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Ezell JM, Pho MT, Ajayi BP, Simek E, Shetty N, Goddard-Eckrich DA, Bluthenthal RN. Opioid use, prescribing and fatal overdose patterns among racial/ethnic minorities in the United States: A scoping review and conceptual risk environment model. Drug Alcohol Rev 2024; 43:1143-1159. [PMID: 38646735 DOI: 10.1111/dar.13832] [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: 08/29/2023] [Revised: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 04/23/2024]
Abstract
ISSUES To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors. APPROACH Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer-reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual-level risk factors. KEY FINDINGS Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder. IMPLICATIONS There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk-phenomena tied to multi-level forms of entrenched disenfranchisement. CONCLUSION There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines.
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Affiliation(s)
- Jerel M Ezell
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
- Berkeley Center for Cultural Humility, University of California Berkeley, Berkeley, USA
| | - Mai T Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, USA
| | - Babatunde P Ajayi
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
| | - Elinor Simek
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
- Berkeley Center for Cultural Humility, University of California Berkeley, Berkeley, USA
| | - Netra Shetty
- University of California Berkeley, Berkeley, USA
| | | | - Ricky N Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, USA
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Marmor MT, Hu S, Mahadevan V, Floren A, Solans BP, Savic R. Prolonged Opioid Use Is Associated With Poor Pain Alleviation After Orthopaedic Surgery. J Am Acad Orthop Surg 2024; 32:e661-e670. [PMID: 38696825 DOI: 10.5435/jaaos-d-24-00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/17/2024] [Indexed: 05/04/2024] Open
Abstract
INTRODUCTION Severe pain after orthopaedic surgery is common and often results in chronic postsurgical pain and chronic opioid use (COU). Poor pain alleviation (PPA) after surgery is a well-described modifiable risk factor of COU. Although PPA's role in inducing COU is recognized in other areas, it is not well defined in orthopaedic surgery. The aim of this study was to evaluate the influence of PPA on COU in the population who underwent orthopaedic surgery. METHODS Medical records from a large academic medical center from 2015 to 2018 were available for analysis. Patients undergoing nononcologic surgical procedures by the orthopaedic surgery service that also required at least 24 hours of hospital stay for pain control were included in the study. Surgery type, body location, basic demographics, preoperative opioid use, comorbidities, medications administered in the hospital, opioid prescription after discharge, and length of stay were recorded. COU was defined as a continued opioid prescription at ≥ 3 months, ≥ 6 months, or ≥ 9 months after surgery. PPA was defined as having a recorded pain score of eight or more, between 4 and 12 hours apart, three times during the hospital stay. RESULTS A total of 7,001 patients were identified. The overall rate of COU was 25.3% at 3 months after surgery. Charlson Comorbidity Index > 0 and PPA were statistically significant predictors of opioid use at all time points. Preoperative opioid naivety was associated with decreased COU. The type and location of surgical procedures were not associated with COU, after controlling for baseline variables. CONCLUSION Our findings demonstrated an overall high rate of COU. The known risk factors of COU were evident in our study population, particularly the modifiable risk factor of acute postsurgical PPA. Better management of postsurgical pain in orthopaedic patients may lead to a decrease in the rates of COU in this group.
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Affiliation(s)
- Meir T Marmor
- Department of Orthopaedic Surgery, University of California, San Francisco, CA (Marmor), Zuckerberg San Francisco General Hospital, Orthopaedic Trauma Institute, San Francisco, CA (Marmor), University of California, San Francisco, San Francisco, CA (Hu), Creighton University Health Sciences Campus, Phoenix, AZ (Mahadevan), Research Data Analyst (Floren), Postdoctoral Scholar (Solans), Department of Bioengineering and Therapeutic Sciences (Savic), University of California, San Francisco, San Francisco, CA
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Mei F, Garfinkel V, Petroll M, Mancini R. Opioid Usage Following Oculoplastic Procedures. Aesthet Surg J 2024; 44:699-705. [PMID: 38299440 DOI: 10.1093/asj/sjae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND With the rising toll of the opioid crisis, oculoplastic surgeons have been looking at methods to decrease opioid prescription. OBJECTIVES The aim of this study was to identify factors that correlate with opioid usage after oculoplastic surgery. METHODS This was a prospective study conducted at University of Texas Southwestern. All patients who underwent an oculoplastic procedure were eligible for inclusion. Patients enrolled were provided 20 tablets of tramadol 50 mg, to take 1 tablet every 6 hours as needed for pain. At their postoperative week 1 appointment, participants had the remaining number of unused opioid tablets counted. The number of tablets taken were calculated by subtracting the remaining number of tablets from the original prescribed amount. RESULTS A total of 310 patients were enrolled in our study. Of these, 129 patients met the inclusion criteria. There was a statistically significant difference in the number of tramadol tablets taken between procedures for upper eyelids, lower eyelids, and both eyelids (P < .01). There were no statistically significant differences in tramadol usage when comparing procedures on eyelids with orbit procedures(P = .30), cosmetic with noncosmetic procedures (P = .52), males with females (P = .87), or patients naive to oculoplastic procedures with those undergoing reoperation (P = .58). Longer procedures were correlated with greater tramadol usage (R = 0.28, P < .01). CONCLUSIONS This is the first study in the literature that has objectively quantified opioid usage after oculoplastic surgery in a prospective manner. Procedures that involve both upper and lower eyelids simultaneously and longer procedures resulted in higher opioid use. Orbital procedures, cosmetic procedures, sex, and procedural naivety were not found to be associated with higher opioid usage. LEVEL OF EVIDENCE: 4
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Beaulieu-Jones BR, Berrigan MT, Marwaha JS, Robinson KA, Nathanson LA, Fleishman A, Brat GA. Postoperative Opioid Prescribing via Rule-Based Guidelines Derived from In-Hospital Consumption: An Assessment of Efficacy Based on Postdischarge Opioid Use. J Am Coll Surg 2024; 238:1001-1010. [PMID: 38525970 DOI: 10.1097/xcs.0000000000001084] [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: 03/26/2024]
Abstract
BACKGROUND Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline. STUDY DESIGN We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed. RESULTS A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively. CONCLUSIONS Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Brat)
| | - Margaret T Berrigan
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Jayson S Marwaha
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Brat)
| | - Kortney A Robinson
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Larry A Nathanson
- Emergency Medicine (Nathanson), Beth Israel Deaconess Medical Center, Boston, MA
| | - Aaron Fleishman
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Gabriel A Brat
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Brat)
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Dunworth S, Barbeito A, Nagavelli H, Higgins D, Edward S, Williams M, Pyati S. Transitional Pain Service: Optimizing Complex Surgical Patients. Curr Pain Headache Rep 2024; 28:141-147. [PMID: 38117461 DOI: 10.1007/s11916-023-01204-4] [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] [Accepted: 11/19/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW The care of patients with complex postsurgical pain can be challenging and burdensome for the healthcare system. Transitional pain service (TPS) is a relatively new concept and has not been widely adopted in the USA. This article explores the benefits and barriers of transitional pain services and describes the development of a TPS at our institution. RECENT FINDINGS Evidence from a few institutions that have adopted TPS has shown decreased postsurgical opioid consumption for patients on chronic opioids and decreased incidence of chronic postsurgical opioid use for opioid-naïve patients. The development of a transitional pain service may improve outcomes for these complex patients by providing longitudinal and multidisciplinary perioperative pain care. In this article, we describe the implementation of a TPS at a tertiary medical center. Our TPS model involves a multidisciplinary team of anesthesiologists, pain psychologists, surgeons, and advanced practice providers. We provide longitudinal care, including preoperative education and optimization; perioperative multimodal analgesic care; and longitudinal follow-up for 90 days post-procedure. With our TPS service, we aim to reduce long-term opioid use and improve functional outcomes for our patients.
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Affiliation(s)
- Sophia Dunworth
- Department of Anesthesiology, Duke University School of Medicine, PO Box 3094, Durham, NC, 27701, USA
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Atilio Barbeito
- Department of Anesthesiology, Duke University School of Medicine, PO Box 3094, Durham, NC, 27701, USA
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Harika Nagavelli
- Department of Anesthesiology, Duke University School of Medicine, PO Box 3094, Durham, NC, 27701, USA
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Diana Higgins
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Shibu Edward
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Melvania Williams
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Duke University School of Medicine, PO Box 3094, Durham, NC, 27701, USA.
- Anesthesiology Service, Durham Veterans Affairs Healthcare Systems, Durham, NC, USA.
- Present address: Department of Anesthesiology, Duke University School of Medicine, Durham Veterans Affairs Healthcare System, PO Box 3094, Durham, NC, 27701, USA.
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Satapathy T, Singh G, Pandey RK, Shukla SS, Bhardwaj SK, Gidwani B. Novel Targets and Drug Delivery System in the Treatment of Postoperative Pain: Recent Studies and Clinical Advancement. Curr Drug Targets 2024; 25:25-45. [PMID: 38037995 DOI: 10.2174/0113894501271207231127063431] [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: 07/08/2023] [Revised: 10/18/2023] [Accepted: 11/07/2023] [Indexed: 12/02/2023]
Abstract
Pain is generated by a small number of peripheral targets. These can be made more sensitive by inflammatory mediators. The number of opioids prescribed to the patients can be reduced dramatically with better pain management. Any therapy that safely and reliably provides extended analgesia and is flexible enough to facilitate a diverse array of release profiles would be useful for improving patient comfort, quality of care, and compliance after surgical procedures. Comparisons are made between new and traditional methods, and the current state of development has been discussed; taking into account the availability of molecular and cellular level data, preclinical and clinical data, and early post-market data. There are a number of benefits associated with the use of nanotechnology in the delivery of analgesics to specific areas of the body. Nanoparticles are able to transport drugs to inaccessible bodily areas because of their small molecular size. This review focuses on targets that act specifically or primarily on sensory neurons, as well as inflammatory mediators that have been shown to have an analgesic effect as a side effect of their anti- inflammatory properties. New, regulated post-operative pain management devices that use existing polymeric systems were presented in this article, along with the areas for potential development. Analgesic treatments, both pharmacological and non-pharmacological, have also been discussed.
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Affiliation(s)
- Trilochan Satapathy
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Gulab Singh
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Ravindra Kumar Pandey
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Shiv Shankar Shukla
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Shiv Kumar Bhardwaj
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Beena Gidwani
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
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Beaulieu-Jones BR, Marwaha JS, Kennedy CJ, Le D, Berrigan MT, Nathanson LA, Brat GA. Comparing Rationale for Opioid Prescribing Decisions after Surgery with Subsequent Patient Consumption: A Survey of the Highest Quartile of Prescribers. J Am Coll Surg 2023; 237:835-843. [PMID: 37702392 DOI: 10.1097/xcs.0000000000000861] [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: 09/14/2023]
Abstract
BACKGROUND Opioid prescribing patterns, including those after surgery, have been implicated as a significant contributor to the US opioid crisis. A plethora of interventions-from nudges to reminders-have been deployed to improve prescribing behavior, but reasons for persistent outlier behavior are often unknown. STUDY DESIGN Our institution employs multiple prescribing resources and a near real-time, feedback-based intervention to promote appropriate opioid prescribing. Since 2019, an automated system has emailed providers when a prescription exceeds the 75th percentile of typical opioid consumption for a given procedure-as defined by institutional data collection. Emails include population consumption metrics and an optional survey on rationale for prescribing. Responses were analyzed to understand why providers choose to prescribe atypically large discharge opioid prescriptions. We then compared provider prescriptions against patient consumption. RESULTS During the study period, 10,672 eligible postsurgical patients were discharged; 2,013 prescriptions (29.4% of opioid prescriptions) exceeded our institutional guideline. Surveys were completed by outlier prescribers for 414 (20.6%) encounters. Among patients where both consumption data and prescribing rationale surveys were available, 35.2% did not consume any opioids after discharge and 21.5% consumed <50% of their prescription. Only 93 (39.9%) patients receiving outlier prescriptions were outlier consumers. Most common reasons for prescribing outlier amounts were attending preference (34%) and prescriber analysis of patient characteristics (34%). CONCLUSIONS The top quartile of opioid prescriptions did not align with, and often far exceeded, patient postdischarge opioid consumption. Providers cite assessment of patient characteristics as a common driver of decision-making, but this did not align with patient usage for approximately 50% of patients.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Jayson S Marwaha
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Chris J Kennedy
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Danny Le
- David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA (Le)
| | - Margaret T Berrigan
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Larry A Nathanson
- Emergency Medicine (Nathanson), Beth Israel Deaconess Medical Center, Boston, MA
| | - Gabriel A Brat
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
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Feenstra ML, Jansen S, Eshuis WJ, van Berge Henegouwen MI, Hollmann MW, Hermanides J. Opioid-free anesthesia: A systematic review and meta-analysis. J Clin Anesth 2023; 90:111215. [PMID: 37515877 DOI: 10.1016/j.jclinane.2023.111215] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/09/2023] [Accepted: 07/14/2023] [Indexed: 07/31/2023]
Abstract
STUDY OBJECTIVE To evaluate all available evidence thus far on opioid based versus opioid-free anesthesia and its effect on acute and chronic postoperative pain. DESIGN Systematic review and meta-analysis of randomized clinical trials. SETTING Operating room, postoperative recovery room and ward. PATIENTS Patients undergoing general anesthesia. INTERVENTIONS After consulting MEDLINE, EMBASE and Cochrane database, studies which compared opioid free anesthesia (OFA) with opioid based anesthesia (OBA) were included (last search April 15th 2022). MEASUREMENTS Primary outcomes were acute and chronic pain scores in NRS or VAS. Secondary outcomes were quality of recovery and postoperative opioid consumption. Risk of bias was assessed using the RoB2 tool and a random effects model for the meta-analysis was conducted. MAIN RESULTS We identified 1245 citations, of which 38 studies met our inclusion criteria. There is moderate quality evidence showing no clinically relevant difference of Numeric Rating Scale (NRS) scores or opioid consumption in the postoperative period (pooled mean difference of 0.39 points with a CI of 0.19-0.59 and 4.02 MME with a CI of 1.73-6.30). We found only one small-sized study reporting no effect of opioid-free anesthesia on chronic pain. The quality of recovery was superior in patients with opioid-free anesthesia (mean difference of 8.26 points), however, this pooled analysis was comprised of only two studies. Postoperative nausea and vomiting (PONV) occurred less in opioid-free anesthesia, but bradycardia was more frequent. CONCLUSIONS We concluded that we cannot recommend one strategy over the other. Future studies could focus on quality of recovery as outcome measure and adequately powered studies on the effects of opioid-free anesthesia on chronic pain are eagerly awaited.
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Affiliation(s)
- Minke L Feenstra
- Department of Anesthesiology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC location University of Amsterdam, AGEM, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Simone Jansen
- Department of Anesthesiology, LUMC, Albinusdreef 2, Leiden, the Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC location University of Amsterdam, AGEM, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, AGEM, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
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Chen IW, Wang WT, Hung KC. Dexmedetomidine may be favorable for opioid-free anesthesia. J Clin Anesth 2023; 90:111237. [PMID: 37634311 DOI: 10.1016/j.jclinane.2023.111237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023]
Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan city, Taiwan
| | - Wei-Ting Wang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan.
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Lindeberg FCB, Bell M, Larsson E, Hallqvist L. New prolonged opioid consumption after major surgery in Sweden: a population-based retrospective cohort study. BMJ Open 2023; 13:e071135. [PMID: 37185647 PMCID: PMC10151846 DOI: 10.1136/bmjopen-2022-071135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE Given that long-term opioid usage is an important problem worldwide and postsurgical pain is a common indication for opioid prescription, our primary objective was to describe the frequency of new prolonged opioid consumption after major surgery in Sweden and, second, to evaluate potential associated risk factors. DESIGN Cohort study including data from 1 January 2007 to 31 December 2014. Data regarding surgical procedures, baseline characteristics and outcomes was retrieved from the Orbit surgical planning system, the Swedish national patient register and the Swedish cause of death register. SETTING Observational multicentre cohort study with data from 23 Swedish hospitals. PARTICIPANTS We included 216 877 patients aged ≥18 years, undergoing non-cardiac surgery, not exposed to opioids 180 days before and alive 12 months after surgery. PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was collection of at least three opioid prescriptions during the first postoperative year; within 90 days, day 91-180 and 181-365 after surgery in a previously opioid-naïve patient. Second, multivariable logistic regression analysis was conducted to explore potential risk factors associated with prolonged opioid use. RESULTS Of the 216 877 patients identified to undergo analysis, 15 081 (7.0%) developed new prolonged opioid consumption. Several risk factors were identified. Having a history of psychiatric disease was identified as the strongest risk factor (adjusted odds ratio: 1.94; 95% CI: 1.87 to 2.00). CONCLUSION In a large Swedish cohort of surgical patients, 7% developed new prolonged opioid consumption after major surgery. Our data on susceptible patients could help clinicians reduce the number of prolonged opioid users by adapting their analgesic and preventative strategies.
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Affiliation(s)
- Felix C B Lindeberg
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Max Bell
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Emma Larsson
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Linn Hallqvist
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Baxter AL, Thrasher A, Etnoyer-Slaski JL, Cohen LL. Multimodal mechanical stimulation reduces acute and chronic low back pain: Pilot data from a HEAL phase 1 study. FRONTIERS IN PAIN RESEARCH 2023; 4:1114633. [PMID: 37179530 PMCID: PMC10169671 DOI: 10.3389/fpain.2023.1114633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/22/2023] [Indexed: 05/15/2023] Open
Abstract
Background Effective non-opioid pain management is of great clinical importance. The objective of this pilot study was to evaluate the effectiveness of multimodal mechanical stimulation therapy on low back pain. Methods 11 female and 9 male patients aged 22-74 years (Mean 41.9 years, SD 11.04) receiving physical rehabilitation for acute (12) or chronic (8) low back pain chose heat (9) or ice (11) to accompany a 20-minute session of mechanical stimulation (M-Stim) therapy (Registered with Clinicaltrials.gov NCT04494841.) The M-Stim was delivered in 12 possible repeating "therapy cycle" patterns by three vibration motors (50 Hz, 100 Hz, 200 Hz) with amplitudes between 0.1-0.3 m/s2. Ten patients used a contained motor chassis attached to a thermoconductive single-curve metal plate. The next 10 patients' device had motors attached directly to a multidimensionally curved plate. Results Mean pain on a 10 cm Visual Analog Scale (VAS) with the first motor/plate configuration went from 4.9 ± 2.3 cm to 2.5 ± 2.1 cm (57% decrease, p = 0.0112), while the second reduced pain from 4.8 ± 2.0 cm to 3.2 ± 1.9 cm (45%, p = 0.0353). Initial pain was greater with acute injury (5.8 ± 2.0 cm vs. 3.98 ± 1.8, p = 0.025) and for patients older than 40 (5.44 vs. 4.52), but pain reduction was proportional for chronic and younger patients. There was no significant difference between plate configurations. Conclusions A Phase I clinical pilot investigation on a multi-motor multi-modal device was promising for drug free pain relief. Results suggested pain relief independent of thermal modality, patient age, or pain chronicity. Future research should investigate pain reduction over time for acute and chronic pain. Clinical Trial Registration https://ClinicalTrials.gov, identifier: NCT04494841.
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Affiliation(s)
- Amy L Baxter
- Pain Care Labs, Atlanta, GA, United States
- Department of Emergency Medicine, Augusta University, Augusta, GA, United States
| | | | | | - Lindsey L Cohen
- Department of Psychology, Georgia State University, Atlanta, GA, United States
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12
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Morgan K, Solomon LM, Jones N, Picco L, Nielsen S. Building knowledge in opioid prescribing in post-operative treatment. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023:7142871. [PMID: 37186142 DOI: 10.1093/ijpp/riad024] [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: 08/14/2022] [Accepted: 04/02/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Opioids prescribed in hospital are a key risk factor for harm in the community. This study aimed to gain an in-depth understanding of factors affecting post-operative opioid prescribing amongst clinicians using the capability, opportunity, motivation generate behaviour framework, more commonly known as COM-B. METHODS Focus groups and semi-structured interviews were used to gain an in-depth understanding of factors affecting optimal practice when prescribing opioids for post-operative patients at discharge. A topic guide was written using the COM-B behaviour change model to ensure the full range of possible factors influencing prescribing behaviours were explored. RESULTS We found barriers and facilitators of optimal opioid prescribing practice across all three domains of capability, opportunity and motivation. Capability among junior doctors could be increased in the areas of risk assessment and prescribing appropriate discharge analgesia, though education and training were not key barriers to improving practice. Findings indicated that opportunity to practice optimal prescribing was hindered by a lack of time at discharge and technology. Beliefs about one's own and others' responsibilities also impacted motivation to practice optimal prescribing behaviours. Pharmacists were identified as key supports for patient education and appropriate prescribing. CONCLUSIONS Educating prescribers about opioid risks and clinical practice guidelines are necessary interventions, however, our findings indicate that if implemented in isolation, they may not have the desired impact. Interventions also need to address discharge time pressures and presumptions that GPs are aware of whether opioids should be ceased or continued after surgical discharge.
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Affiliation(s)
- Kirsty Morgan
- Peninsula Health, Frankston, Victoria, Australia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | | | | | - Louisa Picco
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University Peninsula Campus, Frankston, Victoria, Australia
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13
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Lentz TA, Gonzalez-Smith J, Huber K, Goertz C, Bleser WK, Saunders R. Overcoming Barriers to the Implementation of Integrated Musculoskeletal Pain Management Programs: A Multi-Stakeholder Qualitative Study. THE JOURNAL OF PAIN 2023; 24:860-873. [PMID: 36634887 DOI: 10.1016/j.jpain.2022.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023]
Abstract
Integrated pain management (IPM) programs can help to reduce the substantial population health burden of musculoskeletal pain, but are poorly implemented. Lessons learned from existing programs can inform efforts to expand IPM implementation. This qualitative study describes how health care systems, payers, providers, health policy researchers, and other stakeholders are overcoming barriers to developing and sustaining IPM programs in real-world settings. Primary data were collected February 2020 through September 2021 from a multi-sector expert panel of 25 stakeholders, 53 expert interviews representing 30 distinct IPM programs across the United States, and 4 original case studies of exemplar IPM programs. We use a consensual team-based approach to systematically analyze qualitative findings. We identified 4 major themes around challenges and potential solutions for implementing IPM programs: navigating coverage, payment, and reimbursement; enacting organizational change; making a business case to stakeholders; and overcoming regulatory hurdles. Strategies to address payment challenges included use of group visits, linked visits between billable and nonbillable providers, and development of value-based payment models. Organizational change strategies included engagement of clinical and administrative champions and co-location of services. Business case strategies involved demonstrating the ability to initially break even and potential to reduce downstream costs, while improving nonfinancial outcomes like patient satisfaction and provider burnout. Regulatory hurdles were overcome with innovative credentialing methods by leveraging available waivers and managed care contracting to expand access to IPM services. Lessons from existing programs provide direction on to grow and support such IPM delivery models across a variety of settings. PERSPECTIVE: Integrated pain management (IPM) programs face numerous implementation challenges related to payment, organizational change, care coordination, and regulatory requirements. Drawing on real-world experiences of existing programs and from diverse IPM stakeholders, we outline actionable strategies that health care systems, providers, and payers can use to expand implementation of these programs.
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Affiliation(s)
- Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina and Washington, DC.
| | - Jonathan Gonzalez-Smith
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina and Washington, DC
| | - Katie Huber
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina and Washington, DC
| | - Christine Goertz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina and Washington, DC
| | - William K Bleser
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina and Washington, DC
| | - Robert Saunders
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina and Washington, DC
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14
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Bérubé M, Côté C, Moore L, Turgeon AF, Belzile ÉL, Richard-Denis A, Dale CM, Berry G, Choinière M, Pagé GM, Guénette L, Dupuis S, Tremblay L, Turcotte V, Martel MO, Chatillon CÉ, Perreault K, Lauzier F. Strategies to prevent long-term opioid use following trauma: a Canadian practice survey. Can J Anaesth 2023; 70:87-99. [PMID: 36163458 PMCID: PMC9513000 DOI: 10.1007/s12630-022-02328-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/10/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. METHODS We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. RESULTS Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. CONCLUSIONS Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Practices Research Unit Research Unit (Trauma - Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC, G1V 1Z4, Canada. .,Faculty of Nursing, Université Laval, Quebec City, QC, Canada. .,Quebec Pain Research Network, Sherbrooke, QC, Canada.
| | - Caroline Côté
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Faculty of Nursing, Université Laval, Quebec City, QC Canada
| | - Lynne Moore
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Department of Social Preventive Medicine, Université Laval, Quebec City, QC Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC Canada
| | - Étienne L. Belzile
- Division of Orthopedic Surgery, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC Canada
| | - Andréane Richard-Denis
- Department of Medicine, Université de Montréal, Montreal, Quebec Canada ,Research Centre of the CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Craig M. Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON Canada ,University of Toronto Centre for the Study of Pain (UTCSP), Toronto, ON Canada
| | - Gregory Berry
- Department of Orthopaedic Surgery, McGill University Health Centre, Montreal, QC Canada
| | - Manon Choinière
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Research Center of the Centre hospitalier de l’Université de Montréal, Montreal, QC Canada ,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC Canada
| | - Gabrielle M. Pagé
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Research Center of the Centre hospitalier de l’Université de Montréal, Montreal, QC Canada ,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC Canada
| | - Line Guénette
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Quebec Pain Research Network, Sherbrooke, QC Canada ,Faculty of Pharmacy, Université Laval, Quebec City, QC Canada
| | - Sébastien Dupuis
- Department of Pharmacy, CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Lorraine Tremblay
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Valérie Turcotte
- Department of Nursing, CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Marc-Olivier Martel
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Faculty of Medicine & Dentistry, McGill University, Montreal, QC Canada
| | - Claude-Édouard Chatillon
- Division of Neurosurgery, CIUSSS de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, QC Canada
| | - Kadija Perreault
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), CIUSSS de la Capitale-Nationale, Quebec City, QC Canada
| | - François Lauzier
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC Canada ,Department of Medicine, Université Laval, Quebec City, QC Canada
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15
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Daksla N, Wang A, Jin Z, Gupta A, Bergese SD. Oliceridine for the Management of Moderate to Severe Acute Postoperative Pain: A Narrative Review. Drug Des Devel Ther 2023; 17:875-886. [PMID: 36987403 PMCID: PMC10040154 DOI: 10.2147/dddt.s372612] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/11/2023] [Indexed: 03/30/2023] Open
Abstract
Despite current advances in acute postoperative pain management, prevalence remains high. Inadequate treatment could lead to poor outcomes and even progression to chronic pain. Opioids have traditionally been the mainstay for treatment of moderate to severe acute pain. However, their use has been associated with opioid-related adverse events (ORAEs), such as respiratory depression, sedation, nausea, vomiting, pruritus, and decreased bowel motility. In addition, their liberal use has been implicated in the current opioid epidemic. As a result, there has been renewed interest in multimodal analgesia to target different mechanisms of action in order to achieve a synergistic effect and minimize opioid usage. Oliceridine is a novel mu-opioid receptor agonist that is part of a new class of biased ligands that selectively activate G-protein signaling and downregulate β-arrestin recruitment. Since G-protein signaling has been associated with analgesia while β-arrestin recruitment has been associated with ORAEs, there is potential for a wider therapeutic window. In this review, we will discuss the clinical evidence behind oliceridine and its potential role in acute postoperative pain management. We have systematically searched the PubMed database using the keywords oliceridine, olinvyk, and trv130. All articles identified were reviewed and evaluated, and all clinical trials were included.
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Affiliation(s)
- Neil Daksla
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA
| | - Ashley Wang
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA
| | - Abhishek Gupta
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA
- Department of Neurosurgery, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA
- Correspondence: Sergio D Bergese, Department of Anesthesiology, Stony Brook University School of Medicine, Health Sciences Center, Level 4, Room 060, Stony Brook, NY, 11794, USA, Tel +1 631 444-2979, Fax +1 631 444-2907, Email
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16
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Dahl JJ, Krebs ED, Teman NR, Hulse M, Thiele RH, Singh K, Yount KW. Cardiac Enhanced Recovery Program Implementation and Its Effect on Opioid Administration in Adult Cardiac Surgery. Semin Thorac Cardiovasc Surg 2022; 35:685-695. [PMID: 35985451 DOI: 10.1053/j.semtcvs.2022.06.020] [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: 02/11/2022] [Accepted: 06/02/2022] [Indexed: 11/11/2022]
Abstract
In light of the worsening opioid epidemic and nationwide parenteral opioid shortage, our institution created an enhanced recovery after surgery (ERAS) protocol. Our objective was to evaluate our initial experience transitioning to ERAS in cardiac surgery. An institutional cardiac ERAS protocol was implemented in April 2018, consisting of opioid-sparing analgesia, liberalization of fasting and activity restrictions, and goal-directed standardization of perioperative care. Clinical outcomes, opioid administration, and pain scores of patients undergoing nonemergent cardiac surgery were reviewed from March 2017 to July 2018. Patients were propensity score matched into pre-ERAS and transition-to-ERAS (t-ERAS) cohorts and compared by univariate analysis. Of 467 patients, 236 patients were well-matched (118 per cohort). The transition to ERAS resulted in a 79% reduction in morphine equivalents through postoperative day 1 (359.3 mg pre-ERAS vs 75.4 mg ERAS, P < 0.0001). Despite less opioid utilization, t-ERAS patients reported lower pain scores (median 4.88 vs 4.14, P = 0.011). There was no difference in mortality (2% vs 0%, P = 0.498) or postoperative complications including initial hours ventilated (5.3 vs 5.2 hours, P = 0.380), prolonged ventilation (9.3% vs 6.8%, P = 0.473), renal failure (3.4% vs 2.5%, P = 0.701), and ICU length of stay (58.3 vs 70.4 hours, P = 0.272). The transition to cardiac ERAS resulted in significantly reduced opioid administration and improved patient pain scores while maintaining excellent outcomes. Well-supported, multidisciplinary teams of cardiac surgeons, anesthesiologists, and intensivists can dramatically reduce opioid use without sacrificing pain control or excellent clinical outcomes.
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Affiliation(s)
- Jolian J Dahl
- University of Virginia School of Medicine, Division of Cardiac Surgery, Charlottesville, Virginia
| | - Elizabeth D Krebs
- University of Virginia School of Medicine, Division of Cardiac Surgery, Charlottesville, Virginia
| | - Nicholas R Teman
- University of Virginia School of Medicine, Division of Cardiac Surgery, Charlottesville, Virginia
| | - Matthew Hulse
- University of Virginia School of Medicine, Department of Anesthesiology, Charlottesville, Virginia
| | - Robert H Thiele
- University of Virginia School of Medicine, Department of Anesthesiology, Charlottesville, Virginia
| | - Karen Singh
- University of Virginia School of Medicine, Department of Anesthesiology, Charlottesville, Virginia
| | - Kenan W Yount
- University of Virginia School of Medicine, Division of Cardiac Surgery, Charlottesville, Virginia.
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17
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Choi H, Song JY, Oh EJ, Chae MS, Yu S, Moon YE. The Effect of Opioid-Free Anesthesia on the Quality of Recovery After Gynecological Laparoscopy: A Prospective Randomized Controlled Trial. J Pain Res 2022; 15:2197-2209. [PMID: 35945992 PMCID: PMC9357397 DOI: 10.2147/jpr.s373412] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/29/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose Opioid-free anesthesia (OFA) is an emerging technique that eliminates intraoperative use of opioids and is associated with lower postoperative opioid consumption and reduced adverse postoperative events. The present study investigated the effect of OFA on the quality of recovery in patients undergoing gynecological laparoscopy. Patients and Methods Seventy-five adult patients undergoing elective gynecological laparoscopy were randomly assigned to the OFA group with dexmedetomidine and lidocaine or the remifentanil-based anesthesia (RA) group with remifentanil. Patients, surgeons, and medical staff members providing postoperative care and assessing outcomes were blinded to group allocation. The anesthesiologist performing general anesthesia could not be blinded due to the different drug administration protocols by groups. The primary outcome was the quality of recovery measured using the Quality of Recovery-40 (QoR-40) questionnaire. Secondary outcomes were postoperative pain score, intraoperative and postoperative adverse events, and stress hormones levels. Results The patients in both groups had comparable baseline characteristics. The QoR-40 score on postoperative day 1 was significantly higher in the OFA group than in the RA group (155.9 ± 21.2 in the RA group vs 166.9 ± 17.8 in the OFA group; mean difference: −11.0, 95% confidence interval: −20.0, −2.0; p = 0.018). The visual analog scale score at 30 min after surgery was significantly lower in the OFA group than in the RA group (6.3 ± 2.3 in the RA group vs 4.1 ± 2.1 in the OFA group; p < 0.001). The incidences of nausea and shivering in the post-anesthetic care unit were also significantly lower in the OFA group (p = 0.014 and 0.025; respectively). Epinephrine levels were significantly lower in the OFA group (p = 0.002). Conclusion OFA significantly improved the quality of recovery in patients undergoing gynecological laparoscopy.
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Affiliation(s)
- Hoon Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Yen Song
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sanghyuck Yu
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Correspondence: Young Eun Moon, Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea, Tel +82-2-22586163, Fax +82-2-5371951, Email
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18
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Zeeni C, Abou Daher L, Shebbo FM, Madi N, Sadek N, Baydoun H, Al-Taki M, Aouad MT. Predictors of postoperative pain, opioid consumption, and functionality after arthroscopic shoulder surgery: A prospective observational study. J Orthop Surg (Hong Kong) 2022; 30:10225536221094259. [PMID: 35393908 DOI: 10.1177/10225536221094259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE This study aims to identify predictors of postoperative pain and opioid consumption after shoulder surgery to help optimize postoperative pain protocols. STUDY DESIGN Observational cohort study. METHODS One thirty-four patients undergoing arthroscopic shoulder repair were included. Variables related to the patient, surgery and anesthesia were collected and correlated with postoperative pain intensity, analgesic consumption, and functionality up to 1-month post-surgery. We used mixed-effect linear models to estimate the association of gender, interscalene block (ISB), preoperative shoulder pain, non-steroidal anti-inflammatory drugs (NSAIDs) consumption before surgery, and type of surgery with each of the following outcomes: postoperative pain scores, opioid consumption, and functionality. We further analyzed the data for pain scores and opioid consumption per body weight using the multiple linear regression analysis to demonstrate the aforementioned associations specifically at 1 h, 6 h, 12 h, 24 h, 72 h, 1 week and 1 month after surgery. RESULTS Omitting the ISB was associated with higher postoperative pain and cumulative opioid consumption over the first 24 h after surgery. Rotator cuff repair and stabilization surgeries were found to be predictive of higher postoperative pain at 24 h, 72 h, and 1 week and lower functionality at 1 week after surgery. Preoperative shoulder pain and NSAIDs consumption were also predictive of postoperative pain and cumulative opioid consumption. CONCLUSION Omitting a single shot ISB is a strong predictor of postoperative pain and opioid consumption in the early postoperative phase, beyond which the type of surgery, particularly rotator cuff repair and stabilization surgery, emerges as the most important predictor of postoperative pain and functionality.
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Affiliation(s)
- Carine Zeeni
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Layal Abou Daher
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadia M Shebbo
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Naji Madi
- Department of Orthopedic Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Nada Sadek
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Hasan Baydoun
- Department of Surgery, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Muhyeddine Al-Taki
- Department of Surgery, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Marie T Aouad
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
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19
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Nielsen A, Dusek J, Taylor-Swanson L, Tick H. Acupuncture therapy as an Evidence-Based Nonpharmacologic Strategy for Comprehensive Acute Pain Care: the Academic Consortium Pain Task Force White Paper Update. PAIN MEDICINE 2022; 23:1582-1612. [PMID: 35380733 PMCID: PMC9434305 DOI: 10.1093/pm/pnac056] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/16/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Abstract
Background A crisis in pain management persists, as does the epidemic of opioid overdose deaths, addiction, and diversion. Pain medicine is meeting these challenges by returning to its origins: the Bonica model of multidisciplinary pain care. The 2018 Academic Consortium White Paper detailed the historical context and magnitude of the pain crisis and the evidence base for nonpharmacologic strategies. More than 50% of chronic opioid use begins in the acute pain care setting. Acupuncture may be able to reduce this risk. Objective This article updates the evidence base for acupuncture therapy for acute pain with a review of systematic reviews and meta-analyses on postsurgical/perioperative pain with opioid sparing and acute nonsurgical/trauma pain, including acute pain in the emergency department. Methods To update reviews cited in the 2018 White Paper, electronic searches were conducted in PubMed, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials for “acupuncture” and “acupuncture therapy” and “acute pain,” “surgery,” “peri-operative,” “trauma,” “emergency department,” “urgent care,” “review(s) ,” “systematic review,” “meta-analysis,” with additional manual review of titles, links, and reference lists. Results There are 22 systematic reviews, 17 with meta-analyses of acupuncture in acute pain settings, and a review for acute pain in the intensive care unit. There are additional studies of acupuncture in acute pain settings. Conclusion The majority of reviews found acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid reliance. Future multicenter trials are needed to clarify the dosage and generalizability of acupuncture for acute pain in the emergency department. With an extremely low risk profile, acupuncture therapy is an important strategy in comprehensive acute pain care.
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Affiliation(s)
- Arya Nielsen
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey Dusek
- University Hospitals, Connor Whole Health, Cleveland Medical Center; Cleveland, Ohio.,Department of Family Medicine and Community Health; Case Western Reserve University, Cleveland, OH
| | | | - Heather Tick
- Department of Family Medicine, and Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington
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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.
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Lee KW, Tram J, Wladis EJ. Effect of Timing of Intravenous Ketorolac Administration on Pain in Orbitotomy Surgery. Ophthalmic Plast Reconstr Surg 2022; 38:185-187. [PMID: 34380997 DOI: 10.1097/iop.0000000000002024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Intravenous ketorolac (IVK) is an effective and safe medication to reduce postoperative pain in the setting of oculofacial surgery. This study was undertaken to determine the impact of timing of IVK administration in orbital surgery on the reduction of postoperative pain score and opioid requirement. METHODS Patients either received IVK immediately before (n = 50), during (n = 50) or after (n = 50) orbital surgery or acted as controls (n = 50). Pain scores were assessed via an analog scale immediately after surgery and on the first postoperative day. The requirements for opioid analgesics were recorded. Statistical analyses were performed via a dedicated computerized software package. RESULTS One hundred fifty patients received IVK; 50 before incision (28 males, 22 females, mean age 52.2), 50 intraoperatively (20 males, 30 females, mean age 49.8) and 50 in the immediate postoperative period (26 males, 24 females, mean age = 55.3). Additionally, 50 patients acted as controls (26 males, 24 females, mean age 54). Immediately after surgery, administration of IVK resulted in statistically significant reduction in pain score regardless of the timing of dosing as compared with control patients (prior = 2.36, intraoperative = 2.34, postoperative = 2.46 vs. control 5.44, p < 0.0001). Eleven patients (22%) in the control group required opioids, whereas, in the IVK cohorts, only 2 (4%-preoperative), 1 (2%-intraoperative), and 1 (2%-postoperative) patients needed these medications (p = 0.0039). CONCLUSIONS In the setting of orbital surgery, IVK reduced pain scores and opioid requirement, regardless of the timing of administration, as compared with patients that did not receive the medication.
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Affiliation(s)
- Kathryn W Lee
- Department of Ophthalmology, Lions Eye Institute, Albany Medical College
| | - Justin Tram
- Department of Ophthalmology, Lions Eye Institute, Albany Medical College
| | - Edward J Wladis
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Lions Eye Institute, Albany Medical College
- Division of Otolaryngology, Department of Surgery, Albany Medical College, Slingerlands, New York, U.S.A
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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.
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Claus CF, Lytle E, Lawless M, Tong D, Sigler D, Garmo L, Slavnic D, Jasinski J, McCabe RW, Kaufmann A, Anton G, Yoon E, Alsalahi A, Kado K, Bono P, Carr DA, Kelkar P, Houseman C, Richards B, Soo TM. The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized, double-blinded, placebo-controlled trial. Spine J 2022; 22:8-18. [PMID: 34506986 DOI: 10.1016/j.spinee.2021.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses. PURPOSE We sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period. STUDY DESIGN/SETTING This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis. PATIENT SAMPLE Adults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index. METHODS A double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis. RESULTS Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications. CONCLUSIONS Short-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.
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Affiliation(s)
- Chad F Claus
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA.
| | - Evan Lytle
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Michael Lawless
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Doris Tong
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Diana Sigler
- Department of Pharmacy, Ascension Providence Hospital, Southfield, MI, USA
| | - Lucas Garmo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Dejan Slavnic
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Jacob Jasinski
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Robert W McCabe
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Ascher Kaufmann
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Gustavo Anton
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Elise Yoon
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Ammar Alsalahi
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Karl Kado
- Division of Neuroradiology, Department of Radiology, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Peter Bono
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Daniel A Carr
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Prashant Kelkar
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Clifford Houseman
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Boyd Richards
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Teck M Soo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
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The effect of opioid-free anesthesia protocol on the early quality of recovery after major surgery (SOFA trial): study protocol for a prospective, monocentric, randomized, single-blinded trial. Trials 2021; 22:855. [PMID: 34838109 PMCID: PMC8627013 DOI: 10.1186/s13063-021-05829-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/13/2021] [Indexed: 01/20/2023] Open
Abstract
Background Since the 2000s, opioid-free anesthesia (OFA) protocols have been spreading worldwide in anesthesia daily practice. These protocols avoid using opioid drugs during anesthesia to prevent short- and long-term opioid side effects while ensuring adequate analgesic control and optimizing postoperative recovery. Proofs of the effect of OFA protocol on optimizing postoperative recovery are still scarce. The study aims to compare the effects of an OFA protocol versus standard anesthesia protocol on the early quality of postoperative recovery (QoR) from major surgeries. Methods The SOFA trial is a prospective, randomized, parallel, single-blind, monocentric study. Patients (n = 140) scheduled for major plastic, visceral, urologic, gynecologic, or ear, nose, and throat (ENT) surgeries will be allocated to one of the two groups. The study group (OFA group) will receive a combination of clonidine, magnesium sulfate, ketamine, and lidocaine. The control group will receive a standard anesthesia protocol based on opioid use. Both groups will receive others standard practices for general anesthesia and perioperative care. The primary outcome measure is the QoR-15 value assessed at 24 h after surgery. Postoperative data such as pain intensity, the incidence of postoperative complication, and opioid consumption will be recorded. We will also collect adverse events that may be related to the anesthetic protocol. Three months after surgery, the incidence of chronic pain and the quality of life will be evaluated by phone interview. Discussion This will be the first study powered to evaluate the effect of OFA versus a standard anesthesia protocol using opioids on global postoperative recovery after a wide range of major surgeries. The SOFA trial will also provide findings concerning the OFA impact on chronic pain incidence and long-term patient quality of life. Trial registration ClinicalTrials.gov NCT04797312. Registered on 15 March 2021
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A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews. Int J Clin Pharm 2021; 44:235-246. [PMID: 34751891 DOI: 10.1007/s11096-021-01340-0] [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: 07/27/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.
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Sharif-Askary B, Abdou SA, Singh T, Song DH. Are US Plastic Surgery Residents Equipped to Face the Opioid Epidemic? A National Survey. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3761. [PMID: 34476156 PMCID: PMC8382490 DOI: 10.1097/gox.0000000000003761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/22/2021] [Indexed: 11/25/2022]
Abstract
The United States opioid epidemic is among this century’s most profound threats to public health and demands that all physicians consider their role in reversing its trajectory. Previous literature demonstrated that plastic surgery trainees lack vital practices that promote opioid stewardship. However, it is not understood why this practice gap exists. This is a national survey-based study evaluating the availability and effectiveness of opioid education in US plastic surgery programs. A total of 91 residents completed the survey. Our study found that there is an unmet need for practical and comprehensive training regarding safe opioid prescribing among plastic surgery trainees. “Informal training,” defined as the “learn as you go” method, was found to be more common than formal training and considerably more valuable according to trainees. Trainees cited real-world applicability of informal training and that it comes from teachers whom they know and trust as valuable attributes of this type of education. Furthermore, the severity of the opioid epidemic has not translated into improved trainee education, as there was no significant difference in knowledge on safe opioid prescribing practices between junior and senior residents. To change the course of the epidemic, plastic surgery programs need to better train younger generations who believe they are critical stakeholders. This study lays the framework for the “formalization of informal training,” and the creation of practical and efficacious educational initiatives.
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Affiliation(s)
- Banafsheh Sharif-Askary
- MedStar Georgetown University Hospital Department of Plastic and Reconstructive Surgery, Washington, D.C
| | - Salma A Abdou
- MedStar Georgetown University Hospital Department of Plastic and Reconstructive Surgery, Washington, D.C
| | - Tanvee Singh
- MedStar Georgetown University Hospital Department of Plastic and Reconstructive Surgery, Washington, D.C
| | - David H Song
- MedStar Georgetown University Hospital Department of Plastic and Reconstructive Surgery, Washington, D.C
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Kin C, Chou L, Safer DL, Morris A, Ding Q, Trickey A, Girod S. Opioid use among patients with pain syndromes commonly seeking surgical consultation: A retrospective cohort. Ann Med Surg (Lond) 2021; 69:102704. [PMID: 34466218 PMCID: PMC8384768 DOI: 10.1016/j.amsu.2021.102704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/07/2021] [Accepted: 08/07/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Surgeons often see patients with pain to exclude organic pathology and consider surgical treatment. We examined factors associated with long-term opioid therapy among patients with foot/ankle, anorectal, and temporomandibular joint pain to aid clinical decision making. METHODS Using the IBM MarketScan® Research Database, we conducted a retrospective cohort analysis of patients aged 18-64 with a clinical encounter for foot/ankle, anorectal, or temporomandibular joint pain (January 2007-September 2015). Multivariable logistic regression was used to estimate adjusted odds ratios for factors associated with long-term opioid therapy, including age, sex, geographic region, pain condition, psychiatric diagnoses, and surgical procedures in the previous year. RESULTS The majority of the cohort of 1,500,392 patients were women (61%). Within the year prior to the first clinical encounter for a pain diagnosis, 14% had an encounter for a psychiatric diagnosis, and 11% had undergone a surgical procedure. Long-term opioid therapy was received by 2.7%. After multivariable adjustment, older age (age 50-64 vs. 18-29: aOR 4.47, 95% CI 4.24-4.72, p < 0.001), region (South vs. Northeast, aOR 1.76, 95% CI 1.70-1.81, p < 0.001), recent surgical procedure (aOR 1.83, 95% CI 1.78-1.87, p < 0.001), male sex (aOR 1.14, 95% CI 1.12-1.16, p < 0.001) and recent psychiatric diagnosis (aOR 2.49, 95% CI 2.43-2.54, p < 0.001) were independently associated with long-term opioid therapy. CONCLUSION Among patients with foot/ankle, anorectal, or temporomandibular joint pain, the risk of long-term opioid therapy significantly increased with older age, recent psychiatric diagnoses and surgical history. Surgeons should be aware of these risk factors in order to make high quality clinical decisions in consultations with these patients.
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Affiliation(s)
- Cindy Kin
- Stanford University Department of Surgery, S-SPIRE, 1070 Arastradero, Palo Alto, CA, 94304, USA
| | - Loretta Chou
- Stanford University Department of Orthopedics, 450 Broadway, Redwood City, CA, 94063, USA
| | - Debra L. Safer
- Stanford University Department of Psychiatry and Behavioral Sciences, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Arden Morris
- Stanford University Department of Surgery, S-SPIRE, 1070 Arastradero, Palo Alto, CA, 94304, USA
| | - Qian Ding
- Stanford University Department of Surgery, S-SPIRE, 1070 Arastradero, Palo Alto, CA, 94304, USA
| | - Amber Trickey
- Stanford University Department of Surgery, S-SPIRE, 1070 Arastradero, Palo Alto, CA, 94304, USA
| | - Sabine Girod
- Stanford University Department of Surgery, S-SPIRE, 1070 Arastradero, Palo Alto, CA, 94304, USA
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Yoon DH, Mirza KL, Wickham C, Noren ER, Chen J, Lee SW, Cologne KG, Ault GT. Reduction of Opioid Overprescribing and Use Following Standardized Educational Intervention: A Survey of Patient Experiences Following Anorectal Procedures. Dis Colon Rectum 2021; 64:1129-1138. [PMID: 34397561 PMCID: PMC8369042 DOI: 10.1097/dcr.0000000000001970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A pilot study conducted at our institution showed that a significant amount of prescribed postoperative opioids is left unused with the potential for diversion and misuse. OBJECTIVE This study aimed to evaluate the impact of provider- and patient-targeted educational interventions on postoperative opioid prescription and use following anorectal procedures. DESIGN Patients were enrolled on July 2019 through March 2020 after implementing educational interventions (study) and were compared with the pilot study group (control) enrolled on August 2018 through May 2019. A telephone survey was conducted 1 week postoperatively. SETTINGS This study was conducted at a 600-bed, safety-net hospital in southern California. PATIENTS Adult patients undergoing ambulatory anorectal procedures were included. Patients who had undergone an examination under anesthesia, had been incarcerated, and had used opioids preoperatively were excluded. INTERVENTIONS Educational interventions were developed based on the pilot study results. Providers received education on recommended opioid prescription quantities and a multimodal pain regimen. Standardized patient education infographics were distributed to patients pre- and postoperatively. MAIN OUTCOME MEASURES The primary outcomes measured were total opioid prescribed, total opioid consumed, pain control satisfaction levels, and the need for additional opioid prescription. RESULTS A total of 104 of 122 (85%) patients enrolled responded to the survey and were compared with the 112 patients included in the control group. Despite similar demographics, the study cohort was prescribed fewer milligram morphine equivalents (78.8 ± 11.3 vs 294.0 ± 33.1, p < 0.001), consumed fewer milligram morphine equivalents (23.0 ± 28.0 vs 57.1 ± 45.8, p < 0.001), and had a higher rate of nonopioid medication use (72% vs 10%, p < 0.001). The 2 groups had similar pain control satisfaction levels (4.1 ± 1.3 vs 3.9 ± 1.1 out of 5, p = 0.12) and an additional opioid prescription requirement (5% vs 4%, p = 1.0). LIMITATIONS This study was limited by its single-center experience with specific patient population characteristics. CONCLUSION Educational interventions emphasizing evidence-based recommended opioid prescription quantities and regimented multimodal pain regimens are effective in decreasing excessive opioid prescribing and use without compromising satisfactory pain control in patients undergoing ambulatory anorectal procedures. See Video Abstract at http://links.lww.com/DCR/B529. REDUCCIN DE LA SOBREPRESCRIPCIN Y EL USO DE OPIOIDES DESPUS DE UNA INTERVENCIN EDUCATIVA ESTANDARIZADA UNA ENCUESTA DE LAS EXPERIENCIAS EN PACIENTES POSTOPERADOS DE PROCEDIMIENTOS ANORRECTALES ANTECEDENTES:Un estudio piloto realizado en nuestra institución mostró que una cantidad significativa de opioides posoperatorios recetados no se usa, con potencial de desvío y uso indebido.OBJETIVO:Evaluar el impacto de las intervenciones educativas dirigidas al paciente y al proveedor sobre la prescripción y el uso de opioides posoperatorios después de procedimientos anorrectales.DISEÑO:Los pacientes se incluyeron entre julio de 2019 y marzo de 2020 después de implementar intervenciones educativas (estudio) y se compararon con el grupo de estudio piloto (control) inscrito entre agosto de 2018 y mayo de 2019. Se realizó una encuesta telefónica una semana después de la cirugía.ENTORNO CLÍNICO:Hospital de 600 camas en el sur de California.PACIENTES:Pacientes adultos sometidos a procedimientos anorrectales ambulatorios. Los criterios de exclusión fueron pacientes que recibieron un examen bajo anestesia, pacientes encarcelados y uso preoperatorio de opioides.INTERVENCIONES:Se desarrollaron intervenciones educativas basadas en los resultados del estudio piloto. Los proveedores recibieron educación sobre las cantidades recomendadas de opioides recetados y un régimen multimodal para el dolor. Se distribuyeron infografías estandarizadas de educación para el paciente antes y después de la operación.PRINCIPALES MEDIDAS DE RESULTADO:Opioide total prescrito, opioide total consumido, niveles de satisfacción del control del dolor y necesidad de prescripción adicional de opioides.RESULTADOS:Un total de 104 de 122 (85%) pacientes inscritos respondieron a la encuesta y se compararon con los 112 pacientes incluidos en el grupo de control. A pesar de una demografía similar, a la cohorte del estudio se le prescribió menos miligramos de equivalente de morfina (MME) (78,8 ± 11,3 frente a 294,0 ± 33,1, p <0,001), consumió menos MME (23,0 ± 28,0 frente a 57,1 ± 45,8, p <0,001) y presentaron una mayor tasa de uso de medicamentos no opioides (72% vs 10%, p <0,001). Los dos grupos tenían niveles similares de satisfacción del control del dolor (4,1 ± 1,3 frente a 3,9 ± 1,1 de 5, p = 0,12) y la necesidad de prescripción de opioides adicionales (5% frente a 4%, p = 1,0).LIMITACIONES:Experiencia en un solo centro con características específicas de la población de pacientes.CONCLUSIÓN:Las intervenciones educativas que enfatizan las cantidades recomendadas de prescripción de opioides basadas en la evidencia y los regímenes de dolor multimodales reglamentados son efectivas para disminuir la prescripción y el uso excesivos de opioides sin comprometer el control satisfactorio del dolor en pacientes sometidos a procedimientos anorrectales ambulatorios. Video Resumen en http://links.lww.com/DCR/B529.
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Affiliation(s)
- Dong Hum Yoon
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kasim L. Mirza
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Carey Wickham
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Erik R. Noren
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jason Chen
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Sang W. Lee
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kyle G. Cologne
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Glenn T. Ault
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Bérubé M, Dupuis S, Leduc S, Roy I, Côté C, Grzelak S, Clairoux S, Panic S, Lauzier F. Tapering Opioid Prescription Program for High-Risk Trauma Patients: A Pilot Randomized Controlled Trial. Pain Manag Nurs 2021; 23:142-150. [PMID: 34479822 DOI: 10.1016/j.pmn.2021.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/02/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chronic opioid use has been documented in up to 20% of patients with traumatic injuries. Hence, we developed the Tapering Opioids Prescription Program for high-risk Trauma (TOPP-Trauma) patients. AIMS To assess the feasibility and acceptability of TOPP-Trauma, examine the feasibility of the research methods, and describe its potential efficacy in reducing long-term opioid use. DESIGN A two-arm pilot randomized controlled trial. METHODS Fifty participants discharged home were assigned to TOPP-Trauma or an educational pamphlet. Feasibility was assessed based on ability to provide the program components. The acceptability was assessed with the Treatment Acceptability and Preference Questionnaire. The feasibility of the research methods was evaluated according to standard parameters. Self-reported morphine equivalent dose (MED) and MEDs supplied by pharmacies were measured at 6 and 12 weeks. RESULTS Eighty percent or more of TOPP-Trauma components were delivered as planned, and the program was deemed highly acceptable. Approximately 10% of screened patients were eligible. Eighty-five percent of eligible patients agreed to participate with 20% attrition rates. TOPP-Trauma participants used less MED/day compared to the control group at 6 and 12 weeks (1.2. vs. 12.2 mg; 0.4. vs 4.0 mg), and pharmacies supplied less than half of cumulative MEDs to those who received the program at 12 weeks, but the differences were not statistically significant. CONCLUSIONS Some challenges need to be addressed before testing TOPP-Trauma. These include creating strategies to decrease attrition, offering the program throughout the care continuum to higher risk patients, and evaluating the impacts of reduced opioid use.
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Affiliation(s)
- Mélanie Bérubé
- Research Center of the CHU de Québec-Université Laval, Population Health and Optimal Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, Canada; Faculty of Nursing, Université Laval, Quebec City, Canada.
| | - Sébastien Dupuis
- Pharmacy Department, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'Île-de-Montréal, Montreal, Canada
| | - Stéphane Leduc
- Orthopaedic Department, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'Île-de-Montréal, Montreal, Canada
| | - Isabel Roy
- Trauma Program, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin, Monteal, Canada
| | - Caroline Côté
- Research Center of the CHU de Québec-Université Laval, Population Health and Optimal Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, Canada; Faculty of Nursing, Université Laval, Quebec City, Canada
| | - Sonia Grzelak
- Research Center of the CHU de Québec-Université Laval, Population Health and Optimal Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, Canada; Faculty of Nursing, Université Laval, Quebec City, Canada
| | - Sarah Clairoux
- Pharmacy Department, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'Île-de-Montréal, Montreal, Canada
| | - Stéphane Panic
- Trauma Program, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin, Monteal, Canada
| | - François Lauzier
- Research Center of the CHU de Québec-Université Laval, Population Health and Optimal Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, Canada
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Olbrecht VA, O'Conor KT, Williams SE, Boehmer CO, Marchant GW, Glynn SM, Geisler KJ, Ding L, Yang G, King CD. Guided Relaxation-Based Virtual Reality for Acute Postoperative Pain and Anxiety in a Pediatric Population: Pilot Observational Study. J Med Internet Res 2021; 23:e26328. [PMID: 34048358 PMCID: PMC8314162 DOI: 10.2196/26328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/02/2021] [Accepted: 05/04/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Distraction-based therapies, such as virtual reality (VR), have been used to reduce pain during acutely painful procedures. However, distraction alone cannot produce prolonged pain reduction to manage sustained postoperative pain. Therefore, the integration of VR with other pain-reducing therapies, like guided relaxation, may enhance its clinical impact. OBJECTIVE The goal of this pilot study was to assess the impact of a single guided relaxation-based VR (VR-GR) session on postoperative pain and anxiety reduction in children. We also explored the influence of pain catastrophizing and anxiety sensitivity on this association. METHODS A total of 51 children and adolescents (7-21 years) with postoperative pain and followed by the Acute Pain Service at Cincinnati Children's Hospital were recruited over an 8-month period to undergo a single VR-GR session. Prior to VR, the patients completed 2 questionnaires: Pain Catastrophizing Scale for Children (PCS-C) and the Child Anxiety Sensitivity Index (CASI). The primary outcome was a change in pain intensity following the VR-GR session (immediately, 15 minutes, and 30 minutes). The secondary outcomes included changes in pain unpleasantness and anxiety. RESULTS The VR-GR decreased pain intensity immediately (P<.001) and at 30 minutes (P=.04) after the VR session, but not at 15 minutes (P=.16) postsession. Reductions in pain unpleasantness were observed at all time intervals (P<.001 at all intervals). Anxiety was reduced immediately (P=.02) but not at 15 minutes (P=.08) or 30 minutes (P=.30) following VR-GR. Patients with higher CASI scores reported greater reductions in pain intensity (P=.04) and unpleasantness (P=.01) following VR-GR. Pain catastrophizing was not associated with changes in pain and anxiety. CONCLUSIONS A single, short VR-GR session showed transient reductions in pain intensity, pain unpleasantness, and anxiety in children and adolescents with acute postoperative pain. The results call for a future randomized controlled trial to assess the efficacy of VR-GR. TRIAL REGISTRATION ClinicalTrials.gov NCT04556747; https://clinicaltrials.gov/ct2/show/NCT04556747.
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Affiliation(s)
- Vanessa A Olbrecht
- Center for Understanding Pediatric Pain, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Keith T O'Conor
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Sara E Williams
- Center for Understanding Pediatric Pain, Division of Behavioral Medicine and Clinical Psychology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Chloe O Boehmer
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Gilbert W Marchant
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Susan M Glynn
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Kristie J Geisler
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Gang Yang
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Christopher D King
- Center for Understanding Pediatric Pain, Division of Behavioral Medicine and Clinical Psychology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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Fortune S, Frawley J. Optimizing Pain Control and Minimizing Opioid Use in Trauma Patients. AACN Adv Crit Care 2021; 32:89-104. [PMID: 33725102 DOI: 10.4037/aacnacc2021519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Adverse effects of opioids and the ongoing crisis of opioid abuse have prompted providers to reduce prescribing opioids and increase use of multiple nonpharmacologic therapies, nonopioid analgesics, and co-analgesics for pain management in trauma patients. Nonopioid agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, central α2 agonists, and lidocaine, can be used as adjuncts or alternatives to opioids in the trauma population. Complementary therapies such as acupuncture, virtual reality, and mirror therapy are modalities that also may be helpful in reducing pain. Performing pain assessments is fundamental to identify pain and evaluate treatment effectiveness in the critically ill trauma patient. The efficacy, safety, and availability of opioid-sparing therapies and multimodal pain regimens are reviewed.
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Affiliation(s)
- Shanna Fortune
- Shanna Fortune is Advanced Practice Registered Nurse, Trauma Acute Pain Management Service, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Jennifer Frawley
- Jennifer Frawley is Trauma Critical Care Clinical Pharmacy Specialist, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
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Song JY, Choi H, Chae M, Ko J, Moon YE. The effect of opioid-free anesthesia on the quality of recovery after gynecological laparoscopy: study protocol for a prospective randomized controlled trial. Trials 2021; 22:207. [PMID: 33712080 PMCID: PMC7953824 DOI: 10.1186/s13063-021-05166-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 03/02/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Because of the indiscriminate use of opioids during the perioperative period, opioid-free anesthesia (OFA) has been increasingly required. Nevertheless, the studies on the detailed techniques and effects of OFA are not sufficient. The Quality of Recovery-40 (QoR-40) questionnaire is a validated assessment tool for measuring recovery from general anesthesia. However, no study has used the QoR-40 to determine if OFA leads to better recovery than standard general anesthesia. Therefore, we aim to perform this study to determine the effects of OFA using dexmedetomidine and lidocaine on the quality of recovery as well as the various postoperative outcomes. METHODS The participants (n = 78) will be allocated to one of the two groups; the study group will receive bolus and infusion of dexmedetomidine and lidocaine, and the control group will receive remifentanil infusion during general anesthesia for gynecological laparoscopy. The other processes including anesthetic and postoperative care will be performed similarly in the two groups. Intraoperative hemodynamic, anesthetic, and nociceptive variables will be recorded. Postoperative outcomes such as QoR-40, pain severity, and opioid-related side effects will be assessed. Additionally, an ancillary cytokine study (inflammatory cytokine, stress hormone, and reactive oxygen species) will be performed during the study period. DISCUSSION This will be the first study to determine the effect of OFA, using the combination of dexmedetomidine and lidocaine, on the quality of recovery after gynecological laparoscopy compared with standard general anesthesia using remifentanil. The findings from this study will provide scientific and clinical evidence on the efficacy of OFA. TRIAL REGISTRATION ClinicalTrials.gov NCT04409964 . Registered on 28 May 2020.
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Affiliation(s)
- Jae Yen Song
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Hoon Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Minsuk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Jemin Ko
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Young Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea.
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Anwar S, Herath B, O'Brien B. Adding Insult to Injury-Are We Fueling the Opioid Crisis During the Perioperative Period? J Cardiothorac Vasc Anesth 2021; 35:1712-1714. [PMID: 33814246 DOI: 10.1053/j.jvca.2021.02.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 02/26/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sibtain Anwar
- Department of Perioperative Medicine, Barts Heart Centre and St. Bartholomew's Hospital, London, UK; William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK; Outcomes Research Consortium, Cleveland, OH
| | - Brian Herath
- Department of Perioperative Medicine, Barts Heart Centre and St. Bartholomew's Hospital, London, UK; William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Benjamin O'Brien
- Department of Perioperative Medicine, Barts Heart Centre and St. Bartholomew's Hospital, London, UK; Outcomes Research Consortium, Cleveland, OH; German Heart Center, Berlin, Germany
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Petrosan A, Zassman S, Cohn S, Guerra M, Soares K, Kennedy J, Abdelghany O, Gutman E. Impact of Intravenous Methadone Administered Intraoperatively on Postoperative Opioid Utilization. Ann Pharmacother 2021; 55:1341-1346. [PMID: 33615830 DOI: 10.1177/1060028021997390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Studies have shown that intravenous methadone intraoperatively can reduce opioid usage postoperatively. OBJECTIVE This study's purpose was to evaluate the effect of intravenous methadone on postoperative opioid use. METHODS A prospective, single-center observational study was conducted to evaluate patients who received intravenous methadone intraoperatively. A control group was identified by matching procedure, gender, and age in a 1:3 ratio of methadone to control. Exclusion criteria included patients less than 18 years old or on methadone maintenance therapy. The primary outcome was morphine milligram equivalents (MME) administered 24h postoperatively. Secondary outcomes included MME administered 48h and 72h postoperatively, discharge prescription MME, daily mean postoperative pain scores, and length of hospital stay. A subgroup analysis was performed comparing opioid-naïve patients. RESULTS A total of 240 patients were included in the analysis. At 24h, postoperative MME was increased in the methadone group (142.6 vs 84.5; P = 0.0026). Postoperative MME was also increased in the methadone group at 48h and 72h. Daily pain scores were similar between both groups at all time intervals. Discharge prescription MME was reduced in the methadone group compared with controls, but not statistically significant. A subgroup analysis of opioid-naïve patients showed a significant reduction in MME at 48h (P = 0.0240) and daily pain scores at 24h (P = 0.0366) in the methadone group. CONCLUSION AND RELEVANCE Intravenous methadone intraoperatively did not show a significant reduction in postoperative opioid use and discharge prescription MMEs when comparing all patients; however, benefit was seen when examining opioid-naïve patients.
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Affiliation(s)
| | | | - Sara Cohn
- Yale New Haven Hospital, New Haven, CT, USA
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Madden K, Busse JW. Cochrane in CORR®: Oral Nonsteroidal Anti-inflammatory Drugs versus Other Oral Analgesic Agents for Acute Soft Tissue Injury. Clin Orthop Relat Res 2021; 479:17-23. [PMID: 33239520 PMCID: PMC7899588 DOI: 10.1097/corr.0000000000001595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Kim Madden
- K. Madden, Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, and the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Department of Health Research Methods, Evidence, and Impact, McMaster University, and the Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Jason W Busse
- K. Madden, Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, and the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- J. W. Busse, Department of Health Research Methods, Evidence, and Impact, McMaster University, and the Department of Anesthesia, McMaster University, Hamilton, ON, Canada
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Olbrecht VA, Williams SE, O'Conor KT, Boehmer CO, Marchant GW, Glynn SM, Geisler KJ, Ding L, Yang G, King CD. Guided relaxation-based virtual reality versus distraction-based virtual reality or passive control for postoperative pain management in children and adolescents undergoing Nuss repair of pectus excavatum: protocol for a prospective, randomised, controlled trial (FOREVR Peds trial). BMJ Open 2020; 10:e040295. [PMID: 33380482 PMCID: PMC7780540 DOI: 10.1136/bmjopen-2020-040295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Virtual reality (VR) offers an innovative method to deliver non-pharmacological pain management. Distraction-based VR (VR-D) using immersive games to redirect attention has shown short-term pain reductions in various settings. To create lasting pain reduction, VR-based strategies must go beyond distraction. Guided relaxation-based VR (VR-GR) integrates pain-relieving mind-body based guided relaxation with VR, a novel therapy delivery mechanism. The primary aim of this study is to assess the impact of daily VR-GR, VR-D and 360 video (passive control) on pain intensity. We will also assess the impact of these interventions on pain unpleasantness, anxiety and opioid and benzodiazepine consumption. The secondary aim of this study will assess the impact of psychological factors (anxiety sensitivity and pain catastrophising) on pain following VR. METHODS AND ANALYSIS This is a single centre, prospective, randomised, clinical trial. Ninety children/adolescents, aged 8-18 years, presenting for Nuss repair of pectus excavatum will be randomised to 1 of 3 study arms (VR-GR, VR-D and 360 video). Patients will use the Starlight Xperience (Google Daydream) VR suite for 10 min. Patients randomised to VR-GR (n=30) will engage in guided relaxation/mindfulness with the Aurora application. Patients randomised to VR-D (n=30) will play 1 of 3 distraction-based games, and those randomised to the 360 video (n=30) will watch the Aurora application without audio instructions or sound. Primary outcome is pain intensity. Secondary outcomes include pain unpleasantness, anxiety and opioid and benzodiazepine consumption. ETHICS AND DISSEMINATION This study follows Standard Protocol Items: Recommendations for Interventional Trials guidelines. The protocol was approved by the Cincinnati Children's Hospital Medical Center's institutional review board. Patient recruitment began in July 2020. Written informed consent will be obtained for all participants. All information acquired will be disseminated via scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04351776.
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Affiliation(s)
- Vanessa A Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sara E Williams
- Division of Behavioral Medicine and Clinical Psychology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Keith T O'Conor
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Chloe O Boehmer
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Gilbert W Marchant
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Susan M Glynn
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kristie J Geisler
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lili Ding
- Divsion of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Gang Yang
- Divsion of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher D King
- Division of Behavioral Medicine and Clinical Psychology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Stakeholder Perspective on Opioid Stewardship After Prostatectomy: Evaluating Barriers and Facilitators From the Pennsylvania Urology Regional Collaborative. Urology 2020; 145:120-126. [DOI: 10.1016/j.urology.2020.05.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 02/01/2023]
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Shen Y, Bhagwandass H, Branchcomb T, Galvez SA, Grande I, Lessing J, Mollanazar M, Ourhaan N, Oueini R, Sasser M, Valdes IL, Jadubans A, Hollmann J, Maguire M, Usmani S, Vouri SM, Hincapie-Castillo JM, Adkins LE, Goodin AJ. Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions. THE JOURNAL OF PAIN 2020; 22:246-262. [PMID: 33031943 DOI: 10.1016/j.jpain.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/24/2023]
Abstract
The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.
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Affiliation(s)
- Yun Shen
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Hemita Bhagwandass
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Tychell Branchcomb
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Sophia A Galvez
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivanna Grande
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Julia Lessing
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Mikela Mollanazar
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Natalie Ourhaan
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Razanne Oueini
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Sasser
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ashmita Jadubans
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Josef Hollmann
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Maguire
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Silken Usmani
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida; Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Lauren E Adkins
- University of Florida Health Science Center Libraries, Gainesville, Florida
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida.
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Rodriguez-Monguio R, Naveed M, Croci R, Gross K, Langnas E, Chen CL, Seoane-Vazquez E. Perioperative Prescribing Practices of Extended-Release Opioids in Noncancer Surgical Patients, 2015-2018. Anesth Analg 2020; 131:1249-1259. [PMID: 32925346 DOI: 10.1213/ane.0000000000004952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Extended-release (ER) opioids are indicated for the management of persistent moderate to severe pain in patients requiring around-the-clock opioid analgesics for an extended period of time. Concerns have been raised regarding safety of ER opioids due to its potential for abuse and dependence. However, little is known about perioperative prescribing practices of ER opioids. This study assessed perioperative prescribing practices of ER opioids in noncancer surgical patients stratified by type of opioid exposure prior to admission and examined predictors of postoperative opioid administration in oral morphine equivalents (OME). METHODS This was a retrospective cohort study using the University of California San Francisco Medical Center electronic health record data. This study included 25,396 adult noncancer patients undergoing elective surgery under general anesthesia in the period 2015-2018. The primary study outcome was predictors of postoperative administration of opioids in hospitalized surgical patients. Secondary outcomes included patients discontinued and initiated on ER opioids during their hospital stay. RESULTS substance use disorder diagnosis and use of opioids, surgery type, and postoperative administration of nonopioid analgesics were associated with postoperative administration of opioids (P < .0001). The estimated adjusted mean (95% confidence interval [CI]) of postoperative administration of OME prior to admission in ER opioid users (170.08 mg; 147.08-196.67) was twice the amount for opioid-naïve patients (81.36 mg; 70.7-93.63; P < .0001). One in 5 prior to admission ER opioid users were weaned off ER opioids while hospitalized without adversely affecting their postoperative pain or hospital length of stay (LOS). Four of 5 patients who used ER opioids prior to admission also received ER opioids after surgery, whereas, 1 in 100 opioid-naïve patients received ER opioids during their hospital stay. CONCLUSIONS We found significant variability in the perioperative prescribing practices of ER opioids in hospitalized noncancer surgical patients by use of opioids prior to admission and surgery type. Pain medicine practitioners and surgeons may play a significant role tackling the surgery-related risk of exposure to ER opioids and decreasing opioid-related complications.
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Affiliation(s)
- Rosa Rodriguez-Monguio
- From the Department of Clinical Pharmacy
- Medication Outcomes Center
- Philip R. Lee Institute for Health Policy Studies
| | | | | | - Kendall Gross
- Medication Outcomes Center
- Department of Pharmaceutical Services, UCSF Health
| | - Erica Langnas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (UCSF), San Francisco, California
| | - Catherine L Chen
- Philip R. Lee Institute for Health Policy Studies
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (UCSF), San Francisco, California
| | - Enrique Seoane-Vazquez
- Department of Biomedical and Pharmaceutical Sciences, School of Pharmacy, Chapman University, Irvine, California
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Bérubé M. Evidence-Based Strategies for the Prevention of Chronic Post-Intensive Care and Acute Care-Related Pain. AACN Adv Crit Care 2020; 30:320-334. [PMID: 31951659 DOI: 10.4037/aacnacc2019285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Chronic pain is prevalent in intensive care survivors and in patients who require acute care treatments. Many adverse consequences have been associated with chronic post-intensive care and acute care-related pain. Hence, interest in interventions to prevent these pain disorders has grown. To improve the understanding of the mechanisms of action of these interventions and their potential impacts, this article outlines the pathophysiology involved in the transition from acute to chronic pain, the epidemiology and consequences of chronic post-intensive care and acute care- related pain, and risk factors for the development of chronic pain. Pharmacological, nonpharmacological, and multimodal preventive interventions specific to the targeted populations and their levels of evidence are presented. Nursing implications for preventing chronic pain in patients receiving critical and acute care are also discussed.
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Affiliation(s)
- Melanie Bérubé
- Mélanie Bérubé is a Researcher in the Population Health and Optimal Practices research unit (Trauma, Emergency, and Critical Care Medicine) at the CHU de Québec Université Laval Research Center, Quebec City, QC, Canada, and Assistant Professor in the Faculty of Nursing, Laval University, 1050 Avenue de la Médecine, Quebec City, QC, Canada, G1V 0A6
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Piper KN, Baxter KJ, Wetzel M, McCracken C, Travers C, Slater B, Cairo SB, Rothstein DH, Cina R, Dassinger M, Bonasso P, Lipskar A, Denning NL, Huang E, Shah SR, Cunningham ME, Gonzalez R, Kauffman JD, Heiss KF, Raval MV. Provider education decreases opioid prescribing after pediatric umbilical hernia repair. J Pediatr Surg 2020; 55:1319-1323. [PMID: 31109731 DOI: 10.1016/j.jpedsurg.2019.04.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/09/2019] [Accepted: 04/14/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To improve opioid stewardship for umbilical hernia repair in children. METHODS An educational intervention was conducted at 9 centers with 79 surgeons. The intervention highlighted the importance of opioid stewardship, demonstrated practice variation, provided prescribing guidelines, encouraged non-opioid analgesics, and encouraged limiting doses/strength if opioids were prescribed. Three to six months of pre-intervention and 3 months of post-intervention prescribing practices for umbilical hernia repair were compared. RESULTS A total of 343 patients were identified in the pre-intervention cohort and 346 in the post-intervention cohort. The percent of patients receiving opioids at discharge decreased from 75.8% pre-intervention to 44.6% (p < 0.001) post-intervention. After adjusting for age, sex, umbilicoplasty, and hospital site, the odds ratio for opioid prescribing in the post- versus the pre-intervention period was 0.27 (95% CI = 0.18-0.39, p < 0.001). Among patients receiving opioids, the number of doses prescribed decreased after the intervention (adjusted mean 14.3 to 10.4, p < 0.001). However, the morphine equivalents/kg/dose did not significantly decrease (adjusted mean 0.14 to 0.13, p = 0.20). There were no differences in returns to emergency departments or hospital readmissions between the pre- and post-intervention cohorts. CONCLUSIONS Opioid stewardship can be improved after pediatric umbilical hernia repair using a low-fidelity educational intervention. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Kaitlin N Piper
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Katherine J Baxter
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Martha Wetzel
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Bethany Slater
- Department of Pediatric Surgery, The University of Chicago Medical Center, Chicago, IL, USA
| | - Sarah B Cairo
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - David H Rothstein
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - Robert Cina
- Division of Pediatric Surgery, Medical University Of South Carolina, Charleston, SC, USA
| | - Melvin Dassinger
- Department of Pediatric Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Patrick Bonasso
- Department of Pediatric Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Aaron Lipskar
- Division of Pediatric Surgery, Department Of Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Naomi-Liza Denning
- Division of Pediatric Surgery, Department Of Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Eunice Huang
- Division of Pediatric Surgery, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, TN, USA
| | - Sohail R Shah
- Division of Pediatric Surgery, Baylor College of Medicine, TX, USA
| | | | - Raquel Gonzalez
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, MD, USA
| | - Jeremy D Kauffman
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, MD, USA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
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Kim CH, Lefkowits C, Holschneider C, Bixel K, Pothuri B. Managing opioid use in the acute surgical setting: A society of gynecologic oncology clinical practice statement. Gynecol Oncol 2020; 157:563-569. [DOI: 10.1016/j.ygyno.2020.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 12/22/2022]
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Bérubé M, Moore L, Lauzier F, Côté C, Vogt K, Tremblay L, Martel MO, Pagé G, Tardif PA, Pinard AM, Hameed SM, Perreault K, Sirois C, Bélanger C, Turgeon AF. Strategies aimed at preventing chronic opioid use in trauma and acute care surgery: a scoping review protocol. BMJ Open 2020; 10:e035268. [PMID: 32295777 PMCID: PMC7200027 DOI: 10.1136/bmjopen-2019-035268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Globally every year, millions of patients sustain traumatic injuries and require acute care surgeries. A high incidence of chronic opioid use (up to 58%) has been documented in these populations with significant negative individual and societal impacts. Despite the importance of this public health issue, optimal strategies to limit the chronic use of opioids after trauma and acute care surgery are not clear. We aim to identify existing strategies to prevent chronic opioid use in these populations. METHODS AND ANALYSIS We will perform a scoping review of peer-reviewed and non-peer-reviewed literature to identify studies, reviews, recommendations and guidelines on strategies aimed at preventing chronic opioid use in patients after trauma and acute care surgery. We will search MEDLINE, EMBASE, PsycINFO, CINHAL, Cochrane Central Register of Controlled Trials, Web of Science, ProQuest and websites of trauma and acute care surgery, pain, government and professional organisations. Databases will be searched for papers published from 1 January 2005 to a maximum of 6 months before submission of the final manuscript. Two reviewers will independently evaluate studies for eligibility and extract data from included studies using a standardised data abstraction form. Preventive strategies will be classified according to their types and targeted trauma populations and acute care surgery procedures. ETHICS AND DISSEMINATION Research ethics approval is not required as this study is based on the secondary use of published data. This work will inform research and clinical stakeholders on the required next steps towards the uptake of effective strategies aimed at preventing chronic opioid use in trauma and acute care surgery patients.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
- Faculty of Nursing, Université Laval, Québec, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Québec, Canada
| | - Caroline Côté
- Faculty of Nursing, Université Laval, Québec, Québec, Canada
| | - Kelly Vogt
- Department of Surgery, London Health Sciences Centre (Victoria Hospital), London, Ontario, Canada
| | - Lorraine Tremblay
- Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Departement of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Marc-Olivier Martel
- Faculty of Dentistry & Department of Anesthesia, McGill University, Montréal, Québec, Canada
| | - Gabrielle Pagé
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Québec, Canada
- Research center of the Centre hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
| | - Anne-Marie Pinard
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Québec, Canada
| | - S Morad Hameed
- Department of Surgery, Vancouver Costal Health (Vancouver General Hospital), Vancouver, British Columbia, Canada
| | - Kadija Perreault
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - Caroline Sirois
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - Carole Bélanger
- Faculty of Nursing, Université Laval, Québec, Québec, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Québec, Canada
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Young JC, Jonsson Funk M, Dasgupta N. Medical Use of Long-term Extended-release Opioid Analgesics in Commercially Insured Adults in the United States. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:724-735. [PMID: 31340004 PMCID: PMC7534397 DOI: 10.1093/pm/pnz155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES We examined the proportion of patients initiating extended-release (ER) opioids who become long-term users and describe how pain-related diagnoses before initiation of opioid therapy vary between drugs and over time. METHODS Using MarketScan (2006-2015), a US national commercial insurance database, we examined pain-related diagnoses in the 182-day baseline period before initiation of ER opioid therapy to characterize indications for opioid initiation. We report the proportion who became long-term users, the median length of opioid therapy, and the proportion with cancer and other noncancer chronic pain, by active ingredient. RESULTS Among 1,077,566 adults initiating ER opioids, 31% became long-term users, with a median length of use of 209 days. The most common ER opioids prescribed were oxycodone (26%) and fentanyl (23%), and the most common noncancer pain diagnoses were back pain (65%) and arthritis (48%). Among all long-term users, 16% had a diagnosis of cancer. We found notable variation by drug. Eighteen percent of patients initiating drugs approved by the Food and Drug Administration >10 years ago had evidence of cancer during baseline compared with only 8% of patients who received newer drugs. CONCLUSIONS In a national sample of adults with private insurance, back pain was the most common diagnosis preceding initiation of opioid therapy. Opioids that have been approved within the last 10 years were more frequently associated with musculoskeletal pains and less frequently associated with cancer. Amid increasing concerns regarding long-term opioid therapy, our findings provide context regarding the conditions for which long-term opioid therapy is prescribed.
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Affiliation(s)
- Jessica C Young
- Department of Epidemiology, Gillings
School of Global Public Health
| | | | - Nabarun Dasgupta
- Injury Prevention Research Center,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Intravenous Ketorolac Reduces Pain Score and Opioid Requirement in Orbital Surgery. Ophthalmic Plast Reconstr Surg 2020; 36:132-134. [DOI: 10.1097/iop.0000000000001484] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sceats LA, Ayakta N, Merrell SB, Kin C. Drivers, Beliefs, and Barriers Surrounding Surgical Opioid Prescribing: A Qualitative Study of Surgeons’ Opioid Prescribing Habits. J Surg Res 2020; 247:86-94. [DOI: 10.1016/j.jss.2019.10.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/30/2019] [Accepted: 10/19/2019] [Indexed: 02/02/2023]
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Small C, Laycock H. Acute postoperative pain management. Br J Surg 2020; 107:e70-e80. [DOI: 10.1002/bjs.11477] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/22/2019] [Indexed: 12/16/2022]
Abstract
AbstractBackgroundAcute postoperative pain is common. Nearly 20 per cent of patients experience severe pain in the first 24 h after surgery, a figure that has remained largely unchanged in the past 30 years. This review aims to present key considerations for postoperative pain management.MethodsA narrative review of postoperative pain strategies was undertaken. Searches of the Cochrane Library, PubMed and Google Scholar databases were performed using the terms postoperative care, psychological factor, pain management, acute pain service, analgesia, acute pain and pain assessment.ResultsInformation on service provision, preoperative planning, pain assessment, and pharmacological and non-pharmacological strategies relevant to acute postoperative pain management in adults is presented, with a focus on enhanced recovery after surgery pathways.ConclusionAdequate perioperative pain management is integral to patient care and outcomes. Each of the biological, psychological and social dimensions of the pain experience should be considered and understood in order to provide optimum pain management in the postoperative setting.
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Affiliation(s)
- C Small
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - H Laycock
- Department of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
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Characterizing the Risk of Long-Term Opioid Utilization in Patients Undergoing Lumbar Spine Surgery. Spine (Phila Pa 1976) 2020; 45:E54-E60. [PMID: 31415465 DOI: 10.1097/brs.0000000000003199] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Single-institution retrospective cohort study. OBJECTIVE To determine whether prescribing practices at discharge are associated with opioid dependence (OD) in patients undergoing discectomy or laminectomy procedures for degenerative indications. SUMMARY OF BACKGROUND DATA Long-term opioid use in spine surgery is associated with higher healthcare utilization and worse postoperative outcomes. The impact of prescribing practices at discharge within this surgical population is poorly understood. METHODS A query of an administrative database was conducted to identify all patients undergoing discectomy or laminectomy procedures at our high-volume tertiary referral center between 2007 and 2016. For patients included in the analysis, opioid prescription data on admission and discharge were manually abstracted from the electronic health record, including opioid type, frequency, route, and dose, and then converted to daily morphine equivalent dose (MED) values. We defined OD as a consecutive narcotic prescription lasting for at least 90 days within the first 12 months after the index surgical procedure. RESULTS Of the 819 total patients, 499 (60.9%) patients had an active opioid prescription before surgery. Postoperatively, 813 (99.3%) received at least one narcotic prescription within 30 days of index surgery, and 162 (19.8%) continued with sustained opioid use in the 12 months after surgery. In adjusted analysis, patients with OD had a higher incidence of preoperative depression (P = 0.012) and preoperative opioid use (P < 0.001), as well as a higher frequency of preoperative benzodiazepine prescriptions (P = 0.009), and discharge MED value exceeding 120 mg/day (P = 0.013). Postoperative OD was observed in 7.5% of previously opioid-naïve patients. CONCLUSION This is the first study to test for an association between MED values prescribed at discharge and sustained opioid use after lumbar spine surgery. In addition to previously reported risk factors, discharge prescription dose exceeding 120 mg/day is independently associated with OD after spine surgery. LEVEL OF EVIDENCE 3.
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