Perioperative Pain Management for the Chronic Pain Patient With Long-Term Opioid Use

Improving Pain Self-Efficacy in Orthopedic Surgery Patients Through Video-Based Education: A Quality Improvement Project

BACKGROUND

Effective pain management following discharge is critical for postoperative recovery, with pain self-efficacy serving as a crucial component in this process. Patient education plays a key role in enhancing self-efficacy. Among various educational modalities, a growing body of evidence supports the efficacy of video-based methods.

LOCAL PROBLEM

A lack of evidence-based pain education programs for patients undergoing elective orthopedic surgery was identified at an urban academic hospital on the East Coast of the United States. This quality improvement project aimed to develop and assess a video-based pain education program, focusing on pain self-efficacy and self-reported preparedness among adult patients prescribed opioids for postsurgical pain.

METHODS

This project adopted a pretest-posttest design, utilizing the knowledge-to-action framework. Data collection spanned 3 months. Among the 69 patients screened for eligibility, 13 participants were included in the analysis. The primary intervention consisted of a 15-minute educational video covering essential pain management aspects. Following the intervention, pain self-efficacy and self-reported preparedness were evaluated using the Pain Self-Efficacy Questionnaire and a five-point Likert scale, respectively.

RESULTS

Median (IQR) scores on the Pain Self-Efficacy Questionnaire increased significantly from 20 (16) to 32 (14) (p < .01). Mean (SD) scores for patients' self-reported preparedness also increased from 21.92 (6.53) to 31.85 (2.41) (p < .01). All participants reported being satisfied or very satisfied with the educational intervention.

CONCLUSION

Video-based education is a time-efficient and cost-effective approach. Healthcare providers can consider integrating video education to enhance pain self-efficacy in the postoperative phase, thus enhancing postsurgical pain outcomes and overall recovery experience.

Efficacy of Serratus Anterior Plane Block Versus Paravertebral and Intercostal Blocks for Pain Control After Surgery:: A Systematic Review and Meta-analysis

OBJECTIVE

Our study aimed to compare the analgesic efficacy of serratus anterior plane block (SAB) with the paravertebral block (PVB) and intercostal block (ICB) for patients undergoing surgical procedures.

MATERIALS AND METHODS

A literature search was performed on the databases of ScienceDirect, Google Scholar, PubMed, and Embase from inception to October 24, 2021. Only randomized controlled trials comparing SAB with either PVB or ICB and reporting pain outcomes were included.

RESULTS

A total of 16 randomized controlled trials were included. Thirteen compared SAB with PVB and 3 with ICB. Comparing SAB with PVB, we noted no difference in 24-hour morphine consumption between the groups (mean difference: 1.37; 95% CI: -0.33, 3.08; I2 = 96%; P = 0.11). However, the exclusion of 1 study indicated significantly increased analgesic consumption with the SAB. No difference was found in pain scores between SAB and PVB at 2, 4, 6, 8, 12, and 24 hours. Meta-analysis failed to demonstrate any statistically significant difference in time to the first analgesic request between the two groups (mean difference: -0.79; 95% CI: -0.17, 1.75; I2 = 94%; P = 0.11). We also noted no statistically significant difference in the incidence of nausea/vomiting with SAB or PVB (odds ratio: 0.79; 95% CI: 0.41, 1.51; I2 = 0%; P = 0.47).

CONCLUSIONS

Evidence on the analgesic efficacy of the SAB versus the PVB is conflicting. Twenty-four-hour total analgesic consumption may be higher with the SAB as compared with PVB but with no difference in pain scores and time to the first analgesic request. Data on the comparison of the SAB with the ICB is insufficient to draw strong conclusions.

The Role of Genicular Radiofrequency Ablation in the Management of Persistent Pain after Total Knee Arthroplasty

Persistent pain is one of the most frequent complications following total knee arthroplasty (TKA) and can be devastating for the patient's quality of life. The use of genicular nerve radiofrequency ablation (GNRFA) is prevalent regarding non-surgical treatment of knee osteoarthritis. However, it is controversial when employed for the management of residual pain after TKA. This study aims to evaluate the efficacy of GNRFA for the treatment of post-TKA chronic pain and to assess the potential benefits of its use. Twelve patients sustaining chronic pain after TKA underwent GNRFA treatment. The intervention included the superior medial genicular nerve, the superior lateral genicular nerve and the inferior medial genicular nerve. Visual analog scale (VAS) system was utilized for pain assessment at 1-week, 6-month, and 1-year follow-ups. Patients experiencing chronic knee pain derived from other or unspecified causes were excluded. Mean VAS score before the treatment was 8.3, while it ended up 2.3, 5.7, and 7.9 at the 1-week, 6-month, and 1-year follow-up, respectively. Some patients reported residual pain that they regarded more bearable than before the procedure at the 1-week evaluation, with no significant alterations in the 6-month reassessment. In 2 cases results at the 1-week follow-up were dissatisfying, however, this aided us in distinguishing the cause of the persistent pain. We were not able to conclude that GNRFA used for the treatment of chronic pain after TKA is as efficacious as in knee osteoarthritis pain. However, in some cases, it proved to be beneficial regarding discerning the etiology of the pain.

Healthcare delivery gaps in pain management within the first 3 months after discharge from inpatient noncardiac surgeries: a scoping review

BACKGROUND

Poor pain control during the postoperative period has negative implications for recovery, and is a critical risk factor for development of persistent postsurgical pain. The aim of this scoping review is to identify gaps in healthcare delivery that patients undergoing inpatient noncardiac surgeries experience in pain management while recovering at home.

METHODS

Searches were conducted by a medical librarian in PubMed, MEDLINE, EMBASE, EBSCO CINAHL, Web of Science, and Cochrane Database of Systematic Reviews for articles published between 2016 and 2022. Inclusion criteria were adults (≥18 yr), English language, inpatient noncardiac surgery, and included at least one gap in care for acute and/or persistent pain management after surgery within the first 3 months of recovery at home. Two reviewers independently screened articles for inclusion and extracted data. Quotations from each article related to gaps in care were synthesised using thematic analysis.

RESULTS

There were 4794 results from databases and grey literature, of which 38 articles met inclusion criteria. From these, 23 gaps were extracted, encompassing all six domains of healthcare delivery (capacity, organisational structure, finances, patients, care processes and infrastructure, and culture). Identified gaps were synthesised into five overarching themes: education (22 studies), provision of continuity of care (21 studies), individualised management (10 studies), support for specific populations (11 studies), and research and knowledge translation (10 studies).

CONCLUSIONS

This scoping review identified health delivery gaps during a critical period in postoperative pain management. These gaps represent potential targets for quality improvement and future research to improve perioperative care and longer-term patient-centred outcomes.

SCOPING REVIEW PROTOCOL

Open Science Framework (https://osf.io/cq5m6/).

Nonpharmacological interventions for acute pain management in patients with opioid abuse or opioid tolerance: a scoping review

OBJECTIVE

The objective of this scoping review was to identify and map the evidence on nonpharmacological interventions for acute pain management in patients with opioid tolerance or opioid abuse.

INTRODUCTION

Opioid therapy is the mainstay of pain management for adults experiencing moderate-to-severe acute pain. However, considering the known risks of opioid use and the growing number of patients with opioid tolerance or opioid abuse, nonpharmacological pain management interventions are of increasing interest to health care providers. Nonpharmacological techniques have shown potential in reducing postoperative pain, opioid consumption, stress, and anxiety.

INCLUSION CRITERIA

Eligible studies included participants in either inpatient or outpatient health care settings who were experiencing acute pain and a tolerance to opioid medications or opioid abuse. Studies that examined nonpharmacological interventions for treating acute pain in these patients were considered. Nonpharmacological interventions included, but were not limited to, acupuncture, electroacupuncture, massage, mindfulness, electroanalgesia, low-level light therapy, meditation, biofeedback, hypnosis, and relaxation techniques.

METHODS

MEDLINE, CINAHL, Scopus, Embase, Europe PubMed Central, PsycINFO, Cochrane Central Register of Controlled Trials, and the US National Library of Medicine ( https://ClinicalTrials.gov/ ) were searched, as were sources of unpublished studies on December 30, 2020. Only studies published in English were included, and there was no limit on date of publication. After screening the titles and abstracts of identified citations, 2 independent reviewers retrieved potentially relevant full-text studies and extracted data. Data are presented in diagrammatic format, and accompany the narrative synthesis.

RESULTS

Fourteen articles were included in the study, including 10 expert opinion papers or chapters, 3 case reports, and 1 implementation report. The most common setting was the perioperative setting, specifically orthopedic surgery. Nonpharmacological pain interventions identified in the literature included physical interventions such as acupuncture, physical therapy, therapeutic exercise, yoga, bracing, heat, cold, elevation, compression, chiropractic interventions, massage, manual therapy, transcutaneous electrical nerve stimulation, and pulsed electromagnetic field therapy. Behavioral and psychological modalities included positive affirmations, cognitive behavioral therapy, acceptance and commitment therapy, mindfulness, distraction, guided imagery, meditation, biofeedback, relaxation, hypnosis, breathing exercises, and energy healing. Many expert opinions included only brief mentions or recommendations for nonpharmacological interventions without full explanations, evidence from the literature, or discussion of the level of support for the recommendation.

CONCLUSIONS

The findings of this review indicate that nonpharmacological interventions for patients with opioid tolerance or dependence include physical, psychological, and multimodal approaches. Nonpharmacological interventions in this scoping review were often presented as combined with opioid or non-opioid medications for a pain management regimen that is opioid-sparing, opioid-free, or drug-free. More primary research is needed on the nonpharmacological acute pain management of patients with opioid dependence or opioid tolerance.

The impact of pain neuroscience education in a Hispanic-American population: A mixed-methods exploratory study

BACKGROUND

Chronic pain and pain catastrophization are growing problems across the United States, within the Hispanic-American population. Pain neuroscience education (PNE) changes pain knowledge and beliefs in many populations, but its impact on reconceptualization in people of Hispanic-American origin is unknown.

PURPOSE

Explore the changes in pain knowledge in Hispanic-American individuals and the process involved in reconceptualization following a PNE lecture.

METHODS

Eight Hispanic-American adults participated in a mixed-methods exploratory study. The Revised Neurophysiology of Pain Questionnaire (R-NPQ) was completed before, immediately after, and eight months after an adapted PNE lecture. A focus group involving four participants discussed the impact of PNE. Transcripts were translated and theme coded, and a concept map was developed by consensus.

RESULTS

R-NPQ scores improved from 25.3% to 43.5% post-lecture, and the number of unsure responses decreased from 41.5% to 18.4%. At eight months, R-NPQ scores remained stable (44.2%) but unsure responses increased (28.9%). Themes that contributed to the process of change included cognitive dissonance, relevance of instruction, idea exchange through peer interaction, reflection, confidence, changed behaviors, and educational utility.

CONCLUSION

While small improvements in knowledge and perception of pain appeared to occur with the PNE, knowledge remained low. Consideration of adult learning principles such as applicability, peer-interaction, the confrontation of beliefs, and reflection throughout PNE may enhance its impact. Future investigation should explore the efficacy of this intervention, when compared or combined with other techniques in the treatment of Hispanic-Americans experiencing persistent pain.

Management of Refractory Pain After Total Joint Replacement

PURPOSE OF REVIEW

Chronic pain after total joint replacement (TJA), specifically total knee replacement (TKA), is becoming more of a burden on patients, physicians, and the healthcare system as the number of joint replacements performed increases year after year. The management of this type of pain is critical, and therefore, understanding the various modalities physicians can use to help patients with refractory pain after TJA is essential.

RECENT FINDINGS

The modalities by which chronic pain can be successfully managed include genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). Meta-analyses and case reports have demonstrated the effectiveness of these treatment options in improving pain and functional outcomes in patients with chronic pain after TKA. The purpose of this paper is to review and synthesize the current literature investigating the different ways that refractory pain is managed after TJA, with the goal being to provide treatment recommendations for providers treating these patients.

Improving satisfaction with postoperative pain management for patients with persistent pain: a preoperative pain medicine consultation intervention

PURPOSE

Preoperative pain medicine consultations with opioid-tolerant patients allow for an accurate medication history, patient involvement in the postoperative plan, and realistic goal setting. The purpose of this quality improvement project was to increase attendance at preoperative pain consultations, thereby increasing patient satisfaction.

METHODS

Retrospective chart reviews identified patients who had a preoperative pain consultation ordered from May through July 2016. Patient interviews determined reasons for not attending appointments, involvement in goal setting, engagement in pain management planning, and satisfaction with postoperative pain management.

RESULTS

Retrospective chart reviews and interviews were conducted after the intervention (May-July 2017). Scheduling changes increased attendance at preoperative pain consultations by 14 percentage points (50% vs 64%). Those who attended consultations were more involved in goal setting and decisions and were more satisfied.

CONCLUSIONS

Preoperative pain consultations with opioid-tolerant patients can increase satisfaction through realistic goal setting and involvement in the pain management plan.

A Practical Approach to Acute Postoperative Pain Management in Chronic Pain Patients

In the United States, more than 100 million people suffer from chronic pain. Among patients presenting for surgery, about one in four have chronic pain. Acute perioperative pain management in this population is challenging because many patients with chronic pain require long-term opioids for the management of this pain, which may result in tolerance, physical dependence, addiction, and opioid-induced hyperalgesia. These challenges are compounded by the ongoing opioid epidemic that has resulted in calls for a reduction in opioid use, with a concurrent increase in the number of patients with chronic opioid exposure presenting for surgery. This article aims to summarize practical considerations for acute postoperative pain management in patients with chronic pain conditions. A patient-centered acute pain management plan, including nonopioid analgesics, regional anesthesia, and careful selection of opioid medications, can lead to adequate analgesia and satisfaction with care. Also, a meticulous rotation from one opioid to another may decrease opioid requirement, increase analgesic effectiveness, and improve satisfaction with care.

A Systematic Review of Care Needs for Surgical Patients with Chronic Opioid Use

An understudied aspect of the opioid crisis with implications for nursing is care of hospitalized surgical patients with chronic opioid use. Care needs of these patients are not well understood. This systematic review identified salient care needs and explored the role of nursing in meeting these needs.