intervention group 52/55 patients and control group 51/55 patients). Forty-two patients (proportion = 0.81, 95% CI 0.67-0.89) in the intervention group compared to 31 (0.61, 95% CI 0.47-0.73; p = .026) patients in the control group succeeded in tapering to zero 1 year after discharge (p = .026). One patient (0.02, 95% CI 0.01-0.13) in the intervention group compared to seven patients (0.14, 95% CI 0.07-0.26) in the control group were unable to taper to their preoperative dose 1 year after discharge (p = .025). Back/neck and radicular pain intensity was similar between study groups. CONCLUSION These results suggest that an individualised tapering plan at discharge combined with telephone counselling 1 week after discharge can reduce opioid use 1 year after spine surgery.
Collapse
Affiliation(s)
- Peter Gaarsdal Uhrbrand
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mikkel Mylius Rasmussen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Simon Haroutounian
- Department of Anaesthesiology, Washington University, St. Louis, Missouri, USA
| | - Lone Nikolajsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
6
|
Huon JF, Nizet P, Caillet P, Lecompte H, Victorri-Vigneau C, Fournier JP. Evaluation of the effectiveness of a joint general practitioner-pharmacist intervention on the implementation of benzodiazepine deprescribing in older adults (BESTOPH-MG trial): protocol for a cluster-randomized controlled trial. Front Med (Lausanne) 2023; 10:1228883. [PMID: 37711743 PMCID: PMC10498124 DOI: 10.3389/fmed.2023.1228883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/15/2023] [Indexed: 09/16/2023] Open
Abstract
Background Deprescribing benzodiazepines and related drugs (BZDR) is a challenge due to a lack of time on physicians' part, a lack of involvement of other health professionals, and the need for adapted tools. This study is based on primary care collaboration, by evaluating the effectiveness of a joint intervention between general practitioners and community pharmacists on the implementation of BZDR deprescribing in older adults. Methods This is a cluster randomized controlled trial in which each cluster will be formed by a physician-pharmacist pair. Within a cluster allocated to the intervention, the pharmacist will be trained in motivational interviewing (MI), and will offer the patient 3 interviews after inclusion by the physician. They will base their intervention on validated deprescribing guidelines. The pharmacist will receive methodological support during the first interviews. Interprofessional collaboration will be encouraged by writing reports for the physician after each interview. The following implementation outcomes will be evaluated: acceptability/adoption, appropriateness, cost, and fidelity. They will be measured by means of sociological interviews, observations, logbooks, and cost-utility analysis. Focus groups with physicians and pharmacists will be carried out to identify levers and barriers experienced in this collaboration. Observations will be conducted with pharmacists to assess their approach of the MIs. Effectiveness outcomes will be based on medication (discontinuation or reduction of BZDR) and clinical outcomes (such as quality of life, insomnia or anxiety), assessed by health insurance databases and validated questionnaires. Discussion This study will determine whether collaboration in primary care between physicians and pharmacists, as well as training and coaching of pharmacists in motivational interviewing, allows the implementation of BZDR deprescribing in the older adults.This study will provide an understanding of the processes used to implement deprescribing guidelines, and the contribution of collaborative practice in implementing BZDR discontinuation. The cluster methodology will allow to assess the experience of the relationship between the different primary care actors, and the related obstacles and levers.The results obtained will make it possible to produce guidelines on the involvement of community pharmacists in the management of substance abuse in older adults, or even to legislate new missions or care pathways. Clinical trial registration ClinicalTrials.gov, identifier, NCT05765656.
Collapse
Affiliation(s)
- Jean-François Huon
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, Nantes, France
- Nantes Université, CHU Nantes, Pharmacie, Nantes, France
| | - Pierre Nizet
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, Nantes, France
- Nantes Université, CHU Nantes, Pharmacie, Nantes, France
| | - Pascal Caillet
- Public Health Department, Nantes Université, CHU Nantes, Nantes, France
| | - Hélène Lecompte
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, Nantes, France
| | - Caroline Victorri-Vigneau
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, Nantes, France
- Centre d'évaluation et d'information sur la Pharmacodépendance-Addictovigilance, CHU Nantes, Nantes, France
| | - Jean-Pascal Fournier
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, Nantes, France
- Département de Médecine Générale, Université de Nantes, Nantes, France
| |
Collapse
|
7
|
Nizet P, Evin A, Brociero E, Vigneau CV, Huon JF. Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review. BMC Geriatr 2023; 23:428. [PMID: 37438697 DOI: 10.1186/s12877-023-04155-y] [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: 04/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.
Collapse
Affiliation(s)
- Pierre Nizet
- Nantes Université, CHU Nantes, 44000, Pharmacie, France.
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France.
| | - Adrien Evin
- Nantes Université, CHU Nantes, Service de Soins Palliatifs Et de Support, 44000, Nantes, France
| | - Emma Brociero
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
| | - Caroline Victorri Vigneau
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
| |
Collapse
|
8
|
Sandbrink F, Murphy JL, Johansson M, Olson JL, Edens E, Clinton-Lont J, Sall J, Spevak C. The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med 2023; 176:388-397. [PMID: 36780654 DOI: 10.7326/m22-2917] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
DESCRIPTION In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. This synopsis summarizes the recommendations that the authors believe are the most important to highlight. METHODS In December 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The guideline development team included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline team developed key questions to guide a systematic evidence review that was done by an independent third party and distilled 20 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The guideline team also created 3 one-page algorithms to help guide clinical decision making. This synopsis presents the recommendations and highlights selected recommendations on the basis of clinical relevance. RECOMMENDATIONS This guideline is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain. This synopsis reviews updated recommendations for the initiation and continuation of opioid therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. New additions are highlighted, including recommendations about the use of buprenorphine instead of full agonist opioids; assessing for behavioral health conditions and factors associated with higher risk for harm, such as pain catastrophizing; and the use of pain and opioid education to reduce the risk for prolonged opioid use for postsurgical pain.
Collapse
Affiliation(s)
- Friedhelm Sandbrink
- National Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, Veterans Health Administration, Washington DC VA Medical Center, and Department of Neurology, George Washington University, Washington, DC (F.S.)
| | - Jennifer L Murphy
- Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, Veterans Health Administration, Washington, DC (J.L.M.)
| | - Melanie Johansson
- Walter Reed National Military Medical Center, Bethesda, Maryland (M.J.)
| | | | - Ellen Edens
- Opioid Reassessment Clinic, Yale Addiction Psychiatry Service, National TeleMental Health Center, VA Connecticut Healthcare System, West Haven, Connecticut (E.E.)
| | | | - James Sall
- Evidence Based Practice, Quality and Patient Safety, Veterans Health Administration, Washington, DC (J.S.)
| | | |
Collapse
|
9
|
Complete opioid cessation after surgery improves patient-reported pain measures among chronic opioid users. Surgery 2022; 172:943-948. [PMID: 35688743 DOI: 10.1016/j.surg.2022.04.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Preoperative chronic opioid use is common, but it is unclear whether complete opioid tapering can be achieved postoperatively without adversely affecting pain control and quality of life. This study was designed to assess the association between complete opioid tapering after surgery and patient-reported outcomes for pain intensity and pain interference. METHODS We identified chronic opioid use patients undergoing a spectrum of nonemergency surgical procedures at a single Veterans Affairs medical institution between December 2017 and 2021. All patients were prospectively followed by a transitional pain service that promoted opioid tapering, assessed opioid use (morphine milligram equivalent), and patient-reported outcomes measurement information system for pain intensity (PROMIS-3a) and pain interference (PROMIS-6b). After stratifying based on whether complete versus partial/no opioid tapering was achieved after surgery, longitudinal changes in patient-reported outcomes and morphine milligram equivalents were compared over time. Independent predictors of complete opioid tapering were assessed using logistic regression models. RESULTS In total, 341 surgical patients (91% male, mean age 64 years) with chronic opioid use underwent surgery during the study period, of which 44 (13%) completely tapered off opioids within 60 days after discharge from the hospital. Patients who completely tapered had significant improvement in the change in patient-reported outcomes for pain intensity and interference with significant differences at 30 and 60 days after discharge for both measures when compared to the partial/no taper group (both P < .05). In risk-adjusted analyses, patients with lower baseline morphine milligram equivalents and those staying longer in the hospital were more likely to achieve complete opioid tapering (both P < .01). CONCLUSION Complete opioid tapering can be successfully achieved after surgery among patients with chronic opioid use with corresponding improvements in self-reported pain intensity and pain interference. Our results suggest that the highest potential for improving patient-reported outcomes with opioid tapering occurs among patients undergoing orthopedic procedures early after surgical discharge.
Collapse
|
10
|
Holloway GL, Weymiller AJ, Allemand A. Goal-Directed Opioid Stewardship in Acute-on-Chronic Nonmalignant Pain Management. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
11
|
Sandhu HK, Shaw J, Carnes D, Furlan AD, Tysall C, Adjei H, Muthiah C, Noyes J, Tang NKY, Taylor SJ, Underwood M, Willis A, Eldabe S. Development and testing of an opioid tapering self-management intervention for chronic pain: I-WOTCH. BMJ Open 2022; 12:e053725. [PMID: 35296478 PMCID: PMC8928279 DOI: 10.1136/bmjopen-2021-053725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To describe the design, development and pilot of a multicomponent intervention aimed at supporting withdrawal of opioids for people with chronic non-malignant pain for future evaluation in the Improving the Wellbeing of people with Opioid Treated CHronic pain (I-WOTCH) randomised controlled trial. DESIGN The I-WOTCH intervention draws on previous literature and collaboration with stakeholders (patient and public involvement). Intervention mapping and development activities of Behaviour Change Taxonomy are described. SETTING The intervention development was conducted by a multidisciplinary team with clinical, academic and service user perspectives. The team had expertise in the development and testing of complex health behaviour interventions, opioid tapering and pain management in primary and secondary care, I.T programming, and software development-to develop an opioid tapering App. PARTICIPANTS The I-WOTCH trial participants are adults (18 years and over) with chronic non-malignant pain using strong opioids for at least 3 months and on most days in the preceding month. OUTCOMES A multicomponent self-management support package to help people using opioids for chronic non-malignant pain reduce opioid use. INTERVENTIONS AND RESULTS Receiving information on the impact of long-term opioid use, and potential adverse effects were highlighted as important facilitators in making the decision to reduce opioids. Case studies of those who have successfully stopped taking opioids were also favoured as a facilitator to reduce opioid use. Barriers included the need for a 'trade-off to fill the deficit of the effect of the drug'. The final I-WOTCH intervention consists of an 8-10 week programme incorporating: education; problem-solving; motivation; group and one to one tailored planning; reflection and monitoring. A detailed facilitator manual was developed to promote consistent delivery of the intervention across the UK. CONCLUSIONS We describe the development of an opioid reduction intervention package suitable for testing in the I-WOTCH randomised controlled trial. TRIAL REGISTRATION NUMBER ISRCTN49470934.
Collapse
Affiliation(s)
- Harbinder Kaur Sandhu
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jane Shaw
- Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Dawn Carnes
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Andrea D Furlan
- Toronto Rehabilitation Institute, University Health Network, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Institute for Work & Health, Toronto, Ontario, Canada
| | - Colin Tysall
- UNTRAP, University of Warwick, Coventry, West Midlands, UK
- SUCE, Coventry University, Coventry, West Midlands, UK
| | - Henry Adjei
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chockalingam Muthiah
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jennifer Noyes
- Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Nicole K Y Tang
- Department of Psychology, University of Warwick, Coventry, West Midlands, UK
| | - Stephanie Jc Taylor
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Adrian Willis
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sam Eldabe
- Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
12
|
Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review. BMC Musculoskelet Disord 2022; 23:238. [PMID: 35277150 PMCID: PMC8917706 DOI: 10.1186/s12891-022-05044-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 01/18/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.
Methods
This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.
Results
A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.
Conclusions
This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.
Collapse
|
13
|
Abstract
This review summarizes current evidence related to perioperative opioid prescription fulfillment and use and discusses the role of personalized anesthesia care in mitigating opioid-related harms without compromising analgesia.
Collapse
|
14
|
Preoperative Chronic Opioid Trajectories: A Change (in Any Direction) Would Do You Good? Anesthesiology 2021; 135:945-947. [PMID: 34731248 DOI: 10.1097/aln.0000000000004021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Preoperative Opioid Utilization Patterns and Postoperative Opioid Utilization: A Retrospective Cohort Study. Anesthesiology 2021; 135:1015-1026. [PMID: 34731242 DOI: 10.1097/aln.0000000000004026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Among chronic opioid users, the association between decreasing or increasing preoperative opioid utilization and postoperative outcomes is unknown. The authors hypothesized that decreasing utilization would be associated with improved outcomes and increasing utilization with worsened outcomes. METHODS Using commercial insurance claims, the authors identified 57,019 chronic opioid users (10 or more prescriptions or 120 or more days supplied during the preoperative year), age 18 to 89 yr, undergoing one of 10 surgeries between 2004 and 2018. Patients with a 20% or greater decrease or increase in opioid utilization between preoperative days 7 to 90 and 91 to 365 were compared to patients with less than 20% change (stable utilization). The primary outcome was opioid utilization during postoperative days 91 to 365. Secondary outcomes included alternative measures of postoperative opioid utilization (filling a minimum number of prescriptions during this period), postoperative adverse events, and healthcare utilization. RESULTS The average age was 63 ± 13 yr, with 38,045 (66.7%) female patients. Preoperative opioid utilization was decreasing for 12,347 (21.7%) patients, increasing for 21,330 (37.4%) patients, and stable for 23,342 (40.9%) patients. Patients with decreasing utilization were slightly less likely to fill an opioid prescription during postoperative days 91 to 365 compared to stable patients (89.2% vs. 96.4%; odds ratio, 0.323; 95% CI, 0.296 to 0.352; P < 0.001), though the average daily doses were similar among patients who continued to utilize opioids during this timeframe (46.7 vs. 46.5 morphine milligram equivalents; difference, 0.2; 95% CI, -0.8 to 1.2; P = 0.684). Of patients with increasing utilization, 93.6% filled opioid prescriptions during this period (odds ratio, 0.57; 95% CI, 0.52 to 0.62; P < 0.001), with slightly lower average daily doses (44.3 morphine milligram equivalents; difference, -2.2; 95% CI, -3.1 to -1.3; P < 0.001). Except for alternative measures of persistent postoperative opioid utilization, there were no clinically significant differences for the secondary outcomes. CONCLUSIONS Changes in preoperative opioid utilization were not associated with clinically significant differences for several postoperative outcomes including postoperative opioid utilization. EDITOR’S PERSPECTIVE
Collapse
|
16
|
Ladak SSJ, Sapisochin G, Slepian PM, Clarke H. The intersection of harm reduction and postoperative care for an illicit fentanyl consumer after major surgery: A case report. Can J Pain 2021. [DOI: 10.1080/24740527.2021.1952066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Salima S. J. Ladak
- Department of Anaesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto Lawrence, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Multi-Organ Transplant and HPB Surgical Oncology, Toronto General Hospital, Division of General Surgery, Department of Surgery, University of Toronto, Canada
| | - P. Maxwell Slepian
- Department of Anaesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anaesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
17
|
Liu S, Blake E, Naylor JM, Adie S, Patanwala A, Stevens J, Brady B, Penm J. Letter to the Editor for article entitled 'Opioid Tapering/Detoxification Protocols, A Compendium: Narrative Review'. PAIN MEDICINE 2021; 22:3102-3103. [PMID: 34411253 DOI: 10.1093/pm/pnab259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Shania Liu
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| | - Emma Blake
- Hollywood Private Hospital, Monash Avenue, Nedlands, Western Australia, 6009.,Curtin University, Kent Street, Bentley, Western Australia, 6102
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute, Liverpool, NSW, Australia
| | - Sam Adie
- St. George and Sutherland Clinical School, The University of New South Wales, Kensington, Australia
| | - Asad Patanwala
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia
| | - Jennifer Stevens
- Brian Dwyer Department of Anaesthesia and Pain Medicine, St Vincent's Public Hospital, Darlinghurst, Australia.,St Vincent's Clinical School, The University of New South Wales, Kensington, Australia
| | - Bernadette Brady
- Department of Pain Medicine, Liverpool Hospital, Liverpool, Australia.,School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | - Jonathan Penm
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| |
Collapse
|