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Yessaillian A, Reese M, Clark RC, Becker M, Lopes K, Alving-Trinh A, Llaneras J, McPherson M, Gosman A, Reid CM. A systematic review of morphine equivalent conversions in plastic surgery: Current methods and future directions. J Plast Reconstr Aesthet Surg 2024; 95:142-151. [PMID: 38909598 DOI: 10.1016/j.bjps.2024.06.001] [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: 02/20/2024] [Revised: 05/16/2024] [Accepted: 06/01/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a frequently analyzed outcome. Though often examined, there is no literature standard conversion for morphine milligram equivalents (MME) at present, leading to questionable external validity. We hypothesized significant heterogeneity in MME reporting would exist within plastic surgery literature. METHODS Following the PRISMA guidelines, the authors conducted a systematic review of 16 journals. Clinical studies focused on opioid reduction within plastic surgery were identified. Primary outcomes included reporting of morphine equivalents (ME) delivery (IV/oral), operative ME, inpatient ME, outpatient ME, timeline, and method of calculation. RESULTS Among the 101 studies analyzed, 73% reported opioid requirements in the form of ME. Among those that used ME, 3% reported IV ME, 41% reported oral, 32% reported both, and 25% gave no indication of either. Operative ME were reported in 19% of studies. Furthermore, 54% of studies reported inpatient ME whereas 32% of studies reported outpatient ME. Only 19% reported the number of days opioids were consumed postoperatively. Moreover, 27% of the studies reported the actual method of ME conversion, with 17 unique methods described. Only 8 studies (8%) reported using the Center for Disease Control and Prevention guidelines for ME conversion. CONCLUSION There is significant variability among the reported ME conversion methodology within plastic surgery literature. Highlighting these discrepancies is an essential step in creating and implementing a single, standard method to mitigate opioid morbidity in plastic surgery and to optimize enhanced recovery protocols.
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Affiliation(s)
- Andrea Yessaillian
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - McKay Reese
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Robert Craig Clark
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Miriam Becker
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Kelli Lopes
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Alexandra Alving-Trinh
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Jason Llaneras
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Mary McPherson
- University of Maryland School of Pharmacy, 20 N Pine St, Baltimore, MD 21201, United States
| | - Amanda Gosman
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Chris M Reid
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States.
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Knackstedt RW, Lin JH, Kakoty S. Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5874. [PMID: 38855138 PMCID: PMC11161287 DOI: 10.1097/gox.0000000000005874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/08/2024] [Indexed: 06/11/2024]
Abstract
Background Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus bupivacaine after deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods This retrospective cohort study used the IQVIA claims databases to identify patients undergoing primary DIEP flap breast reconstruction in 2016-2019. Patients receiving LB and those receiving bupivacaine were compared to assess opioid utilization in morphine milligram equivalents (MMEs) and healthcare resource utilization during perioperative (2 weeks before surgery to 2 weeks after discharge) and 6-month postdischarge periods. A generalized linear mixed-effects model and inverse probability of treatment weighting method were performed. Results Weighted baseline characteristics were similar between cohorts (LB, n = 669; bupivacaine, n = 348). The LB cohort received significantly fewer mean MMEs versus the bupivacaine cohort during the perioperative (395 versus 512 MMEs; rate ratio [RR], 0.771 [95% confidence interval (CI), 0.677-0.879]; P = 0.0001), 72 hours after surgery (63 versus 140 MMEs; RR, 0.449 [95% CI, 0.347-0.581]; P < 0.0001), and inpatient (154 versus 303 MMEs; RR, 0.508 [95% CI, 0.411-0.629]; P < 0.0001) periods; postdischarge filled opioid prescriptions were comparable. The LB cohort was less likely to have all-cause inpatient readmission (odds ratio, 0.670 [95% CI, 0.452-0.993]; P = 0.046) and outpatient clinic/office visits (odds ratio, 0.885 [95% CI, 0.785-0.999]; P = 0.048) 3 months after discharge than the bupivacaine cohort; other all-cause healthcare resource utilization outcomes were not different. Conclusions LB was associated with fewer perioperative MMEs and all-cause 3-month inpatient readmissions and outpatient clinic/office visits than bupivacaine in patients undergoing DIEP flap breast reconstruction.
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Clark RC, Segal R, Kordahi A, Sendek G, Alving-Trinh A, Abramson W, Sztain J, Swisher M, Gabriel RA, Gosman A, Said ET, Reid CM. An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery. Ann Plast Surg 2024; 92:549-556. [PMID: 38563567 DOI: 10.1097/sap.0000000000003833] [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: 04/04/2024]
Abstract
INTRODUCTION Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions. METHODS All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared. RESULTS Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01). CONCLUSIONS This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.
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Affiliation(s)
| | | | | | | | | | - Wendy Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Jacklynn Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Matthew Swisher
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | | | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA
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Jankulov A, As-Sanie S, Zimmerman C, Virzi J, Srinivasan S, Choe HM, Brummett CM. Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study. J Pain Res 2024; 17:667-675. [PMID: 38375407 PMCID: PMC10875180 DOI: 10.2147/jpr.s432262] [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: 07/26/2023] [Accepted: 12/28/2023] [Indexed: 02/21/2024] Open
Abstract
Purpose The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy. Patients and Methods The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert. Results 332 patients were included. The BPA triggered 29 times. The following actions were taken among 16 patients for whom the BPA triggered: "override the alert" (n=13); "cancel the alert" (n=2); and 'remove the opioid order set' (n=1). 12/16 patients had discharge prescriptions: one patient received 20 tablets; two received 10 tablets; and nine received 15 tablets. Top reasons for over prescribing included concerns for pain control and lack of alternatives. Conclusion Implementing a post-discharge opioid prescribing BPA aligned opioid prescribing following benign minimally invasive hysterectomy with guideline recommendations.
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Affiliation(s)
- Alexandra Jankulov
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
| | - Sawsan As-Sanie
- Department of Obstetrics & Gynecology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Christopher Zimmerman
- Department of Health Information and Technology Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jessica Virzi
- Department of Precision Health, University of Michigan Health System, Ann Arbor, MI, USA
| | - Sudharsan Srinivasan
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Hae Mi Choe
- Department of Health Information and Technology Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI, USA
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Radhakrishna U, Sadhasivam S, Radhakrishnan R, Forray A, Muvvala SB, Metpally RP, Patel S, Rawal RM, Vishweswaraiah S, Bahado-Singh RO, Nath SK. Placental cytochrome P450 methylomes in infants exposed to prenatal opioids: exploring the effects of neonatal opioid withdrawal syndrome on health horizons. Front Genet 2024; 14:1292148. [PMID: 38264209 PMCID: PMC10805101 DOI: 10.3389/fgene.2023.1292148] [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: 09/11/2023] [Accepted: 11/24/2023] [Indexed: 01/25/2024] Open
Abstract
Background: Neonatal opioid withdrawal syndrome (NOWS), arises due to increased opioid use during pregnancy. Cytochrome P450 (CYP) enzymes play a pivotal role in metabolizing a wide range of substances in the human body, including opioids, other drugs, toxins, and endogenous compounds. The association between CYP gene methylation and opioid effects is unexplored and it could offer promising insights. Objective: To investigate the impact of prenatal opioid exposure on disrupted CYPs in infants and their anticipated long-term clinical implications. Study Design: DNA methylation levels of CYP genes were analyzed in a cohort of 96 placental tissues using Illumina Infinium MethylationEPIC (850 k) BeadChips. This involved three groups of placental tissues: 32 from mothers with infants exposed to opioids prenatally requiring pharmacologic treatment for NOWS, 32 from mothers with prenatally opioid-exposed infants not needing NOWS treatment, and 32 from unexposed control mothers. Results: The study identified 20 significantly differentially methylated CpG sites associated with 17 distinct CYP genes, with 14 CpGs showing reduced methylation across 14 genes (CYP19A1, CYP1A2, CYP4V2, CYP1B1, CYP24A1, CYP26B1, CYP26C1, CYP2C18, CYP2C9, CYP2U1, CYP39A1, CYP2R1, CYP4Z1, CYP2D7P1 and), while 8 exhibited hypermethylation (CYP51A1, CYP26B1, CYP2R1, CYP2U1, CYP4X1, CYP1A2, CYP2W1, and CYP4V2). Genes such as CYP1A2, CYP26B1, CYP2R1, CYP2U1, and CYP4V2 exhibited both increased and decreased methylation. These genes are crucial for metabolizing eicosanoids, fatty acids, drugs, and diverse substances. Conclusion: The study identified profound methylation changes in multiple CYP genes in the placental tissues relevant to NOWS. This suggests that disruption of DNA methylation patterns in CYP transcripts might play a role in NOWS and may serve as valuable biomarkers, suggesting a future pathway for personalized treatment. Further research is needed to confirm these findings and explore their potential for diagnosis and treatment.
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Affiliation(s)
- Uppala Radhakrishna
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI, United States
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rupa Radhakrishnan
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Srinivas B. Muvvala
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Raghu P. Metpally
- Department of Molecular and Functional Genomics, Geisinger, Danville, PA, United States
| | - Saumya Patel
- Department of Botany, Bioinformatics and Climate Change Impacts Management, School of Science, Gujarat University, Ahmedabad, India
| | - Rakesh M. Rawal
- Department of Life Sciences, School of Sciences, Gujarat University, Ahmedabad, India
| | - Sangeetha Vishweswaraiah
- Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI, United States
| | - Ray O. Bahado-Singh
- Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI, United States
| | - Swapan K. Nath
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
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Fearon NJ, Kurtzman J, Benfante N, Assel M, Vickers A, Carlsson S, Laudone VP, Levine M, Simon BA, Mehrara BJ, Nelson JA. Reducing opioid prescribing after ambulatory breast reconstruction surgery. J Surg Oncol 2023; 128:1235-1242. [PMID: 37653689 PMCID: PMC10841230 DOI: 10.1002/jso.27427] [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: 05/21/2023] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND The lack of evidence-based guidelines for postoperative opioid prescriptions following breast reconstruction contributes to a wide variation in prescribing practices and increases potential for misuse and abuse. METHODS Between August and December 2019, women who underwent outpatient breast reconstruction were surveyed 7-10 days before (n = 97) and after (n = 101) implementing a standardized opioid prescription reduction initiative. We compared postoperative opioid use, pain control, and refills in both groups. Patient reported outcomes were compared using the BREAST-Q physical wellbeing of the chest domain and a novel symptom Recovery Tracker. RESULTS Before changes in prescriptions, patients were prescribed a median of 30 pills and consumed three pills (interquartile range [IQR: 1,9]). After standardization, patients were prescribed eight pills and consumed three pills (IQR: 1,6). There was no evidence of a difference in the proportion of patients experiencing moderate to very severe pain on the Recovery Tracker or in the early BREAST-Q physical wellbeing of the chest scores (p = 0.8 and 0.3, respectively). CONCLUSION Standardizing and reducing opioid prescriptions for patients undergoing reconstructive breast surgery is feasible and can significantly decrease the number of excess pills prescribed. The was no adverse impact on early physical wellbeing, although larger studies are needed to obtain further data.
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Affiliation(s)
- Nkechi J. Fearon
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joey Kurtzman
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicole Benfante
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa Assel
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew Vickers
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sigrid Carlsson
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Sweden
| | - Vincent P. Laudone
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marcia Levine
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brett A. Simon
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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7
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Mundra L, Garossi K, Iorio M, Mathes D, Winocour J, Kaoutzanis C. Opioid-Prescribing Patterns in Body Contouring Surgery. Aesthet Surg J 2023; 43:978-985. [PMID: 37185594 DOI: 10.1093/asj/sjad117] [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: 01/27/2023] [Revised: 04/16/2023] [Accepted: 04/23/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND The United States is experiencing the highest opioid overdose death rate in our nation's history. Misuse and addiction to opioids, including prescription pain relievers, is a serious national crisis that affects public health as well as social and economic welfare. OBJECTIVES The aim of the study was to critically evaluate postoperative opioid-prescribing patterns. METHODS The PearlDiver database (Colorado Springs, CO) was queried for body contouring patients from 2010 to 2020. We identified patients that underwent panniculectomy, abdominoplasty, brachioplasty, thighplasty, mastopexy, breast augmentation, breast reduction, and liposuction for analysis. We subsequently analyzed the opioid use, with a focus on comorbid conditions and complications that are associated with increased use of opioids. RESULTS A total of 56,773 patients underwent body contouring surgery. The most common opioid prescribed was hydrocodone with acetaminophen (37,017 patients). Average days of therapy was 17.92 days. Comorbid conditions and postoperative complications were examined for risk of increased opioid prescriptions. Patients with peripheral vascular disease and smoking were prescribed significantly more morphine milliequivalents (MME) of opioids than patients without peripheral vascular disease (871.97 vs 535.41; P < .001) and smoking (1069.57 vs 440.84; P < .001). Patients who developed surgical site infection, disruption of wound, and venous thromboembolism were prescribed a significantly higher MME of opioids (1213.63 vs 561.59; P < .001). CONCLUSIONS Our data provide information on opioid prescription patterns in the body contouring population, with focused review of comorbid conditions and complications in relation to opioid-prescribing patterns. We hope that the data will improve opioid prescription habits among plastic surgeons in the setting of a global opioid crisis.
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Cheah MA, Sarmiento S, Lesko RP, El Eter L, Siotos C, McColl MA, Manahan MA, Sacks JM, Maher DP, Rosson GD, Cooney CM. Association of preoperative opioid use and postoperative complications following breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 83:258-265. [PMID: 37285777 DOI: 10.1016/j.bjps.2023.05.007] [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: 09/28/2021] [Revised: 03/14/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). METHODS We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. RESULTS Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. CONCLUSION We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.
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Affiliation(s)
- Michael A Cheah
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA; Department of Plastic and Reconstructive Surgery, UT Southwestern, Dallas, TX 75390, USA
| | - Samuel Sarmiento
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Robert P Lesko
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Leen El Eter
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Charalampos Siotos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Michael A McColl
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Michele A Manahan
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO 63110, USA
| | - Dermot P Maher
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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Zhang KK, Blum K, Chu JJ, Zewdu A, Janse S, Skoracki R, Janis JE, Barker JC. A Personalized Opioid Prescription Model for Predicting Postoperative Discharge Opioid Needs. Plast Reconstr Surg 2023; 151:450-460. [PMID: 36696335 PMCID: PMC10449368 DOI: 10.1097/prs.0000000000009865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Opioid overprescribing after surgery is common. There is currently no universal predictive tool available to accurately anticipate postdischarge opioid need in a patient-specific manner. This study examined the efficacy of a patient-specific opioid prescribing framework for estimating postdischarge opioid consumption. METHODS A total of 149 patients were evaluated for a single-center retrospective cohort study of plastic and reconstructive surgery patients. Patients with length of stay of 2 to 8 days and quantifiable inpatient opioid consumption (n = 116) were included. Each patient's daily postoperative inpatient opioid consumption was used to generate a personalized logarithmic regression model to estimate postdischarge opioid need. The validity of the personalized opioid prescription (POP) model was tested through comparison with actual postdischarge opioid consumption reported by patients 4 weeks after surgery. The accuracy of the POP model was compared with two other opioid prescribing models. RESULTS The POP model had the strongest association (R2 = 0.899; P < 0.0001) between model output and postdischarge opioid consumption when compared to a procedure-based (R2 = 0.226; P = 0.025) or a 24-hour (R2 = 0.152; P = 0.007) model. Accuracy of the POP model was unaffected by age, gender identity, procedure type, or length of stay. Odds of persistent use at 4 weeks increased, with a postdischarge estimated opioid need at a rate of 1.16 per 37.5 oral morphine equivalents (P = 0.010; 95% CI, 1.04 to 1.30). CONCLUSIONS The POP model accurately estimates postdischarge opioid consumption and risk of developing persistent use in plastic surgery patients. Use of the POP model in clinical practice may lead to more appropriate and personalized opioid prescribing.
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Affiliation(s)
- Kevin K. Zhang
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Kevin Blum
- Center for Regenerative Medicine, Nationwide Children’s Hospital, Columbus, OH
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH
| | - Jacqueline J. Chu
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abeba Zewdu
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Sarah Janse
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Medical Center, Columbus, OH
| | - Roman Skoracki
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Jenny C. Barker
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
- Center for Regenerative Medicine, Nationwide Children’s Hospital, Columbus, OH
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Muscat SM, Deems NP, Butler MJ, Scaria EA, Bettes MN, Cleary SP, Bockbrader RH, Maier SF, Barrientos RM. Selective TLR4 Antagonism Prevents and Reverses Morphine-Induced Persistent Postoperative Cognitive Dysfunction, Dysregulation of Synaptic Elements, and Impaired BDNF Signaling in Aged Male Rats. J Neurosci 2023; 43:155-172. [PMID: 36384680 PMCID: PMC9838714 DOI: 10.1523/jneurosci.1151-22.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/07/2022] [Accepted: 11/10/2023] [Indexed: 11/18/2022] Open
Abstract
Perioperative neurocognitive disorders (PNDs) are characterized by confusion, difficulty with executive function, and episodic memory impairment in the hours to months following a surgical procedure. Postoperative cognitive dysfunction (POCD) represents such impairments that last beyond 30 d postsurgery and is associated with increased risk of comorbidities, progression to dementia, and higher mortality. While it is clear that neuroinflammation plays a key role in PND development, what factors underlie shorter self-resolving versus persistent PNDs remains unclear. We have previously shown that postoperative morphine treatment extends POCD from 4 d (without morphine) to at least 8 weeks (with morphine) in aged male rats, and that this effect is likely dependent on the proinflammatory capabilities of morphine via activation of toll-like receptor 4 (TLR4). Here, we extend these findings to show that TLR4 blockade, using the selective TLR4 antagonist lipopolysaccharide from the bacterium Rhodobacter sphaeroides (LPS-RS Ultrapure), ameliorates morphine-induced POCD in aged male rats. Using either a single central preoperative treatment or a 1 week postoperative central treatment regimen, we demonstrate that TLR4 antagonism (1) prevents and reverses the long-term memory impairment associated with surgery and morphine treatment, (2) ameliorates morphine-induced dysregulation of the postsynaptic proteins postsynaptic density 95 and synaptopodin, (3) mitigates reductions in mature BDNF, and (4) prevents decreased activation of the BDNF receptor TrkB (tropomyosin-related kinase B), all at 4 weeks postsurgery. We also reveal that LPS-RS Ultrapure likely exerts its beneficial effects by preventing endogenous danger signal HMGB1 (high-mobility group box 1) from activating TLR4, rather than by blocking continuous activation by morphine or its metabolites. These findings suggest TLR4 as a promising therapeutic target to prevent or treat PNDs.SIGNIFICANCE STATEMENT With humans living longer than ever, it is crucial that we identify mechanisms that contribute to aging-related vulnerability to cognitive impairment. Here, we show that the innate immune receptor toll-like receptor 4 (TLR4) is a key mediator of cognitive dysfunction in aged rodents following surgery and postoperative morphine treatment. Inhibition of TLR4 both prevented and reversed surgery plus morphine-associated memory impairment, dysregulation of synaptic elements, and reduced BDNF signaling. Together, these findings implicate TLR4 in the development of postoperative cognitive dysfunction, providing mechanistic insight and novel therapeutic targets for the treatment of cognitive impairments following immune challenges such as surgery in older individuals.
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Affiliation(s)
- Stephanie M Muscat
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, Ohio 43210
- Biomedical Sciences Graduate Program, The Ohio State University, Columbus, Ohio 43210
| | - Nicholas P Deems
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, Ohio 43210
- Neuroscience Graduate Program, The Ohio State University, Columbus, Ohio 43210
| | - Michael J Butler
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, Ohio 43210
| | - Emmanuel A Scaria
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, Ohio 43210
| | - Menaz N Bettes
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, Ohio 43210
| | - Sean P Cleary
- Campus Chemical Instrumentation Center, The Ohio State University, Columbus, Ohio 43210
| | - Ross H Bockbrader
- Pharmaceutical Sciences Graduate Program, Division of Medicinal Chemistry and Pharmacognosy, The Ohio State University, Columbus, Ohio 43210
| | - Steven F Maier
- Department of Psychology and Neuroscience, Center for Neuroscience, University of Colorado Boulder, Boulder, Colorado 80309
| | - Ruth M Barrientos
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, Ohio 43210
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, Ohio 43210
- Department of Neuroscience, The Ohio State University, Columbus, Ohio 43210
- Chronic Brain Injury Program, The Ohio State University, Columbus, Ohio 43210
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11
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Cogan JC, Raghunathan RR, Beauchemin MP, Accordino MK, Huang Y, Elkin EB, Melamed A, Wright JD, Hershman DL. New and Persistent Sedative-Hypnotic Use After Adjuvant Chemotherapy for Breast Cancer. J Natl Cancer Inst 2022; 114:1698-1705. [PMID: 36130058 PMCID: PMC9745429 DOI: 10.1093/jnci/djac170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/19/2022] [Accepted: 08/23/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Sedative-hypnotic medications are used to treat chemotherapy-related nausea, anxiety, and insomnia. However, prolonged sedative-hypnotic use can lead to dependence, misuse, and increased health-care use. We aimed to estimate the rates at which patients who receive adjuvant chemotherapy for breast cancer become new persistent users of sedative-hypnotic medications, specifically benzodiazepines and nonbenzodiazepine sedative-hypnotics (Z-drugs). METHODS Using the MarketScan health-care claims database, we identified sedative-hypnotic-naïve patients who received adjuvant chemotherapy for breast cancer. Patients who filled 1 and more prescriptions during chemotherapy and 2 and more prescriptions up to 1 year after chemotherapy were classified as new persistent users. Univariate and multivariable logistic regression analyses were used to estimate odds of new persistent use and associated characteristics. RESULTS We identified 22 039 benzodiazepine-naïve patients and 23 816 Z-drug-naïve patients who received adjuvant chemotherapy from 2008 to 2017. Among benzodiazepine-naïve patients, 6159 (27.9%) filled 1 and more benzodiazepine prescriptions during chemotherapy, and 963 of those (15.6%) went on to become new persistent users. Among Z-drug-naïve patients, 1769 (7.4%) filled 1 and more prescriptions during chemotherapy, and 483 (27.3%) became new persistent users. In both groups, shorter durations of chemotherapy and receipt of opioid prescriptions were associated with new persistent use. Medicaid insurance was associated with new persistent benzodiazepine use (odds ratio = 1.88, 95% confidence interval = 1.43 to 2.47) compared with commercial or Medicare insurance. CONCLUSIONS Patients who receive sedative-hypnotic medications during adjuvant chemotherapy for breast cancer are at risk of becoming new persistent users of these medications after chemotherapy. Providers should ensure appropriate sedative-hypnotic use through tapering dosages and encouraging nonpharmacologic strategies when appropriate.
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Affiliation(s)
- Jacob C Cogan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Rohit R Raghunathan
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Melissa P Beauchemin
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Melissa K Accordino
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Yongmei Huang
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Elena B Elkin
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
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12
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Santosa KB, Wang CS, Hu HM, Mullen CR, Brummett CM, Englesbe MJ, Bicket MC, Myers PL, Waljee JF. Opioid Coprescribing with Sedatives after Implant-Based Breast Reconstruction. Plast Reconstr Surg 2022; 150:1224e-1235e. [PMID: 36103669 PMCID: PMC9712174 DOI: 10.1097/prs.0000000000009726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Skeletal muscle relaxants and benzodiazepines are thought to mitigate against postoperative muscle contraction. The Centers for Disease Control and Prevention and the Food and Drug Administration warn against coprescribing them with opioids because of increased risks of overdose and death. The authors evaluated the frequency of coprescribing of opioids with skeletal muscle relaxants or benzodiazepines after implant-based reconstruction. METHODS The authors examined health care claims to identify women (18 to 64 years old) who underwent implant-based breast reconstruction between January of 2008 and June of 2019 to determine the frequency of coprescribing, factors associated with coprescribing opioids and skeletal muscle relaxants or benzodiazepines, and the impact on opioid refills within 90 days of reconstruction. RESULTS A total of 86.7 percent of women ( n = 7574) who had implant-based breast reconstruction filled an opioid prescription perioperatively. Of these, 27.7 percent of women filled prescriptions for opioids and benzodiazepines, 14.4 percent for opioids and skeletal muscle relaxants, and 2.4 percent for opioids, benzodiazepines, and skeletal muscle relaxants. Risk factors for coprescribing opioids and benzodiazepines included use of acellular dermal matrix, immediate reconstruction, and history of anxiety. Women who filled prescriptions for opioids and skeletal muscle relaxants, opioids and benzodiazepines, and opioids with skeletal muscle relaxants and benzodiazepines were significantly more likely to refill opioid prescriptions, even when controlling for preoperative opioid exposure. CONCLUSIONS Nearly half of women filled an opioid prescription with a benzodiazepine, skeletal muscle relaxant, or both after implant-based breast reconstruction. Coprescribing of opioids with skeletal muscle relaxants may potentiate opioid use after surgery and should be avoided given the risks of sedation. Identifying strategies that avoid sedatives to manage pain after breast reconstruction is critical to mitigate high-risk prescribing practices. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Katherine B. Santosa
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Christine S. Wang
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Hsou-Mei Hu
- Analyst, Michigan Opioid Prescribing Engagement Network (Michigan OPEN), University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Connor R. Mullen
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Chad M. Brummett
- Professor, Division of Pain Research, Department of Anesthesiology, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Michael J. Englesbe
- Professor of Surgery, Section of Transplantation, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Mark C. Bicket
- Assistant Professor, Division of Pain Research, Department of Anesthesiology University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Paige L. Myers
- Assistant Professor, Section of Plastic Surgery, Department of Surgery, University Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Jennifer F. Waljee
- Associate Professor, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
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13
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Chattopadhyay A, Shah JK, Yesantharao P, Ho VT, Sheckter CC, Nazerali R. Transversus abdominus plane blocks do not reduce rates of postoperative prolonged opioid use following abdominally based autologous breast reconstruction: a nationwide longitudinal analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022; 46:203-213. [PMID: 36212234 PMCID: PMC9530417 DOI: 10.1007/s00238-022-01996-5] [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: 06/05/2022] [Accepted: 08/26/2022] [Indexed: 12/02/2022]
Abstract
Background The transversus abdominus plane (TAP) block reduces postoperative donor site pain in patients undergoing autologous breast reconstruction with an abdominally based flap. This study aimed to determine the effect of TAP blocks on rates of conversion to chronic opioid use. Methods The Clinformatics Data Mart was queried from 2003 to 2019, extracting adult encounters for abdominally based free and pedicled flaps based on common procedural terminology (CPT) codes. Patients were excluded if they had filled a narcotic prescription 1 year to 30 days prior to surgery. The exposure variable-TAP block-was identified by CPT codes. Outcomes were evaluated using morphine milligram equivalents (MME) from prescriptions filled between 30 days prior to and 30 days after surgery. Chronic opioid use (COU) was defined as receiving 4 unique prescriptions or a 60-day supply between 30 and 180 days after surgery. Results Of the 4091 patients, (mean age 51.2 ± 9.0 years), 181 (4.4%) had a TAP block placed. Perioperative MMEs/day, postoperative COU, and length of stay did not differ in patients who received a TAP block (p = 0.142; p = 0.271). Significant predictors of risk of conversion to COU included younger age, pedicled abdominal flap, Elixhauser comorbidity index score > 3, filling a psychiatric medication prescription, and filling a benzodiazepine prescription. Conclusions In patients undergoing autologous breast reconstruction with abdominally based flap reconstruction, TAP blocks do not decrease perioperative MME/day, conversion to chronic opioid use, or length of stay. These data suggest that intraoperative TAP block placement may be a low-yield opioid-reduction strategy.Level of evidence: Level III, risk/prognostic study.
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Affiliation(s)
- Arhana Chattopadhyay
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road Suite 400, Palo Alto, 94304 CA USA
| | - Jennifer Krupa Shah
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road Suite 400, Palo Alto, 94304 CA USA
| | - Pooja Yesantharao
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road Suite 400, Palo Alto, 94304 CA USA
| | - Vy Thuy Ho
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road Suite 400, Palo Alto, 94304 CA USA
| | - Clifford C. Sheckter
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road Suite 400, Palo Alto, 94304 CA USA
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road Suite 400, Palo Alto, 94304 CA USA
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14
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Kowa CY, Jin Z, Gan TJ. Framework, component, and implementation of enhanced recovery pathways. J Anesth 2022; 36:648-660. [PMID: 35789291 PMCID: PMC9255474 DOI: 10.1007/s00540-022-03088-x] [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: 06/30/2021] [Accepted: 06/15/2022] [Indexed: 12/01/2022]
Abstract
The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).
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Affiliation(s)
- Chao-Ying Kowa
- Department of Anaesthesia, Whittington Hospital, Magdala Ave, London, N19 5NF, UK
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA.
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15
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Pak LM, Pawloski KR, Sevilimedu V, Kalvin HL, Le T, Tokita HK, Tadros A, Morrow M, Van Zee KJ, Kirstein LJ, Moo TA. How Much Pain Will I Have After Surgery? A Preoperative Nomogram to Predict Acute Pain Following Mastectomy. Ann Surg Oncol 2022; 29:6706-6713. [PMID: 35699814 PMCID: PMC9196152 DOI: 10.1245/s10434-022-11976-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Acute postoperative pain affects time to opioid cessation and quality of life, and is associated with chronic pain. Effective screening tools are needed to identify patients at increased risk of experiencing more severe acute postoperative pain, and who may benefit from multimodal analgesia and early pain management referral. In this study, we develop a nomogram to preoperatively identify patients at high risk of moderate-severe pain following mastectomy. METHODS Demographic, psychosocial, and clinical variables were retrospectively assessed in 1195 consecutive patients who underwent mastectomy from January 2019 to December 2020 and had pain scores available from a post-discharge questionnaire. We examined pain severity on postoperative days 1-5, with moderate-severe pain as the outcome of interest. Multivariable logistic regression was performed to identify variables associated with moderate-severe pain in a training cohort of 956 patients. The final model was determined using the Akaike information criterion. A nomogram was constructed using this model, which also included a priori selected clinically relevant variables. Internal validation was performed in the remaining cohort of 239 patients. RESULTS In the training cohort, 297 patients reported no-mild pain and 659 reported moderate-severe pain. High body mass index (p = 0.042), preoperative Distress Thermometer score ≥4 (p = 0.012), and bilateral surgery (p = 0.003) predicted moderate-severe pain. The resulting nomogram accurately predicted moderate-severe pain in the validation cohort (AUC = 0.735). CONCLUSIONS This nomogram incorporates eight preoperative variables to provide a risk estimate of acute moderate-severe pain following mastectomy. Preoperative risk stratification can identify patients who may benefit from individually tailored perioperative pain management strategies and early postoperative interventions to treat pain and assist with opioid tapering.
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Affiliation(s)
- Linda M Pak
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah L Kalvin
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tiana Le
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Hanae K Tokita
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA.
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16
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Samuel AR, Fuhr L, DeGeorge BR, Black J, Campbell C, Stranix JT. Prolonged Opioid Use Among Opioid-Naive Women Undergoing Breast Reconstructive Surgery. Arch Plast Surg 2022; 49:339-345. [PMID: 35832151 PMCID: PMC9142247 DOI: 10.1055/s-0042-1744419] [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] [Indexed: 10/26/2022] Open
Abstract
Abstract
Background Patients that undergo mastectomy for breast cancer with reconstruction may be prone to prolonged opioid use. As risk factors are not well-established, this article sought to better understand the risk factors that may be associated with this.
Methods Patients that underwent breast reconstruction between 2010 and 2018 were identified in PearlDiver, a national insurance claims database. Patient demographics and comorbidities were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis was used to evaluate the association of risk factors and complications.
Results Breast reconstruction patients of 24,765 were identified from this database. Obesity, tobacco use, benzodiazepine use, and anticonvulsant use were all associated with prolonged opioid prescriptions greater than 90 days after both alloplastic and autologous reconstruction.
Conclusion Prolonged opioid use continues to remain a topic of concern, and particularly in cancer patients that undergo breast reconstruction. Providers should be aware of potential risk factors for this to reduce this chance following breast reconstruction surgery.
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Affiliation(s)
- Ankhita R. Samuel
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Laura Fuhr
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Brent R. DeGeorge
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Jonathan Black
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Christopher Campbell
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - John T. Stranix
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
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17
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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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Affiliation(s)
- Daniel B. Larach
- Department of Anesthesiology, Vanderbilt University Medical Center (Nashville, TN)
| | - Jennifer M. Hah
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine (Stanford, CA)
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan Medical School (Ann Arbor, MI)
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18
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Sabik LM, Eom KY, Sun Z, Merlin JS, Bulls HW, Moyo P, Pruskowski JA, van Londen G, Rosenzweig M, Schenker Y. Patterns and Trends in Receipt of Opioids Among Patients Receiving Treatment for Cancer in a Large Health System. J Natl Compr Canc Netw 2022; 20:460-467.e1. [PMID: 35231900 PMCID: PMC10463265 DOI: 10.6004/jnccn.2021.7104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/18/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer. METHODS Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis. RESULTS The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10-5.86), 5.09 (95% CI, 3.88-6.69), and 3.31 (95% CI, 2.68-4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type. CONCLUSIONS Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non-cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.
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Affiliation(s)
- Lindsay M. Sabik
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Kirsten Y. Eom
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Zhaojun Sun
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Jessica S. Merlin
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
| | - Hailey W. Bulls
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
| | - Patience Moyo
- Brown University School of Public Health, Department of Health Services, Policy, and Practice
| | | | - G.J. van Londen
- University of Pittsburgh School of Medicine, Department of Medicine, Divisions of Hematology-Oncology and Geriatric Medicine
| | - Margaret Rosenzweig
- University of Pittsburgh School of Nursing, Department of Acute & Tertiary Care
| | - Yael Schenker
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
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19
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Li X, Li Y. Nerve Block on Pain After Mammaplasty: A Meta-Analysis of randomized controlled studies. Plast Surg (Oakv) 2022; 30:32-38. [PMID: 35096690 PMCID: PMC8793749 DOI: 10.1177/2292550320969648] [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: 02/03/2023] Open
Abstract
BACKGROUND Nerve block showed some potential in alleviating pain after mammaplasty. This systematic review and meta-analysis was conducted to investigate the efficacy of nerve block for pain control after mammaplasty. METHODS The databases including PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases were systematically searched for collecting the randomized controlled trials (RCTs) regarding the impact of nerve block on pain intensity after mammaplasty. RESULTS This meta-analysis included 4 RCTs. Compared with control group after mammaplasty, nerve block resulted in remarkably reduced pain scores at 1 hour (mean difference [MD] = -1.84; 95% CI = -2.49 to -1.20; P < .00001), 3 hours (MD = -1.04; 95% CI = -1.47 to -0.62; P < .00001), 6 hours (MD = -0.96; 95% CI = -1.48 to -0.43; P = .0004), and analgesic consumption (standard mean difference = -1.27; 95% CI = -1.73 to -0.82; P < .00001), but showed no significant impact on pain scores within 24 hours (MD = -0.31; 95% CI = -1.05 to 0.43; P = .41). CONCLUSIONS Nerve block was associated with substantially reduced pain intensity after mammaplasty.
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Affiliation(s)
- Xiaoxia Li
- Burn Plastic and Cosmetic Surgery Department, Bayannur City Hospital, Inner Mongolia, People’s Republic of China,Xiaoxia Li, Burn Plastic and Cosmetic Surgery Department, Bayannur City Hospital, No.98, Wulanbuhe Road, Bayannur city, Inner Mongolia 015000, People’s Republic of China.
| | - Ying Li
- Burn Plastic and Cosmetic Surgery Department, Bayannur City Hospital, Inner Mongolia, People’s Republic of China
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Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3932. [PMID: 34796086 PMCID: PMC8594660 DOI: 10.1097/gox.0000000000003932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 12/30/2022]
Abstract
Introduction: Pain and discomfort are frequently experienced following mastectomy with concomitant breast implant- or tissue expander-based alloplastic breast reconstruction (AlBR). Unfortunately, postoperative opioids have decreased efficacy in AlBR, short-term complication profiles, and are fraught by long-term dependence. This systematic review aims to identify opioid-sparing pain management strategies in AlBR. Methods: A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane Central Register was performed in September 2018. PRISMA guidelines were followed, and the review was prospectively registered in PROSPERO (CRD42018107911). The search identified 1184 articles. Inclusion criteria were defined as patients 18 years or older undergoing AlBR. Results: Fourteen articles were identified assessing opioid-sparing strategies in AlBR. This literature included articles evaluating enhanced recovery protocols (two), intercostal blocks (two), paravertebral blocks (four), liposomal bupivacaine (three), diclofenac (one), and local anesthesia infusion pumps (two). The literature included five randomized trials and nine cohort studies. Study characteristics, bias (low to high risk), and reporting outcomes were extensively heterogeneous between articles. Qualitative analysis suggests reduced opioid utilization in enhanced recovery after surgery (ERAS) pathways, paravertebral blocks, and use of liposomal bupivacaine. Conclusions: A variety of opioid-sparing strategies are described for pain management in AlBR. Multimodal analgesia should be provided via ERAS pathways as they appear to reduce pain and spare opioid use. Targeted paravertebral blocks and liposomal bupivacaine field blocks appear to be beneficial in sparing opioids and should be considered as essential components of ERAS protocols. Additional prospective, randomized trials are necessary to delineate the efficacy of other studied modalities.
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21
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Zhu CY, Schumm MA, Hu TX, Nguyen DT, Kim J, Tseng CH, Lin AY, Yeh MW, Livhits MJ, Wu JX. Patient-Centered Decision-making for Postoperative Narcotic-Free Endocrine Surgery: A Randomized Clinical Trial. JAMA Surg 2021; 156:e214287. [PMID: 34495283 DOI: 10.1001/jamasurg.2021.4287] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Historically, opioid pain medications have been overprescribed following thyroid and parathyroid surgery. Many narcotic prescriptions are incompletely consumed, creating waste and opportunities for abuse. Objective To determine whether limiting opioid prescriptions after outpatient thyroid and parathyroid surgery to patients who opt in to narcotic treatment reduces opioid consumption without increasing postoperative pain compared with usual care (routine narcotic prescriptions). Design, Setting, and Participants A randomized clinical trial of Postoperative Opt-In Narcotic Treatment (POINT) or routine narcotic prescription (control) was conducted at a single tertiary referral center from June 1 to December 30, 2020. A total of 180 adults undergoing ambulatory cervical endocrine surgery, excluding patients currently receiving opioids, were assessed for eligibility. POINT patients received perioperative pain management counseling and were prescribed opioids only on patient request. Patients reported pain scores (0-10) and medication use through 7 daily postoperative surveys. Logistic regression was used to determine factors associated with opioid consumption. Interventions Patients in the POINT group were able to opt in or out of receiving prescriptions for opioid pain medication on discharge. Control patients received routine opioid prescriptions on discharge. Main Outcomes and Measures Daily peak pain score through postoperative day 7 was the primary outcome. Noninferiority was defined as a difference less than 2 on an 11-point numeric rating scale from 0 to 10. Analysis was conducted on the evaluable population. Results Of the 180 patients assessed for eligibility, the final study cohort comprised 102 patients: 48 randomized to POINT and 54 to control. Of these, 79 patients (77.5%) were women and median age was 52 (interquartile range, 43-62) years. A total of 550 opioid tablets were prescribed to the control group, and 230 tablets were prescribed to the POINT group, in which 23 patients (47.9%) opted in for an opioid prescription. None who opted out subsequently required rescue opioids. In the first postoperative week, 17 POINT patients (35.4% of survey responders in the POINT group) reported consuming opioids compared with 27 (50.0%) control patients (P = .16). Median peak outpatient pain scores were 6 (interquartile range, 4-8) in the control group vs 6 (interquartile range, 5-7) in the POINT group (P = .71). In multivariate analysis, patients with a history of narcotic use were 7.5 times more likely to opt in (95% CI, 1.61-50.11; P = .02) and 4.8 times more likely to consume opioids (95% CI, 1.04-1.52; P = .01). Higher body mass index (odds ratio, 1.11; 95% CI, 1.01-1.23; P = .03) and highest inpatient postoperative pain score (odds ratio, 1.24; 95% CI, 1.04-1.52; P = .02) were also associated with opioid consumption. Conclusions and Relevance In this trial, an opt-in strategy for postoperative narcotics reduced opioid prescription without increasing pain after cervical endocrine surgery. Trial Registration ClinicalTrials.gov Identifier: NCT04710069.
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Affiliation(s)
- Catherine Y Zhu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Max A Schumm
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Theodore X Hu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Dalena T Nguyen
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jiyoon Kim
- Department of Biostatistics, UCLA School of Public Health, Los Angeles, California
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Anne Y Lin
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Michael W Yeh
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Masha J Livhits
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - James X Wu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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22
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Guliyeva G, Torres RA, Avila FR, Kaplan JL, Lu X, Forte AJ. The Impact of implant-based reconstruction on persistent pain after breast cancer surgery: A systematic review. J Plast Reconstr Aesthet Surg 2021; 75:519-527. [PMID: 34801428 DOI: 10.1016/j.bjps.2021.09.079] [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: 02/06/2021] [Revised: 06/16/2021] [Accepted: 09/27/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION With the increasing number of breast cancer survivors and reconstruction operations, persistent pain following breast cancer surgery (PPBCT) and its management is becoming a challenge for plastic surgeons. To date, most studies compared the difference in the level of PPBCT in reconstruction versus nonreconstruction groups. We systematically reviewed the literature to assess the impact of implant-based reconstruction on PPBCT levels. MATERIALS AND METHODS PubMed, Embase, CINAHL, and Scopus databases were searched for relevant articles. We used five search strategies: (persistent pain after breast cancer surgery AND reconstruction), (chronic postsurgical pain AND breast reconstruction), (Breast Implantation [MeSH Terms] AND "Chronic Pain" [MeSH Terms]), (breast reconstruction AND chronic pain), and (postmastectomy pain syndrome AND breast reconstruction). RESULTS A total of 2281 articles were detected. After scanning for the title and abstract, full-text articles were reviewed to identify the eligible articles. Eleven articles were included in the final review, with seven of these reporting no increased chance of PPBCT following reconstruction with implants, whereas two articles described lower chances of PPBCT following implant-based reconstruction. CONCLUSION We discovered that implant-based reconstruction does not increase the risk of PPBCT in comparison to other surgical techniques or mastectomy alone. This relationship may facilitate doctors and their patients in the decision-making of the appropriate reconstruction technique to use. In addition, our results should prompt plastic surgeons to prescribe the same dosage and frequency of analgesics to patients undergoing implant reconstruction as they would to their patients not undergoing reconstruction.
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Affiliation(s)
- Gunel Guliyeva
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Ricardo A Torres
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Jamie L Kaplan
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Xiaona Lu
- Section of Plastic Surgery, Yale University, New Haven, CT, United States
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, United States.
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23
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Opioid Overprescribing and Procedure-Specific Opioid Consumption Patterns for Plastic and Reconstructive Surgery Patients. Plast Reconstr Surg 2021; 147:669e-679e. [PMID: 33761520 DOI: 10.1097/prs.0000000000007782] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioid prescribing practices contribute to opioid misuse, dependency, and diversion. There are currently no comprehensive and quantitative evidence-based guidelines that give procedure-specific recommendations regarding opioid prescribing in plastic surgery. METHODS A retrospective review of 479 plastic surgery patients encompassing 23 different plastic surgery procedure categories was performed. Opioid prescribing patterns and patient-reported opioid use at 1 and 3 months postoperatively are reported. RESULTS Opioid overprescribing was common, averaging an excess of 13 pills per patient across all procedure categories (prescribed versus consumed, 25.4 ± 23.1 versus 12.1 ± 19.7; p = 3.0 × 10-19), with a total excess of 5895 pills (30,967 oral morphine equivalents) for the study's sample. Fifty-two percent of all opioid pills prescribed went unused. Opioid consumption ranged between four and 37 pills across procedure categories. A greater proportion of patients who reported a history of preoperative opioid use were still using opioids at the time of their 1-month and 3-month follow-up appointments (62 percent versus 9 percent at 1 month, and 31 percent versus 1 percent at 3 months). Most patients (83 percent) did not store opioids in a locked location, and 64 percent did not dispose of opioids at 1 month. CONCLUSIONS Opioids are commonly overprescribed by plastic surgery providers. This study determined procedure-specific opioid consumption patterns, which can help providers reduce opioid waste. In addition, patients do not properly store or dispose of opioids, demonstrating the need for better patient education.
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Rao F, Wang Z, Chen X, Liu L, Qian B, Guo Y. Ultrasound-Guided Thoracic Paravertebral Block Enhances the Quality of Recovery After Modified Radical Mastectomy: A Randomized Controlled Trial. J Pain Res 2021; 14:2563-2570. [PMID: 34456586 PMCID: PMC8385420 DOI: 10.2147/jpr.s325627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/31/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Ultrasound-guided thoracic paravertebral block (TPVB) has become increasingly popular for postoperative analgesia after breast surgery. We designed this prospective, randomized, double-blind, placebo-controlled trial to test the hypothesis that TPVB is superior to placebo in improving the patient quality of recovery following modified radical mastectomy. PATIENTS AND METHODS Sixty-eight female patients undergoing elective unilateral modified radical mastectomy were enrolled. Patients were randomized to receive preoperative ultrasound-guided TPVB with 0.5% ropivacaine (TPVB group, n=34) or 0.9% saline (Control group, n=34). The primary outcome was quality of recovery, measured 24 h after surgery using the 40-item Quality of recovery questionnaire (QoR-40). Secondary outcomes were the area under the curve of the visual analog scale pain scores over 24 h, postoperative 24-h morphine consumption, time to first rescue analgesia, length of post-anesthesia care unit stay, postoperative nausea and vomiting, and patient satisfaction. RESULTS The global QoR-40 score 24 h postoperatively (median [interquartile range]) was 173 [170-177] in the TPVB group and 161 [160-164] in the control group (P<0.001), respectively, with a median difference (95% confidence interval) of 11 (9-14). Compared with the control group, preoperative TPVB decreased the area under the curve of the visual analog scale pain scores over 24 h, reduced postoperative 24-h morphine consumption, prolonged the time to first rescue analgesia, shortened the length of post-anesthesia care unit stay, lessened postoperative nausea and vomiting, and improved the patient satisfaction. CONCLUSION A single preoperative injection of TPVB with ropivacaine enhances the quality of recovery and postoperative analgesia in patients following modified radical mastectomy.
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Affiliation(s)
- Fudong Rao
- Department of Anesthesiology, People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, People’s Republic of China
| | - Zongjie Wang
- Department of Anesthesiology, Longyan First Hospital Affiliated to Fujian Medical University, Longyan, Fujian, People’s Republic of China
| | - Xijuan Chen
- Department of Nephrology, Hematology and Pediatrics, People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, People’s Republic of China
| | - Linwei Liu
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, People’s Republic of China
| | - Bin Qian
- Department of Anesthesiology, People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, People’s Republic of China
| | - Yanhua Guo
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, People’s Republic of China
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25
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Ruffolo LI, Jackson KM, Juviler P, Kaur R, Chennell T, Glover DM, Linehan DC, Moalem J. Narcotic Free Cervical Endocrine Surgery: A Shift in Paradigm. Ann Surg 2021; 274:e143-e149. [PMID: 31356280 DOI: 10.1097/sla.0000000000003443] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVE The opioid epidemic has stimulated initiatives to reduce the number of unnecessary narcotic prescriptions. We adopted an opt-in prescription system for patients undergoing ambulatory cervical endocrine surgery (CES). We hypothesized that empowering patients to decide whether or not to receive narcotics for pain control would result in fewer unnecessary opioid prescriptions. METHODS We enrolled all patients scheduled for outpatient CES between July 2017 and June 2018 in a narcotic opt-in program. Patient demographics, procedure characteristics, and postoperative pain scores were collected prospectively. Statistical analyses were performed to correlate clinical predictors with narcotic request. Results were compared against a historical control group. The study was approved by the University IRB. RESULTS A total of 216 consecutive patients underwent outpatient CES following implementation of the program. Only nine (4%) requested prescription narcotic medication at discharge, and no patient called after discharge to request analgesic medications. Compared with our prior treatment paradigm, we achieved a 96.6% reduction in the number of narcotic tablets prescribed, and a 98% reduction in unconsumed tablets. Univariate analysis suggested history of substance abuse (P < 0.001), anxiety (P = 0.01), depression (P < 0.001), baseline narcotic use (P = 0.004), highest pain postoperatively (P = 0.004), and incision length (P = 0.007) as predictive for narcotic request. Multivariate analysis retained significance with incision length and history of substance abuse. CONCLUSION By empowering patients undergoing ambulatory CES to accept or decline a prescription, we reduced the number of prescribed narcotic tablets by 96.6%. Although longer incisions and prior substance abuse predict higher likelihood of requesting pain medication on discharge, 207 of 216 patients were treated with acetaminophen alone.
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Affiliation(s)
- Luis I Ruffolo
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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26
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Cogan JC, Raghunathan RR, Beauchemin MP, Accordino MK, Elkin EB, Melamed A, Wright JD, Hershman DL. New and persistent controlled substance use among patients undergoing mastectomy and reconstructive surgery. Breast Cancer Res Treat 2021; 189:445-454. [PMID: 34089118 DOI: 10.1007/s10549-021-06275-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Prolonged use of controlled substances can place patients at increased risk of dependence and complications. Women who have mastectomy and reconstructive surgery (M + R) may be vulnerable to becoming new persistent users (NPUs) of opioid and sedative-hypnotic medications. METHODS Using the MarketScan health-care claims database, we identified opioid- and sedative-hypnotic-naïve women who had M + R from 2008 to 2017. Women who filled ≥ 1 peri-operative prescription and ≥ 2 post-operative prescriptions within one year after surgery were classified as NPUs. Univariate and multivariable logistic regression analyses were used to estimate rates of new persistent use and predictive factors. Risk summary scores were created based on the sum of associated factors. RESULTS We evaluated 23,025 opioid-naïve women and 25,046 sedative-hypnotic-naïve women. We found that 17,174 opioid-naïve women filled a peri-operative opioid prescription, and of those, 2962 (17.2%) became opioid NPUs post-operatively. Additionally, 9426 sedative-hypnotic-naïve women filled a peri-operative sedative-hypnotic prescription, and of those, 1612 (17.1%) became sedative-hypnotic NPUs. Development of new persistent sedative-hypnotic use was associated with age ≤ 49 [OR 1.77 (95% CI 1.40-2.24)] and age 50-64 [1.60 (1.27-2.03)] compared to age ≥ 65; Medicaid insurance [2.34 (1.40-3.90)]; southern residence [1.42 (1.22-1.64)]; breast cancer diagnosis [2.24 (1.28-3.91)]; and chemotherapy [2.17 (1.94-2.42)]. Risk of NPU increased with higher risk score. Women with ≥ 3 of these risk factors were three times more likely to become sedative-hypnotic NPUs than patients with 0 or 1 factors [2.94 (2.51-3.43)]. Comparable findings were seen regarding new persistent opioid use. CONCLUSION Women who have M + R are at risk of developing both new persistent opioid and new persistent sedative-hypnotic use. A patient's risk of becoming an NPU increases as their number of risk factors increases. Non-pharmacologic strategies are needed to manage pain and anxiety following cancer-related surgery.
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Affiliation(s)
- Jacob C Cogan
- Columbia University College of Physicians and Surgeons, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, USA.,NewYork-Presbyterian Hospital, New York, USA
| | - Rohit R Raghunathan
- Joseph L. Mailman School of Public Health, Columbia University, New York, USA
| | - Melissa P Beauchemin
- Columbia University College of Physicians and Surgeons, New York, USA.,Joseph L. Mailman School of Public Health, Columbia University, New York, USA.,NewYork-Presbyterian Hospital, New York, USA
| | - Melissa K Accordino
- Columbia University College of Physicians and Surgeons, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, USA.,NewYork-Presbyterian Hospital, New York, USA
| | - Elena B Elkin
- Joseph L. Mailman School of Public Health, Columbia University, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, USA
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, USA.,NewYork-Presbyterian Hospital, New York, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, USA.,NewYork-Presbyterian Hospital, New York, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, New York, USA. .,Joseph L. Mailman School of Public Health, Columbia University, New York, USA. .,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, USA. .,NewYork-Presbyterian Hospital, New York, USA.
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27
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Wright JD, Cogan JC, Huang Y, Tergas AI, St. Clair CM, Hou JY, Khoury-Collado F, Gockley A, Accordino M, Melamed A, Hershman DL. Association of New Perioperative Benzodiazepine Use With Persistent Benzodiazepine Use. JAMA Netw Open 2021; 4:e2112478. [PMID: 34081136 PMCID: PMC8176328 DOI: 10.1001/jamanetworkopen.2021.12478] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Increased use of benzodiazepines has resulted in increasing rates of misuse and adverse effects associated with these drugs. Little is known about the initial exposure and source of benzodiazepines among those who use them persistently. OBJECTIVE To examine the frequency of use and persistent use of benzodiazepines among patients undergoing major and minor surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 2 509 599 adult patients who underwent 1 of 11 common surgical procedures in the United States from 2009 to 2017 and were recorded in the MarketScan database. The rates of perioperative and persistent benzodiazepine use were examined in benzodiazepine-naive patients. Data analysis was conducted from July to November 2020. MAIN OUTCOMES AND MEASURES Receipt of a perioperative benzodiazepine prescription and persistent use (ie, fill of a second prescription 90-180 days after surgery) among those who received a benzodiazepine perioperatively. RESULTS Among 2 509 599 included patients, the mean (SD) age was 54.4 (15.3) years, and 1 596 137 (63.6%) were women. Perioperative benzodiazepine use was noted in 63 931 patients (2.6%). The median (interquartile range) benzodiazepine supply was 10 (5-23) days. Among benzodiazepine-naive patients prescribed a perioperative benzodiazepine, the rate of persistent benzodiazepine use was 19.5% (95% CI, 19.2%-19.8%). During the 90 to 180-day period after surgery, 7013 of 12 468 patients (56.2%) received 1 prescription for benzodiazepines while 5455 (43.8%) received 2 or more prescriptions. Among patients prescribed a benzodiazepine, persistent use was more common in Medicaid recipients (vs patients with commercial insurance: adjusted rate ratio [aRR], 1.29; 95% CI, 1.03-1.62), patients 70 years or older (vs those aged 40-49 years: aRR, 1.14; 95% CI, 1.05-1.23), in women (vs men: aRR, 1.10; 95% CI, 1.06-1.15), in patients with more medical comorbidities (eg, Elixhauser comorbidity score ≥3 vs 0: aRR, 1.11; 95% CI, 1.04-1.19), and in those with diagnoses of anxiety, depression, insomnia or substance use disorder (eg, with vs without anxiety: aRR, 1.43; 95% CI, 1.37-1.50). CONCLUSIONS AND RELEVANCE In this study, a relatively small percentage of surgical patients were prescribed benzodiazepines in the perioperative period; however, 1 in 5 of these patients went on to persistent benzodiazepine use.
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Affiliation(s)
- Jason D. Wright
- Columbia University College of Physicians and Surgeons, New York, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- New York Presbyterian Hospital, New York
| | - Jacob C. Cogan
- Columbia University College of Physicians and Surgeons, New York, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- New York Presbyterian Hospital, New York
| | - Yongmei Huang
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Ana I. Tergas
- Columbia University College of Physicians and Surgeons, New York, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- New York Presbyterian Hospital, New York
- Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Caryn M. St. Clair
- Columbia University College of Physicians and Surgeons, New York, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- New York Presbyterian Hospital, New York
| | - June Y. Hou
- Columbia University College of Physicians and Surgeons, New York, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- New York Presbyterian Hospital, New York
| | - Fady Khoury-Collado
- Columbia University College of Physicians and Surgeons, New York, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- New York Presbyterian Hospital, New York
| | - Allison Gockley
- Columbia University College of Physicians and Surgeons, New York, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- New York Presbyterian Hospital, New York
| | - Melissa Accordino
- Columbia University College of Physicians and Surgeons, New York, New York
- New York Presbyterian Hospital, New York
- Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Dawn L. Hershman
- Columbia University College of Physicians and Surgeons, New York, New York
- Herbert Irving Comprehensive Cancer Center, New York, New York
- New York Presbyterian Hospital, New York
- Joseph L. Mailman School of Public Health, Columbia University, New York, New York
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Yang A, Nadav D, Legler A, Chen GH, Hingula L, Puttanniah V, Gulati A. An Interventional Pain Algorithm for the Treatment of Postmastectomy Pain Syndrome: A Single-Center Retrospective Review. PAIN MEDICINE 2021; 22:677-686. [PMID: 33155049 DOI: 10.1093/pm/pnaa343] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Breast cancer is the most common female malignancy worldwide. Breast surgery and adjuvant oncological therapies are often required to increase survival. Treatment-related pain may persist and evolve into postmastectomy pain syndrome (PMPS) in a significant subset of breast cancer survivors. In this retrospective investigation, we will present our experience in applying an interventional algorithmic approach to treat PMPS. DESIGN A retrospective study. SETTING An academic cancer hospital. SUBJECTS Adult females with PMPS diagnosis. METHODS We reviewed 169 records with the diagnosis of PMPS from 2015 to 2019 within our health system. Pre- and post-injection pain scores, relief duration, and medication usage changes were collected. The decision to perform each procedure was based on the anatomic location of the painful area with the corresponding peripheral sensory innervation. Decision-making flow diagrams were created to present our experience in managing PMPS beyond peripheral nerve blocks. RESULTS Ultrasound-guided peripheral nerve block results (n=350) were analyzed. The mean baseline pain score was 7, compared with the post-treatment mean score of 3 (95% confidence interval: 3.58 to 3.98, P = 0.0001). Among the responders, the mean pain relief duration was 45 days, with a median of 84 days. Opioid medication consumption was reduced by 11% (t = 0.72, P = 0.47). CONCLUSIONS Ultrasound-guided nerve blocks of this area could be performed safely and effectively after breast surgeries. We also present our proposed algorithm to provide a stepwise application for selecting the appropriate therapies in the management of more complex PMPS.
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Affiliation(s)
- Ajax Yang
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.,The Spine and Pain Institute of New York, New York, USA
| | - Danielle Nadav
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Aron Legler
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Grant H Chen
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lee Hingula
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay Puttanniah
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Nelson JA, Polanco TO, Shamsunder MG, Coriddi M, Matros E, Hicks MEV, Disa JJ, Mehrara BJ, Allen RJ, Dayan JH, Afonso A. Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes. Ann Surg Oncol 2021; 28:7823-7833. [PMID: 33959829 DOI: 10.1245/s10434-021-10023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/26/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction. METHODS We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q. RESULTS Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores. CONCLUSION System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.
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Affiliation(s)
- Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Thais O Polanco
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meghana G Shamsunder
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Joseph J Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph H Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Van Boerum MS, Mann SL, Veith JP, Collier W, Hosein RC, Manum JS, Agarwal J, Kwok AC. Patient-reported opioid use for tissue expander-based breast reconstruction. J Plast Reconstr Aesthet Surg 2021; 74:2899-2905. [PMID: 34078588 DOI: 10.1016/j.bjps.2021.03.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/07/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION There is limited evidence for appropriate post-operative opioid prescribing in breast reconstruction patients. We sought to describe postoperative outpatient prescription opioid use patterns (quantity and duration) following discharge after immediate breast reconstruction with tissue expanders (TE) and to identify demographic and/or clinical risk factors associated with postoperative outpatient opioid use. METHODS Patients 18 years and older undergoing immediate TE-based breast reconstruction were given a 28-day postoperative pain medication log book. Descriptive statistics were performed to describe the quantity and duration of opioid use. Preoperative, intraoperative, and postoperative characteristics were examined and tested for their associations with postoperative opioid use. RESULTS A total of 45 logbooks were completed. On average, patients used opioids for 7.42 days (SD = 6.45) after discharge home and used 15.9 (SD = 18.71) oxycodone 5 mg tablet equivalents (119.3 morphine milligram equivalents, SD = 140.31). The total number of oxycodone 5 mg equivalents consumed prior to discharge was associated with the amount of post-discharge opioid consumption (IRR=1.08, p<0.01). Each additional year of age was associated with a reduction in the days-to-opioid cessation by a factor of 0.97 (p=0.01). Each additional oxycodone 5mg equivalent consumed prior to hospital discharge was associated with an increase in the days-to-cessation after discharge by a factor of 1.04 (p=0.026). CONCLUSIONS These patient-reported data will provide a benchmark which plastic surgeons can use to minimize narcotic use in patients and will help prevent issues of dependence, misuse, and diversion, while being mindful of adequate pain control. For patients discharging home after a one-night stay for immediate TE breast reconstruction, we recommend a prescription for 10 oxycodone 5 mg tablets, or 15 tablets if they are less than age 49 or have had high inpatient opioid use. Patients should also be counseled that the expected duration of outpatient opioid use is 7-11 days, and that 20 % of patients did not use any opioids following hospital discharge, making nonnarcotic pain regimens a real possibility.
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Affiliation(s)
- Melody S Van Boerum
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Sara L Mann
- University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Jacob P Veith
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Willem Collier
- Department of Population Health Sciences, University of Utah School of Medicine, Williams Building, Room 1N490 295 Chipeta Way, Salt Lake City, UT 84108
| | - Rayaad C Hosein
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Joanna S Manum
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Jayant Agarwal
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Alvin C Kwok
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132.
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Shammas RL, Marks CE, Broadwater G, Le E, Glener AD, Sergesketter AR, Cason RW, Rezak KM, Phillips BT, Hollenbeck ST. The Effect of Lavender Oil on Perioperative Pain, Anxiety, Depression, and Sleep after Microvascular Breast Reconstruction: A Prospective, Single-Blinded, Randomized, Controlled Trial. J Reconstr Microsurg 2021; 37:530-540. [PMID: 33548936 DOI: 10.1055/s-0041-1724465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. METHODS This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale. RESULTS Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p < 0.001), while depression scores were significantly higher postoperatively as compared with preoperatively (p = 0.005). CONCLUSION In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.
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Affiliation(s)
- Ronnie L Shammas
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Caitlin E Marks
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Gloria Broadwater
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Elliot Le
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Adam D Glener
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Amanda R Sergesketter
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Roger W Cason
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Kristen M Rezak
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Brett T Phillips
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Scott T Hollenbeck
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
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Predictors of Opioid Prescription After Orthognathic Surgery in Opioid Naive Adults From a Large Database. J Craniofac Surg 2021; 32:978-982. [PMID: 33496521 DOI: 10.1097/scs.0000000000007473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Orthognathic surgery often requires postoperative opioid pain management. The goal of this study was to examine opioid prescribing patterns in adults after orthognathic surgery and to analyze factors associated with high-dose postoperative opioid administration and persistent opioid use. METHODS We included opioid naive adults in the IBM MarketScan Databases who had undergone orthognathic surgery from 2003 to 2017. Three outcomes were examined: presence of a perioperative outpatient opioid claim; total oral morphine milliequivalents (MMEs) in the perioperative period; and persistent opioid use. Univariate analysis and multiple regression were used to determine associations between the outcomes and independent variables. RESULTS Our study yielded a cohort of 8163 opioid naive adults, 45.6% of whom had an opioid claim in the perioperative period. The average prescribed MMEs in the perioperative period was 466 MMEs total, and 66 MMEs daily. Of patients with an opioid claim, 17.9% had persistent opioid use past 90 days. The presence of a complication was a predictor of having an opioid claim (P<0.001). Increasing age (P<0.001) and days hospitalized (P < 0.001) were associated with increased opioid usage. Persistent opioid use was associated with being prescribed more than 600 MMEs in the perioperative period (P < 0.001), as well as increasing age and days hospitalized. Interestingly, patients undergoing double-jaw surgery did not have significantly more opioids prescribed than those undergoing single-jaw surgery. CONCLUSIONS Prescription opioids are relatively uncommon after jaw surgery, although 17.9% of patients continue to use opioids beyond 3 months after surgery. Predictors of persistent opioid use in this population include the number of days hospitalized, increasing age, and increasing amount of opioid prescribed postoperatively.
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Schreiber KL, Zinboonyahgoon N, Flowers KM, Hruschak V, Fields KG, Patton ME, Schwartz E, Azizoddin D, Soens M, King T, Partridge A, Pusic A, Golshan M, Edwards RR. Prediction of Persistent Pain Severity and Impact 12 Months After Breast Surgery Using Comprehensive Preoperative Assessment of Biopsychosocial Pain Modulators. Ann Surg Oncol 2021; 28:5015-5038. [PMID: 33452600 DOI: 10.1245/s10434-020-09479-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Persistent post-mastectomy pain (PPMP) is a significant negative outcome occurring after breast surgery, and understanding which individual women are most at risk is essential to targeting of preventive efforts. The biopsychosocial model of pain suggests that factors from many domains may importantly modulate pain processing and predict the progression to pain persistence. METHODS This prospective longitudinal observational cohort study used detailed and comprehensive psychosocial and psychophysical assessment to characterize individual pain-processing phenotypes in 259 women preoperatively. Pain severity and functional impact then were longitudinally assessed using both validated surgery-specific and general pain questionnaires to survey patients who underwent lumpectomy, mastectomy, or mastectomy with reconstruction in the first postsurgical year. An agnostic, multivariable modeling strategy identified consistent predictors of several pain outcomes at 12 months. RESULTS The preoperative characteristics most consistently associated with PPMP outcomes were preexisting surgical area pain, less education, increased somatization, and baseline sleep disturbance, with axillary dissection emerging as the only consistent surgical variable to predict worse pain. Greater pain catastrophizing, negative affect, younger age, higher body mass index (BMI), and chemotherapy also were independently predictive of pain impact, but not severity. Sensory disturbance in the surgical area was predicted by a slightly different subset of factors, including higher preoperative temporal summation of pain. CONCLUSIONS This comprehensive approach assessing consistent predictors of pain severity, functional impact, and sensory disturbance may inform personalized prevention of PPMP and also may allow stratification and enrichment in future preventive studies of women at higher risk of this outcome, including pharmacologic and behavioral interventions and regional anesthesia.
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Affiliation(s)
- Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - K Mikayla Flowers
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Valerie Hruschak
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kara G Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Megan E Patton
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily Schwartz
- Department of Medical Oncology, Dana-Farber Cancer Institute and Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Desiree Azizoddin
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Mieke Soens
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tari King
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ann Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute and Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea Pusic
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mehra Golshan
- Department of Surgery, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Rob R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Darrach H, Kraenzlin FS, Khavanin N, He W, Lee E, Sacks JM. Pectoral placement of tissue expanders affects inpatient opioid use. Breast J 2021; 27:126-133. [PMID: 33438303 DOI: 10.1111/tbj.14149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 11/27/2022]
Abstract
Prepectoral breast reconstruction promises to minimize breast animation deformity and decrease pain associated with subpectoral dissection and tissue expansion. This latter benefit is particularly timely given the ongoing opioid epidemic; however, this theoretical benefit remains to be demonstrated clinically. As such, this study aimed to compare inpatient opioid use and prescription practices following prepectoral and subpectoral expander-based breast reconstruction. A retrospective review was performed of patients undergoing immediate tissue expander placement between January 2017 and April 2018. Medical records were reviewed for surgical details, 24-hour inpatient PRN opioid usage (oral morphine equivalents [OME]), and discharge prescriptions. Comparisons were made using chi-squared and student's t tests where appropriate. Two hundred and thirty-one patients were identified, (mean age 48.8 years), 222 of which met inclusion criteria. 89 underwent subpectoral and 133 prepectoral tissue expander placements. All but two subpectoral patients and two prepectoral patients were opioid-naïve. The rate of bilateral procedures did not differ between cohorts (P = .194). Overall, 94% of patients were discharged within 24 hours, and length of stay did not differ between cohorts (P = .0753). Two subpectoral and two prepectoral patients required prolonged admission due to postoperative pain. All patients were ordered standing acetaminophen, celecoxib, and gabapentin, and subpectoral patients cyclobenzaprine. Narcotic pain medication was offered on an "as needed" (PRN) basis. Opioid usage within the first 24-hours was halved in the prepectoral cohort (22.2 vs 44.5 OME, P = .0003), which was not associated with bi/unilaterality of procedure or the presence of any psychiatric conditions. The amount of opioids prescribed on discharge was not significantly different between cohorts (308.42 OME prepectoral vs 336.99 subpectoral, P = .3197). Prepectoral expander placement appears to be associated with decreased inpatient opioid use postoperatively. This may represent an opportunity to improve patient satisfaction and safety by decreasing outpatient opioid prescriptions.
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Affiliation(s)
- Halley Darrach
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Franca S Kraenzlin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Nima Khavanin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Waverley He
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Erica Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery in the Department of Surgery, Washington University in St Louis, St Louis, MI, USA
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Sakamoto MR, Eguchi M, Azelby CM, Diamond JR, Fisher CM, Borges VF, Bradley CJ, Kabos P. New Persistent Opioid and Benzodiazepine Use After Curative-Intent Treatment in Patients With Breast Cancer. J Natl Compr Canc Netw 2021; 19:29-38. [PMID: 33406490 DOI: 10.6004/jnccn.2020.7612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/26/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioid and benzodiazepine use and abuse is a national healthcare crisis to which patients with cancer are particularly vulnerable. Long-term use and risk factors for opioid and benzodiazepine use in patients with breast cancer is poorly characterized. METHODS We conducted a retrospective population-based study of patients with breast cancer diagnosed between 2008 and 2015 undergoing curative-intent treatment identified through the SEER-Medicare linked database. Primary outcomes were new persistent opioid use and new persistent benzodiazepine use. Factors associated with new opioid and benzodiazepine use were investigated by univariate and multivariable logistic regression. RESULTS Among opioid-naïve patients, new opioid use was observed in 22,418 (67.4%). Of this group, 611 (2.7%) developed persistent opioid use at 3 months and 157 (0.7%) at 6 months after treatment. Risk factors for persistent use at 3 and 6 months included stage III disease (odds ratio [OR], 2.16; 95% CI, 1.49-3.12, and OR, 3.48; 95% CI, 1.58-7.67), surgery plus chemotherapy (OR, 1.44; 95% CI, 1.10-1.88, and OR, 2.28; 95% CI, 1.40-3.71), surgery plus chemoradiation therapy (OR, 1.47; 95% CI, 1.10-1.96, and OR, 2.34; 95% CI, 1.38-3.96), and initial tramadol use (OR, 2.66; 95% CI, 2.05-3.46, and OR, 3.12; 95% CI, 1.93-5.04). Among benzodiazepine-naïve patients, new benzodiazepine use was observed in 955 (10.3%), and 111 (11.6%) developed new persistent use at 3 months. Tamoxifen use was statistically significantly associated with new persistent benzodiazepine use at 3 months. CONCLUSIONS A large percentage of patients receiving curative-intent treatment of breast cancer were prescribed new opioids; however, only a small number developed new persistent opioid use. In contrast, a smaller proportion of patients received a new benzodiazepine prescription; however, new persistent use after completion of treatment was more likely and particularly related to concurrent treatment with tamoxifen.
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Affiliation(s)
| | - Megan Eguchi
- Department of Health Systems, Management, and Policy
| | | | | | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | - Peter Kabos
- Division of Medical Oncology, Department of Medicine, and
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Hite M, Dippre A, Heldreth A, Cole D, Lockett M, Klauber-DeMore N, Abbott AM. A Multifaceted Approach to Opioid Education, Prescribing, and Disposal for Patients with Breast Cancer Undergoing Surgery. J Surg Res 2021; 257:597-604. [DOI: 10.1016/j.jss.2020.06.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/28/2020] [Accepted: 06/16/2020] [Indexed: 01/17/2023]
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Crystal DT, Cuccolo NG, Plewinski MJ, Ibrahim AMS, Sinkin JC, Lin SJ, Agag RL, Lee BT. Assessment of Opioid-Prescribing Practices in Breast Augmentation: Future Directions for Prescribing Guidelines. Ann Plast Surg 2021; 86:11-18. [PMID: 32568754 DOI: 10.1097/sap.0000000000002430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The United States (US) is in the mid of an opioid epidemic propagated, in part, by prescription opioids. With excess overprescribing documented in a variety of surgical procedures, several societies have recommended opioid-prescribing guidelines. Considering the scope and postoperative pain associated with aesthetic plastic surgery procedures, earnest evaluation into opioid-prescribing practices for breast augmentation was conducted. METHODS Members of the American Society for Aesthetic Plastic Surgery were electronically surveyed on their opioid-prescribing patterns. The survey was distributed to 1709 plastic surgeons. Descriptive statistics were collated into percentages, deviations, and morphine milligram equivalents (MMEs), when appropriate. RESULTS Two hundred twenty-nine American Society for Aesthetic Plastic Surgery members (13.4%) provided responses. A total of 91.2% of respondents prescribe opioids to patients undergoing breast augmentation. The most commonly prescribed agents included oxycodone/acetaminophen (Percocet, 47.0%) and hydrocodone/acetaminophen (Vicodin, 38.3%). On average, 165.3 ± 81.7 MMEs were dispensed (range, 25.0-600.0 MMEs; number tablets, 5-60). Prescribers felt that a lack of phone-in prescribing (52.4%) and the ease of preemptively prescribing opioids (52.4%) propagate opioid overprescribing. A total of 61.3% of respondents reported that they are or may be in favor of developing plastic surgery societal guidelines related to opioid prescribing. These respondents indicated support for guidelines on opioid-sparing pain management strategies (74.2%) and guidelines identifying the type (54.7%), duration of use (69.5%), and number of opioid tablets (61.7%) necessary for procedures. CONCLUSIONS Considerable variability exists among prescribing patterns after breast augmentation. Societal guidelines aimed at providers and patients may serve a future role in opioid prescribing.
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Affiliation(s)
| | | | - Michael J Plewinski
- Division of Plastic Surgery, Robert Wood Johnson University Hospital, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Ahmed M S Ibrahim
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeremy C Sinkin
- Division of Plastic Surgery, Robert Wood Johnson University Hospital, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Samuel J Lin
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Richard L Agag
- Division of Plastic Surgery, Robert Wood Johnson University Hospital, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Bernard T Lee
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Insurance-Associated Disparities in Opioid Use and Misuse Among Patients Undergoing Gynecologic Surgery for Benign Indications. Obstet Gynecol 2020; 136:565-575. [PMID: 32769642 DOI: 10.1097/aog.0000000000003948] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare perioperative use and persistent postoperative opioid use among Medicaid-insured women and commercially insured women who underwent gynecologic surgery for benign indications. METHODS The Truven Health MarketScan database, a nationwide data source collecting commercial insurance claims across all states and Medicaid insurance claims from 12 states, was used to identify opioid-naïve women without cancer aged 18-64 years who underwent common gynecologic surgeries from 2012 to 2016 and filled a prescription for an opioid perioperatively. Persistent opioid use was defined as filling an opioid prescription 90-180 days after the surgery. Opioid use disorder (OUD) was defined as hospitalizations or emergency department visits for opioid dependence, misuse, or overdose. Multivariable models were developed to examine the insurance-associated disparity in persistent opioid use and OUD. RESULTS A total of 31,155 Medicaid-insured women and 270,716 commercially insured women were identified. Medicaid-insured women received greater quantities of opioids and for longer durations than did commercially insured women. Persistent postoperative opioid use was identified in 14.1% of Medicaid-insured women and 5.8% of commercially insured women (P<.001). More opioid prescriptions filled, longer days supplied, and higher total doses perioperatively contributed most to the prediction of persistent opioid use. Medicaid-insured patients who persistently used opioids were two times more likely to develop OUD than commercially insured patients (16.8% vs 5.1% adjusted relative risk 1.99; 99% CI 1.26-3.15). CONCLUSION Medicaid-insured women received larger quantities of opioids perioperatively, were more likely to use them persistently, and were more likely to develop OUD than commercially insured women.
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Krimphove MJ, Reese SW, Chen X, Marchese M, Pucheril D, Cone E, Chou W, Tully KH, Kibel AS, Urman RD, Chang SL, Kluth LA, Dasgupta P, Trinh QD. Recovery from minimally invasive vs. open surgery in kidney cancer patients: Opioid use and workplace absenteeism. Investig Clin Urol 2020; 62:56-64. [PMID: 33314804 PMCID: PMC7801161 DOI: 10.4111/icu.20200194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/23/2020] [Accepted: 07/09/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Does surgical approach (minimally invasive vs. open) and type (radical vs. partial nephrectomy) affects opioid use and workplace absenteeism. Materials and Methods Retrospective multivariable regression analysis of 2,646 opioid-naïve patients between 18 and 64 undergoing radical or partial nephrectomy via either a minimally invasive vs. open approach for kidney cancer in the United States between 2012 and 2017 drawn from the IBM Watson Health Database was performed. Outcomes included: (1) opioid use in opioid-naïve patients as measured by opioid prescriptions in the post-operative setting at early, intermediate and prolonged time periods and (2) workplace absenteeism after surgery. Results Patients undergoing minimally invasive surgery had a lower odds of opioid use in the early and intermediate post-operative periods (early: odds ratio [OR], 0.77; 95% confidence interval [CI], 0.62–0.97; p=0.02, intermediate: OR, 0.60; 95% CI, 0.48–0.75; p<0.01), but not in the prolonged setting (prolonged: OR, 1.00; 95% CI, 0.75–1.34; p=0.98) and had earlier return to work (minimally invasive vs. open: −10.53 days; 95% CI, −17.79 to −3.26; p<0.01). Controlling for approach, patient undergoing partial nephrectomy had lower rates of opioid use across all time periods examined and returned to work earlier than patients undergoing radical nephrectomy (partial vs. radical: −14.41 days; 95% CI, −21.22 to −7.60; p<0.01). Conclusions Patients undergoing various forms of surgery for kidney cancer had lower rates of peri-operative opioid use, fewer days of workplace absenteeism, but no difference in long-term rates of opioid use in patients undergoing minimally invasive as compared to open surgery.
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Affiliation(s)
- Marieke J Krimphove
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Stephen W Reese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Xi Chen
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maya Marchese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Pucheril
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eugene Cone
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wesley Chou
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karl H Tully
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Adam S Kibel
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven L Chang
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Prokar Dasgupta
- Department of Urology, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Guy's Hospital, London, United Kingdom
| | - Quoc Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Krimphove MJ, Chen X, Marchese M, Friedlander DF, Fields AC, Roa L, Pucheril D, Kibel AS, Melnitchouk N, Urman RD, Kluth LA, Dasgupta P, Trinh QD. Association of surgical approach and prolonged opioid prescriptions in patients undergoing major pelvic cancer procedures. BMC Surg 2020; 20:235. [PMID: 33054733 PMCID: PMC7557098 DOI: 10.1186/s12893-020-00879-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 09/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rise in deaths attributed to opioid drugs has become a major public health problem in the United States and in the world. Minimally invasive surgery (MIS) is associated with a faster postoperative recovery and our aim was to investigate if the use of MIS was associated with lower odds of prolonged opioid prescriptions after major procedures. METHODS Retrospective study using the IBM Watson Health Marketscan® Commerical Claims and Encounters Database investigating opioid-naïve cancer patients aged 18-64 who underwent open versus MIS radical prostatectomy (RP), partial colectomy (PC) or hysterectomy (HYS) from 2012 to 2017. Propensity weighted logistic regression analyses were used to estimate the independent effect of surgical approach on prolonged opioid prescriptions, defined as prescriptions within 91-180 days of surgery. RESULTS Overall, 6838 patients underwent RP (MIS 85.5%), 4480 patients underwent PC (MIS 61.6%) and 1620 patients underwent HYS (MIS 41.8%). Approximately 70-80% of all patients had perioperative opioid prescriptions. In the weighted model, patients undergoing MIS were significantly less likely to have prolonged opioid prescriptions in all three surgery types (Odds Ratio [OR] 0.737, 95% Confidence Interval [CI] 0.595-0.914, p = 0.006; OR 0.728, 95% CI 0.600-0.882, p = 0.001; OR 0.655, 95% CI 0.466-0.920, p = 0.015, respectively). CONCLUSION The use of the MIS was associated with lower odds of prolonged opioid prescription in all procedures examined. While additional studies such as clinical trials are needed for further confirmation, our findings need to be considered for patient counseling as postoperative differences between approaches do exist.
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Affiliation(s)
- Marieke J Krimphove
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Xi Chen
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA
| | - Maya Marchese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA
| | - David F Friedlander
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA
| | - Adam C Fields
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lina Roa
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Daniel Pucheril
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA
| | - Adam S Kibel
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA
| | - Nelya Melnitchouk
- Department of Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Prokar Dasgupta
- Department of Urology, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Guy's Hospital, London, UK
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St., ASB II-3, Boston, MA, 02115, USA.
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Johnson AC, Colakoglu S, Reddy A, Kerwin CM, Flores RA, Iorio ML, Mathes DW. Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction. Anesth Pain Med 2020; 10:e105686. [PMID: 34150564 PMCID: PMC8207839 DOI: 10.5812/aapm.105686] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023] Open
Abstract
CONTEXT High rates of mortality and chemical dependence occur following the overuse of narcotic medications, and the prescription of these medications has become a central discussion in health care. Efforts to curtail opioid prescribing include Enhanced Recovery After Surgery (ERAS) guidelines, which describe local anesthesia techniques to decrease or eliminate the need for opioids when used in a comprehensive protocol. Here, we review effective perioperative blocks for the decreased use of opioid medications post-breast reconstruction surgery. EVIDENCE ACQUISITION A comprehensive review was conducted using keywords narcotics, opioid, surgery, breast reconstruction, pain pump, nerve block, regional anesthesia, and analgesia. Papers that described a local anesthetic option for breast reconstruction for decreasing postoperative narcotic consumption, written in English, were included. RESULTS A total of 52 papers were included in this review. Local anesthetic options included single-shot nerve blocks, nerve block catheters, and local and regional anesthesia. Most papers reported equal or even superior pain control with decreased nausea and vomiting, length of hospital stay, and other outcomes. CONCLUSIONS Though opioid medications are currently the gold standard medication for pain management following surgery, strategies to decrease the dose or number of opioids prescribed may lead to better patient outcomes. The use of a local anesthetic technique has been shown to reduce narcotic use and improve patients' pain scores after breast reconstruction surgery.
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Affiliation(s)
- Ariel Clare Johnson
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Salih Colakoglu
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angela Reddy
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Clara Marie Kerwin
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Roland A Flores
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - David W Mathes
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Discussion: Predictors of Opioid Consumption in Immediate, Implant-Based Breast Reconstruction. Plast Reconstr Surg 2020; 146:742-743. [PMID: 32969996 DOI: 10.1097/prs.0000000000007215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Darnall BD, Ziadni MS, Krishnamurthy P, Flood P, Heathcote LC, Mackey IG, Taub CJ, Wheeler A. "My Surgical Success": Effect of a Digital Behavioral Pain Medicine Intervention on Time to Opioid Cessation After Breast Cancer Surgery-A Pilot Randomized Controlled Clinical Trial. PAIN MEDICINE 2020; 20:2228-2237. [PMID: 31087093 PMCID: PMC6830264 DOI: 10.1093/pm/pnz094] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objective This study aims to assess the feasibility of digital perioperative behavioral pain medicine intervention in breast cancer surgery and evaluate its impact on pain catastrophizing, pain, and opioid cessation after surgery. Design and Setting A randomized controlled clinical trial was conducted at Stanford University (Palo Alto, CA, USA) comparing a digital behavioral pain medicine intervention (“My Surgical Success” [MSS]) with digital general health education (HE). Participants A convenience sample of 127 participants were randomized to treatment group. The analytic sample was 68 patients (N = 36 MSS, N = 32 HE). Main Outcomes The primary outcome was feasibility and acceptability of a digital behavioral pain medicine intervention (80% threshold for acceptability items). Secondary outcomes were pain catastrophizing, past seven-day average pain intensity, and time to opioid cessation after surgery for patients who initiated opioid use. Results The attrition rate for MSS intervention (44%) was notably higher than for HE controls (18%), but it was lower than typical attrition rates for e-health interventions (60–80%). Despite greater attrition for MSS, feasibility was demonstrated for the 56% of MSS engagers, and the 80% threshold for acceptability was met. We observed a floor effect for baseline pain catastrophizing, and no significant group differences were found for postsurgical pain catastrophizing or pain intensity. MSS was associated with 86% increased odds of opioid cessation within the 12-week study period relative to HE controls (hazard ratio = 1.86, 95% confidence interval = 1.12–3.10, P = 0.016). Conclusions Fifty-six percent of patients assigned to MSS engaged with the online platform and reported high satisfaction. MSS was associated with significantly accelerated opioid cessation after surgery (five-day difference) with no difference in pain report relative to controls. Perioperative digital behavioral pain medicine may be a low-cost, accessible adjunct that could promote opioid cessation after breast cancer surgery.
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Affiliation(s)
- Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Maisa S Ziadni
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Parthasarathy Krishnamurthy
- Department of Marketing and Entrepreneurship, CT Bauer College of Business, University of Houston, Houston, Texas
| | - Pamela Flood
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Lauren C Heathcote
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Ian G Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Chloe Jean Taub
- Department of Psychology, University of Miami, Coral Gables, Florida
| | - Amanda Wheeler
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
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Predictors of Opioid Consumption in Immediate, Implant-Based Breast Reconstruction. Plast Reconstr Surg 2020; 146:734-741. [DOI: 10.1097/prs.0000000000007150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Datto CJ, Johansen P, Leon-Casasola OD. Oral analgesic use in postmenopausal women after curative breast cancer treatment: post hoc analysis of the ATAC trial. BREAST CANCER MANAGEMENT 2020. [DOI: 10.2217/bmt-2020-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate analgesic use and associated conditions in postmenopausal women who had undergone curative breast cancer treatment. Materials & methods: This post hoc analysis used the Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial database, which included patient reports of concomitant medications and associated indications during follow-up. Results: Of 3434 women with eligible concomitant medication data, 71.8% reported oral analgesic use. Of 2321 patients using analgesics ≥30 days, 47.9% reported opioid use. Musculoskeletal pain was the most common indication for oral analgesic use. Of patients using opioids, 28.1% reported concomitant laxative use. Conclusion: Approximately half of the patients reported opioid use, most commonly for noncancer (musculoskeletal) pain, suggesting that breast cancer survivors experience chronic pain that should be appropriately managed.
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Affiliation(s)
| | | | - Oscar de Leon-Casasola
- Division of Pain Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA
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46
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Shakir S, Spencer AB, Kozak GM, Nathan SL, Soriano IS, Kanchwala SK. Laparoscopically Assisted DIEP Flap Harvest Minimizes Fascial Incision in Autologous Breast Reconstruction. Plast Reconstr Surg 2020; 146:265e-275e. [PMID: 32842099 DOI: 10.1097/prs.0000000000007048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric vessels permits a decrease in myofascial dissection in deep inferior epigastric artery perforator flap breast reconstruction. The authors present a reliable technique that further decreases donor-site morbidity in autologous breast reconstruction. METHODS The authors conducted a retrospective cohort study of female subjects presenting to the senior surgeon (S.K.K.) from March of 2018 to March of 2019 for autologous breast reconstruction after a newly diagnosed breast cancer. The operative technique is summarized as follows: a supraumbilical camera port is placed at the medial edge of the rectus muscle to enter the retrorectus space; the extraperitoneal plane is developed using a balloon dissector and insufflation; two ports are placed through the linea alba below the umbilicus to introduce dissection instruments; the deep inferior epigastric vessels are dissected from the underside of the rectus muscle; muscle branches and the superior epigastric are ligated using a Ligasure; and the deep inferior epigastric pedicle is ligated and the vessels are delivered through a minimal fascial incision. The flap(s) is transferred to the chest for completion of the reconstruction. RESULTS Thirty-three subjects totaling 57 flaps were included. All flaps were single-perforator deep inferior epigastric artery perforator flaps. Mean fascial incision length was 2.0 cm. Sixty percent of subjects recovered without narcotics. Mean length of stay was 2.5 days. Flap salvage occurred in one subject after venous congestion. Two pedicle transections occurred during harvest that required perforator-to-pedicle anastomosis. CONCLUSION Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric pedicle is a reliable method that decreases the donor-site morbidity of autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Sameer Shakir
- From the Divisions of Plastic Surgery and Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania
| | - Amy B Spencer
- From the Divisions of Plastic Surgery and Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania
| | - Geoffrey M Kozak
- From the Divisions of Plastic Surgery and Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania
| | - Shelby L Nathan
- From the Divisions of Plastic Surgery and Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania
| | - Ian S Soriano
- From the Divisions of Plastic Surgery and Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania
| | - Suhail K Kanchwala
- From the Divisions of Plastic Surgery and Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania
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Zhang L, Ding W, Ji Y. Analgesic effect of pulsed electromagnetic fields for mammaplasty: A meta-analysis of randomized controlled studies. Medicine (Baltimore) 2020; 99:e21449. [PMID: 32871867 PMCID: PMC7458251 DOI: 10.1097/md.0000000000021449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pulsed electromagnetic fields shows some potential in alleviating pain after mammaplasty. This systematic review and meta-analysis is conducted to investigate the analgesic efficacy of pulsed electromagnetic fields for pain control after mammaplasty. METHODS The databases including PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases are systematically searched for collecting the randomized controlled trials regarding the impact of pulsed electromagnetic fields on pain intensity after mammaplasty. RESULTS This meta-analysis has included 4 randomized controlled trials. Compared with control group after mammaplasty, pulsed electromagnetic fields results in remarkably reduced pain scores on 1 day (MD = -1.34; 95% confidence interval [CI] = -2.23 to -0.45; P = .003) and 3 days (MD = -1.86; 95% CI = -3.23 to -0.49; P = .008), as well as analgesic consumption (Std. MD = -5.64; 95% CI = -7.26 to -4.02; P < .00001). CONCLUSIONS Pulsed electromagnetic fields is associated with substantially reduced pain intensity after mammaplasty.
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Affiliation(s)
- Li Zhang
- Department of Plastic Surgery, The First people's Hospital of Xiaoshan
| | - Wei Ding
- Department of Plastic Surgery, The First people's Hospital of Xiaoshan
| | - Yu Ji
- Department of Plastic Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou; Zhejiang Province, P.R. China
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Jin Z, Durrands T, Li R, Gan TJ, Lin J. Pectoral block versus paravertebral block: a systematic review, meta-analysis and trial sequential analysis. Reg Anesth Pain Med 2020; 45:727-732. [DOI: 10.1136/rapm-2020-101512] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 12/23/2022]
Abstract
BackgroundPectoral (PECs) block was first described by Blanco et al for postoperative analgesia in breast surgery. It was proposed to be an easier and safer alternative to thoracic epidural or paravertebral block (PVB). In this systematic review and meta-analysis, we compare the perioperative analgesic efficacy and adverse events of PECs block and PVB.MethodsWe systematically searched PubMed, Central, EMBASE, CINAHL, Google Scholar, Web of Science citation index, US clinical trials register, Wanfang database, as well as recent conference abstracts, for clinical studies comparing the two techniques. Analgesic efficacy was assessed according to the time to first rescue analgesia and 24 hours opioid consumption. Adverse events from the trials were recorded and reported descriptively.ResultsThe literature search was last updated on 20 February 2020. We identified a total of 10 randomized controlled trials (RCTs) comparing PECs to PVB with 252 and 250 patients, respectively. There was no difference in 24 hours opioid consumption between PECs and PVB. There was no significant difference in the time to rescue analgesia between the two cohorts. The most common adverse event noted was postoperative nausea and vomiting). Trial sequence analysis indicate that further studies are unlikely to alter the conclusion regarding opioid requirement.ConclusionOur systematic review suggests that PECs and PVB are comparable in postoperative analgesia efficacy for mastectomy, and further studies are unlikely to alter the conclusion. The choice of technique should, therefore, be based on practitioner skill and institutional guidelines.PROSPERO registration numberCRD42020165137.
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Lee JS, Vu JV, Edelman AL, Gunaseelan V, Brummett CM, Englesbe MJ, Waljee JF. Health Care Spending and New Persistent Opioid Use After Surgery. Ann Surg 2020; 272:99-104. [PMID: 31851641 PMCID: PMC7068728 DOI: 10.1097/sla.0000000000003399] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE We sought to describe the differences in health care spending and utilization among patients who develop persistent postoperative opioid use. SUMMARY OF BACKGROUND DATA Although persistent opioid use following surgery has garnered concern, its impact on health care costs and utilization remains unknown. METHODS We examined insurance claims among 133,439 opioid-naive adults undergoing surgery. Outcomes included 6-month postoperative health care spending; proportion of spending attributable to admission, readmission, ambulatory or emergency care; monthly spending 6 months before and following surgery. We defined persistent opioid use as continued opioid fills beyond 3 months postoperatively. We used linear regression to estimate outcomes adjusting for clinical covariates. RESULTS In this cohort, 8103 patients developed persistent opioid use. For patients who underwent inpatient procedures, new persistent opioid use was associated with health care spending (+$2700 per patient, P < 0.001) compared with patients who did not develop new persistent use. For patients who underwent outpatient procedures, new persistent opioid use was similarly correlated with higher health care spending (+$1500 per patient, P < 0.001) compared with patients who did not develop new persistent use. Patients without persistent opioid use returned to baseline health care spending within 6 months, regardless of other complications. However, patients with persistent opioid use had sustained increases in spending by approximately $200 per month. CONCLUSION Unlike other postoperative complications, persistent opioid use is associated with sustained increases in spending due to greater readmissions and ambulatory care visits. Early identification of patients vulnerable to persistent use may enhance the value of surgical care.
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Affiliation(s)
- Jay S. Lee
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Joceline V. Vu
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | | | | | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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Quantifying the Crisis: Opioid-Related Adverse Events in Outpatient Ambulatory Plastic Surgery. Plast Reconstr Surg 2020; 145:687-695. [PMID: 32097308 DOI: 10.1097/prs.0000000000006570] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The United States is currently in the midst of an opioid epidemic precipitated, in part, by the excessive outpatient supply of opioid pain medications. Accordingly, this epidemic has necessitated evaluation of practice and prescription patterns among surgical specialties. The purpose of this study was to quantify opioid-related adverse events in ambulatory plastic surgery. METHODS A retrospective review of 43,074 patient profiles captured from 2001 to 2018 within an American Association for Accreditation of Ambulatory Surgery Facilities quality improvement database was conducted. Free-text search terms related to opioids and overdose were used to identify opioid-related adverse events. Extracted profiles included information submitted by accredited ambulatory surgery facilities and their respective surgeons. Descriptive statistics were used to quantify opioid-related adverse events. RESULTS Among our cohort, 28 plastic surgery patients were identified as having an opioid-related adverse event. Overall, there were three fatal and 12 nonfatal opioid-related overdoses, nine perioperative opioid-related adverse events, and four cases of opioid-related hypersensitivities or complications secondary to opioid tolerance. Of the nonfatal cases evaluated in the hospital (n = 17), 16 patients required admission, with an average 3.3 ± 1.7 days' hospital length of stay. CONCLUSIONS Opioid-related adverse events are notable occurrences in ambulatory plastic surgery. Several adverse events may have been prevented had different diligent medication prescription practices been performed. Currently, there is more advocacy supporting sparing opioid medications when possible through multimodal anesthetic techniques, education of patients on the risks and harms of opioid use and misuse, and the development of societal guidance regarding ambulatory surgery prescription practices.
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