Weaning From Long-term Opioid Therapy

Satisfaction with opioid prescription and use after minor gynaecologic surgery: a pilot prospective study

To describe predictors of patient satisfaction with pain control including opioid prescribing practices, patients undergoing minor gynaecologic and urogynaecologic surgeries were included in a prospective cohort study. Satisfaction with postoperative pain control by opioid prescription status was analysed using bivariate analysis and multivariable logistic regression, controlling for potential confounders. Among participants completing both postoperative surveys, 112/141 (79.4%) reported pain control satisfaction by day 1-2 and 118/137 (86.1%) by day 14. While we were underpowered to detect a true difference in satisfaction by opioid prescription, there were no differences in opioid prescription among patients satisfied with pain control [52% vs. 60% (p = .43) among satisfied patients at day 1-2 and 58.5% vs. 37% (p = .08) at day 14]. Significant predictors of pain control satisfaction were postoperative day (POD) 1-2 average pain at rest [aOR 0.72 (95% CI 0.52-0.99), p = .04], rating of shared decision-making [aOR 1.16 (95% CI 1.004-1.34), p = .04], amount of pain relief [aOR 1.28 (95% CI 1.07-1.54), p = .008) and POD 14 shared decision-making rating [aOR 1.45 (95% CI 1.19-1.77), p = .002].Impact StatementWhat is already known on this subject? There are little data published on opioid prescription rates after minor gynaecologic procedures and no formal evidence-based guidance for gynaecologic providers for opioid prescribing. Few publications describe rates of opioid prescription and use following minor gynaecologic procedures. In the setting of a dramatic escalation of opioid misuse in the United States over the last decade, we sought to describe our practice of opioid prescription following minor gynaecologic procedures and answer the question of whether patient satisfaction is affected by opioid prescription, fill and use.What do the results of this study add? Though underpowered to detect our primary outcome, our results suggest that patient satisfaction with pain control may primarily be significantly affected by the patient's subjective assessment of shared decision-making with the gynaecologist.What are the implications of these findings for clinical practice and/or further research? Ultimately, these preliminary findings suggest a larger cohort is needed to answer the question of whether pain control satisfaction is influenced by receipt/fill/use of opioids after minor gynaecologic surgery.

Long-term analgesic and opioid prescription after surgery under general or neuraxial anesthesia: A retrospective nationwide sampling study

STUDY OBJECTIVE

Chronic postsurgical pain (CPSP) is a common and underreported but significant outcome following surgery. Pharmacological treatment with analgesics, including non-opioids and opioids, is frequently used. It has been debated whether neuraxial anesthesia can reduce persistent analgesic use. We aimed to survey long-term analgesic prescription after different surgeries under general and neuraxial anesthesia, using a nationwide database.

DESIGN

Retrospective case-control study.

SETTING

This study used data corresponding to the period from 2000 to 2016 from a longitudinal generation tracking database, which includes the claims data of 2 million randomly selected beneficiaries in Taiwan.

PATIENTS

Patients (n = 110,654) who underwent herniorrhaphy, hip/knee replacement, and lower-limb open reduction internal fixation (ORIF) or amputation were enrolled.

INTERVENTIONS

We categorized patients into general or neuraxial anesthesia groups, compared the rates of long-term analgesic prescription between the two groups, and estimated the adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) using multivariable logistic regression analysis.

MAIN RESULTS

Lower rates of long-term analgesic prescription were noted in patients who underwent herniorrhaphy (3 months post-surgery: aOR, 0.88; 95% CI, 0.84-0.93; 6 months post-surgery: aOR, 0.90; 95% CI, 0.84-0.96), hip replacement (3 months post-surgery: aOR, 0.91; 95% CI, 0.85-0.97), and lower-limb ORIF (3 months post-surgery: aOR, 0.91; 95% CI, 0.88-0.94; 6 months post-surgery: aOR, 0.95; 95% CI, 0.92-0.99) under neuraxial anesthesia than under general anesthesia. Lesser long-term opioid prescription after herniorrhaphy (3 months post-surgery: aOR, 0.52; 95% CI, 0.36-0.75; 6 months post-surgery: aOR, 0.58; 95% CI, 0.42-0.81) and lower-limb ORIF (3 months post-surgery: aOR, 0.55; 95% CI, 0.47-0.65; 6 months post-surgery: aOR, 0.67; 95% CI, 0.56-0.80) was observed under neuraxial anesthesia than under general anesthesia.

CONCLUSIONS

Neuraxial anesthesia may be associated with lower rates of long-term analgesic and opioid prescription after some surgeries, especially herniorrhaphy and lower-limb ORIF.

Pain Management in Patients with Serious Illness

Managing pain in patients with serious illness can be complex. However, pain is often a prominent symptom in patients with malignant and nonmalignant serious illness and providers have to be adept at balancing effective pain management and safety. Clinicians should start with a standard pain assessment that lays important groundwork for developing a tailored multimodal approach to pain management. It is important to identify physical causes of pain and also existential causes. Opioids are not always appropriate but are still an important tool for managing pain. Basic opioid management and safe practices are essential when managing this population.