Postoperative analgesia in patients with substance use disorders: Part I

Association of substance-use disorder with outcomes of major elective abdominal operations: A contemporary national analysis

Background

Affecting >20million people in the U.S., including 4 % of all hospitalized patients, substance use disorder (SUD) represents a growing public health crisis. Evaluating a national cohort, we aimed to characterize the association of concurrent SUD with perioperative outcomes and resource utilization following elective abdominal operations.

Methods

All adult hospitalizations entailing elective colectomy, gastrectomy, esophagectomy, hepatectomy, and pancreatectomy were tabulated from the 2016-2020 National Inpatient Sample. Patients with concurrent substance use disorder, comprising alcohol, opioid, marijuana, sedative, cocaine, inhalant, hallucinogen, or other psychoactive/stimulant use, were considered the SUD cohort (others: nSUD). Multivariable regression models were constructed to evaluate the independent association between SUD and key outcomes.

Results

Of ∼1,088,145 patients, 32,865 (3.0 %) comprised the SUD cohort. On average, SUD patients were younger, more commonly male, of lowest quartile income, and of Black race. SUD patients less frequently underwent colectomy, but more often pancreatectomy, relative to nSUD.Following risk adjustment and with nSUD as reference, SUD demonstrated similar likelihood of in-hospital mortality, but remained associated with increased odds of any perioperative complication (Adjusted Odds Ratio [AOR] 1.17, CI 1.09-1.25). Further, SUD was linked with incremental increases in adjusted length of stay (β + 0.90 days, CI +0.68-1.12) and costs (β + $3630, CI +2650-4610), as well as greater likelihood of non-home discharge (AOR 1.54, CI 1.40-1.70).

Conclusions

Concurrent substance use disorder was associated with increased complications, resource utilization, and non-home discharge following major elective abdominal operations. Novel interventions are warranted to address increased risk among this vulnerable population and address significant disparities in postoperative outcomes.

Acute Pain Management of Chronic Pain Patients in Ambulatory Surgery Centers

PURPOSE OF REVIEW

With the widespread growth of ambulatory surgery centers (ASCs), the number and diversity of operations performed in the outpatient setting continue to increase. In parallel, there is an increase in the proportion of patients with a history of chronic opioid use and misuse undergoing elective surgery. Patients with such opioid tolerance present a unique challenge in the ambulatory setting, given their increased requirement for postoperative opioids. Guidelines for managing perioperative pain, anticipating postoperative opioid requirements and a discharge plan to wean off of opioids, are therefore needed.

RECENT FINDINGS

Expert guidelines suggest using multimodal analgesia including non-opioid analgesics and regional/neuraxial anesthesia whenever possible. However, there exists variability in care, resulting in challenges in perioperative pain management. In a recent study of same-day admission patients, anesthesiologists correctly identified most opioid-tolerant patients, but used non-opioid analgesics only half the time. The concept of a focused ambulatory pain specialist on site at each ASC has been suggested, who in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized. This review focuses on perioperative pain management in three subsets of patients who exhibit opioid tolerance: those on large doses of opioids (including abuse-deterrent formulations) for chronic non-malignant or malignant pain; those who have ongoing opioid misuse; and those who were prior addicts and are now on methadone/suboxone maintenance. We also discuss perioperative pain management for patients who have implanted devices such as spinal cord stimulators and intrathecal pain pumps.

The effect of amitriptyline administration on pain-related behaviors in morphine-dependent rats: Hypoalgesia or hyperalgesia?

Pain control in opioid-dependent individuals is a clinical complication. The present study investigated the effects of different doses of amitriptyline in the three stages of the formalin test in morphine-dependent rats (MDRs). Morphine dependency was induced using the oral method, and then, amitriptyline-induced antinociceptive effects were measured at 4 doses (2.5, 5, 10, and 20 mg/kg) and compared with the control group in a formalin-based model of pain. There was no observed antinociceptive effect in the MDRs and morphine-naïve rats (MNRs) in phase I. In the interphase, amitriptyline induced pain suppression at doses of 5 and 20 mg/kg. In phase II, at doses of 5, 10, and 20 mg/kg, the hypoalgesic effect on pain-related behaviors was seen in the MNRs. In MDRs, amitriptyline at doses of 2.5 and 5 mg/kg caused the hyperalgesic effect, whereas at 10 and 20 mg/kg doses, it induced a hypoalgesic effect. A significant attenuation was observed in the latency to fall from the accelerating rotarod at doses of 10 and 20 mg/kg in the MDRs, and at a dose of 20 mg/kg in the MNRs. Data showed that amitriptyline dose-dependently induced paradoxical hypo- and hyper-algesic effects in MDRs.

Pain management for the opioid-dependent patient

This article describes the development, introduction and implementation of'Guidelines for Pain Management in the Opioid-Dependent Patient' in Yeovil District Hospital NHS Foundation Trust, Somerset. It incorporates the relevant background experiences within the organization and establishes the rationale for the development of the guidelines. An outline of the consultation processes with the different professional groups involved is given, together with the strategy for implementation across the Trust. This project challenged old ways of working and embraced new expanding roles. Indications are that both the quality of care and the patient experience have improved as a direct result of the implementation of these guidelines.