Opioid-Sparing Anesthesia: Gabapentin and Postoperative Pain

Perceptions Towards Naloxone among Patients with Cancer Receiving Opioids

CONTEXT

Naloxone nasal spray is recommended for patients with risk factors for opioid overdose. However, cancer patients' perceptions and beliefs regarding naloxone prescriptions and their self-perceived risks for overdose are understudied.

OBJECTIVE

To determine the proportion of cancer patients at risk for overdose who perceived naloxone as beneficial.

METHODS

Between July 2020 and April 2022, we surveyed 150 adult patients from the supportive care ambulatory clinic at a tertiary cancer center in the United States who received a co-prescription of naloxone nasal spray. We measured patients' knowledge of overdose risk-factors, attitudes, beliefs, and education received on naloxone. Risk-factors between beneficial vs. non-beneficial groups were analyzed. The survey was administered on paper or via a telephone interview.

RESULTS

Of the 150 patients, 55% were male, 70% were white, and 81% had advanced cancer. The majority of patients believed naloxone was beneficial (100/150, 67%). When compared to the non-beneficial group, more patients from the beneficial group agreed that the concurrent use of alcohol (100% vs. 90%;p=0.004) or sedating drugs (96% vs.85%;p=0.04) with opioids could result in overdoses and felt safe having naloxone at home (95% vs. 60%;p<0.0001). More patients from the non-beneficial group associated naloxone prescription with being suspected of misusing opioids (12/50 vs. 8/100;p=0.01), and fewer had confidence in their caregivers' ability to administer naloxone (69% vs. 95%;p<0.0001).

CONCLUSION

Most patients understood the benefits of naloxone and felt safe having one at home. More research is needed to identify knowledge gaps and develop educational strategies for those who find it non-beneficial.

The efficacy of gabapentin supplementation for pain control after lumbar laminectomy and discectomy: A meta-analysis study

BACKGROUND

Gabapentin supplementation may have some potential in pain control after lumbar laminectomy and discectomy, and this meta-analysis aims to explore the impact of gabapentin supplementation on postoperative pain management for lumbar laminectomy and discectomy.

METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched, and we included randomized controlled trials assessing the effect of gabapentin supplementation on the pain control of lumbar laminectomy and discectomy.

RESULTS

Five randomized controlled trials were finally included in the meta-analysis. Overall, compared with control intervention for lumbar laminectomy and discectomy, gabapentin supplementation was associated with significantly lower pain scores at 2 hours (MD = -2.75; 95% CI = -3.09 to -2.41; P < .00001), pain scores at 4 hours (MD = -2.28; 95% CI = -3.36 to -1.20; P < .0001), pain scores at 24 hours (MD = -0.70; 95% CI = -0.86 to -0.55; P < .00001) and anxiety score compared to control intervention (MD = -1.32; 95% CI = -1.53 to -1.11; P < .00001), but showed no obvious impact on pain scores at 12 hours (MD = -0.58; 95% CI = -1.39 to 0.22; P = .16). In addition, gabapentin supplementation could significantly decrease the incidence of vomiting in relative to control intervention (OR = 0.31; 95% CI = 0.12-0.81; P = .02), but they had similar incidence of nausea (OR = 0.51; 95% CI = 0.15-1.73; P = .28).

CONCLUSIONS

Gabapentin supplementation benefits to pain control after lumbar laminectomy and discectomy.

Acupoint Stimulation for Pain Control in Enhanced Recovery After Surgery: Systematic Review and Meta-Analysis

Introduction: Postoperative pain control is a challenge in enhanced recovery after surgery (ERAS). The current study reviewed the efficacy and safety of incorporating acupoint stimulation for postoperative pain control in ERAS. Methods: Ten databases for relevant randomized controlled trials (RCTs) published in English or Mandarin Chinese were searched from 1997 to 2022. The quality of each article was appraised using the Cochrane Collaboration Risk of Bias Criteria and the modified Jadad Scale. The primary outcome was pain control, measured using the visual analog scale 24 h after surgery. Results: Eleven trials met the eligibility criteria and were included in the study. Acupoint stimulation was found more effective than control treatments in terms of pain intensity (standardized mean difference [SMD] -0.94; 95% confidence interval [CI] -1.35 to -0.53), analgesic drug consumption (SMD -1.87; 95% CI -2.98 to -0.75), postoperative nausea (PON; SMD 0.31; 95% CI 0.13 to 0.73), postoperative vomiting (POV; SMD 0.57; 95% CI 0.11 to 2.92), and PON and POV (PONV; SMD 0.29; 95% CI 0.16 to 0.53). The Zusanli (ST36) and Neiguan (PC6) were the most-used acupoints in the included trials (8/11). The reported adverse reaction was only one case of bruising. Discussion: Acupoint stimulation improved pain control in patients undergoing ERAS more than control treatments. The findings provide an evidence-based premise for incorporating acupoint stimulation into ERAS strategies. More rigorous RCTs are needed in the future.

Association of Gabapentinoids With Opioid-Related Overdose in the Inpatient Setting: A Single Center Retrospective Case-Control Study

Objectives: Recent data suggest concomitant gabapentinoid use increases opioid-related overdose (ORO) risk; however, this association has not been well studied in the hospital setting. The primary objective of this study was to compare ORO risk, indicated by naloxone administration, in patients receiving opioids plus gabapentinoids versus opioids alone. Methods: In this retrospective case-control study of adults admitted to a large community hospital from 1/1/20 to 12/31/21, all cases (defined as patients who received naloxone more than 24 hours after admission) identified were matched 1:1 to randomly selected controls (defined as patients on opioids who did not receive naloxone). The primary outcome was the percentage of cases and controls with concomitant inpatient gabapentinoid use. Logistic regression was performed to determine the independent association between gabapentinoids and ORO (as evidenced by inpatient naloxone administration). Results: Baseline characteristics were similar between the 144 cases and 144 controls. Gabapentinoid exposure was greater for cases than controls (34.0%vs 20.8%, P = .0118). Median hospital length of stay (11vs 4 days, P < .0001) and mortality (19%vs 5%; P = .0018) were also higher for cases. In logistic regression analysis, ORO (adjusted OR 4.91; 95% CI 1.86-12.96) and serotonergic medication exposure (adjusted OR 4.31; 95% CI 1.50-12.38) were significantly associated with gabapentinoid use. Conclusions: Concomitant gabapentinoid use with opioids was associated with increased ORO risk in the inpatient setting. When considering prescribing gabapentinoids in conjunction with opioids in the hospital setting, potential benefits should be weighed against increased overdose risk.

Trends of Opioid Usage in Surgical Patients in a Small Community Hospital: Analysis of Patient Data Between 2017 and 2021

Purpose: The purpose of our study was to quantify and analyze the annual opioid usage in surgical patients at Wood County Hospital (WCH) between 2017 and 2021. Methods: In this retrospective study, patient data between 2017 and 2021 was analyzed to determine the oral morphine milligram equivalent (MME) of opioids used in surgical patients at WCH. Annual MME prescribed per admission was compared each year using one-way ANOVA followed by Tukey post hoc test. Similarly, the annual use of intravenous (IV) acetaminophen for surgical patients per admission was also calculated and analyzed using the one-way ANOVA followed by Tukey post hoc test. Results: Compared to the year 2017 (42.0 ± 3.6), a statistically significant decrease in opioid usage per surgical admission (mean±SEM of MME) was observed during the years 2018 (32.6 ± 1.4; P = .04), 2019 (30.4 ± 1.2; P = .01), and 2021 (30.8 ± 1.9; P = .01). An analysis of individual opioid use revealed a trend toward lower fentanyl and hydromorphone usage each year since 2017. A significant decrease in the annual morphine usage (mean±SEM of MME) for surgical patients was observed during both 2020 (14.4 ± 0.9; P = .05) and 2021 (14.0 ± 0.7; P = .05) compared to the year 2017 (22.1 ± 2.4). Finally, compared to the year 2017, a statistically significant decrease (P < .05) in the annual use of oxycodone (MME) and IV acetaminophen (mg) for pain management in surgical patients was observed from 2018 to 2021. Conclusion: Our analysis reveals a significant decrease in opioid usage per surgical admission at WCH over 2017 to 2021 indicating a positive impact of the various opioid stewardship measures implemented at the hospital.

Medication treatment for alcohol use disorder in special populations

BACKGROUND AND OBJECTIVES

Alcohol use disorder (AUD) is a significant public health concern, with underutilized effective treatments, particularly in special populations. This article summarizes the current evidence and guidelines for treating AUD in special populations.

METHODS

This article is a literature review that synthesizes the latest research on AUD treatment for special populations. We screened 242 articles and included 57 in our final review.

RESULTS

There are four food and Drug Administration-approved medications for AUD (MAUD): disulfiram, oral naltrexone, extended-release injectable naltrexone (XR-NTX), and acamprosate. Naltrexone and disulfiram have the potential to cause liver toxicity, and acamprosate should be avoided in patients with severe kidney disease. Psychosocial treatments should be considered first-line for pregnant and nursing patients. Naltrexone is contraindicated in patients on opioids, as it may precipitate acute withdrawal. For patients experiencing homelessness, nonabstinent treatment goals may be more practical, and XR-NTX should be considered to improve adherence. Limited evidence suggests medication can improve AUD treatment outcomes in adolescents and young adults. For patients with poor treatment response despite adequate medication adherence, switching to a different medication and augmentation with psychosocial treatments should be considered.

DISCUSSION AND CONCLUSIONS

Understanding the unique considerations for special populations with AUD is crucial, and addressing their special needs may improve their treatment outcomes.

SCIENTIFIC SIGNIFICANCE

Our study significantly contributes to the existing literature by summarizing crucial information for the treatment of AUD in special populations, highlighting distinct challenges, and emphasizing tailored approaches to improve overall health and well-being.

Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction

It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.