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Giakas JA, Israel HA, Ali AH, Kaar SG. Does the addition of post-operative gabapentin reduce the use of narcotics after orthopedic surgery? PHYSICIAN SPORTSMED 2024; 52:283-290. [PMID: 37545473 DOI: 10.1080/00913847.2023.2246177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES To evaluate the efficacy of post-operative gabapentin administration as an analgesic agent and its effect on narcotic use after orthopedic surgery in an outpatient sports medicine practice by comparing patients prior to and after initiating the routine use of gabapentin as part of a standardized post-operative pain medication regimen. We hypothesized that adding gabapentin to a multimodal post-operative pain regimen would decrease the number of requested pain medication refills and have no detrimental effect on Visual Analogue Scale and Single Assessment Numerical Evaluation scores at these early post-operative visits. METHODS All outpatient surgical patients, <90 years of age, undergoing outpatient orthopedic surgery by the study's senior author were included between 08/05/2021 and 02/22/2022. Patients were allowed 1 narcotic refill post-operatively and only in the first 3 weeks. The primary outcome was difference in percentage of patients who requested a narcotic refill within 3 weeks post-op. Two- and 6-week Visual Analogue Scale and Single Assessment Numerical Evaluation scores, and baseline health and demographic data. T-tests were run on continuous variables, Chi-Square or Fisher's Exact Test were run on dichotomous variables, and Mann-Whitney U test was run on all other categorical variables. Statistical significance was set at P < .05 for all tests. RESULTS There was a significant difference in narcotic refills at 3 weeks: 23 pre-gabapentin patients and 9 post-gabapentin patients (22.8% vs 9.0%, respectively: P = .006). There were no differences between 2- and 6-week Visual Analogue Scale and 2-week Single Assessment Numerical Evaluation scores. There was a significant difference in 6-week SANE between groups: mean difference = 6.4 (P = .027) though less than the established MCID. CONCLUSION Addition of gabapentin to a post-operative multimodal pain regimen reduced the use of narcotics after orthopedic sports medicine surgeries while also providing equivalent pain control.
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Affiliation(s)
- Julian A Giakas
- Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Heidi A Israel
- Department of Orthopedic Surgery, Division of Sports Medicine and Shoulder Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Ashley H Ali
- Department of Orthopedic Surgery, Division of Sports Medicine and Shoulder Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Scott G Kaar
- Department of Orthopedic Surgery, Division of Sports Medicine and Shoulder Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
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Mekkawy KL, Rodriguez HC, Gosthe RG, Corces A, Roche MW. Immediate Postoperative Zolpidem Use Increases Risk of Falls and Implant Complication Rates Following Total Hip Arthroplasty: A Retrospective Case-Control Analysis. J Arthroplasty 2024; 39:169-173.e1. [PMID: 37562745 DOI: 10.1016/j.arth.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Zolpidem is the most widely used hypnotic in the United States and has known side effects. However, the morbidity of zolpidem use following total hip arthroplasty (THA) is not well-defined. Thus, the aim of this study was to assess the effects that zolpidem use has on medical and implant complications, falls, lengths of stay, and medical utilizations following THA. METHODS A retrospective query of a nationwide insurance claims database was conducted from 2010 to 2020. All cases of THA and hypnotic use were identified using procedural and national drug codes. Patients who were prescribed zolpidem within 90 days of surgery were matched to hypnotic naive patients 1:5 based on demographic and comorbidity profiles. The 90-day medical complications, falls, fragility fractures, costs, and readmission rates, as well as 2-year implant complications were compared between cohorts. A total of 50,328 zolpidem patients were matched to 251,286 hypnotic naive patients. RESULTS The zolpidem group had significantly higher rates of medical complications, falls, and fragility fractures when compared to the hypnotic-naive group. The zolpidem group had significantly higher rates of dislocation, mechanical loosening, and periprosthetic fracture. Likewise, healthcare utilization was significantly greater in the zolpidem group. CONCLUSION Zolpidem use following THA is associated with significant risk of medical and implant complications, as well as fall risks, increased costs, lengths of stay, and readmissions. The findings of this study may affect discussions between orthopaedic surgeons and their patients on the benefits of sleep quality in their recovery versus the incurred risks of zolpidem use. LEVEL OF EVIDENCE III, retrospective case-control study.
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Affiliation(s)
- Kevin L Mekkawy
- Holy Cross Orthopedic Research Institute, Holy Cross Health, Fort Lauderdale, Florida; Hospital for Special Surgery, West Palm Beach, Florida; Department of Surgery, South Shore Universtiy Hospital, Bay Shore, New York
| | - Hugo C Rodriguez
- Hospital for Special Surgery, West Palm Beach, Florida; Larkin Community Hospital, Department of Orthopaedic Surgery, South Miami, Florida
| | - Raul G Gosthe
- Holy Cross Orthopedic Research Institute, Holy Cross Health, Fort Lauderdale, Florida
| | - Arturo Corces
- Larkin Community Hospital, Department of Orthopaedic Surgery, South Miami, Florida
| | - Martin W Roche
- Holy Cross Orthopedic Research Institute, Holy Cross Health, Fort Lauderdale, Florida; Hospital for Special Surgery, West Palm Beach, Florida
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3
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Wojtalewicz S, Erickson S, Vizmeg J, Shuckra J, Barger K, Cleveland A, Davis J, Niederauer S, Beeman M, Panic V, Wilcox K, Metcalf C, Agarwal J, Lade C, Davis B. Assessment of glyceride-structured oleogels as an injectable extended-release delivery system of bupivacaine. Int J Pharm 2023; 637:122887. [PMID: 36990171 DOI: 10.1016/j.ijpharm.2023.122887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
This manuscript systematically assesses three different glycerides (tripalmitin, glyceryl monostearate, and a blend of mono-, di- and triesters of palmitic and stearic acids (Geleol™)) as potential gelator structuring agents of medium-chain triglyceride oil to form an oleogel-based injectable long-acting local anesthetic formulation for postoperative pain management. Drug release testing, oil-binding capacity, injection forces, x-ray diffraction, differential scanning calorimetry, and rheological testing were serially performed to characterize the functional properties of each oleogel. After benchtop assessment, the superior bupivacaine-loaded oleogel formulation was compared to bupivacaine HCl, liposomal bupivacaine, and bupivacaine-loaded medium-chain triglyceride oil in a rat sciatic nerve block model to assess in vivo long-acting local anesthetic performance. In vitro drug release kinetics were similar for all formulations, indicating that drug release rate is primarily dependent on the drug's affinity to the base oil. Glyceryl monostearate-based formulations had superior shelf-life and thermal stability. The glyceryl monostearate oleogel formulation was selected for in vivo evaluation. It was found to have a significantly longer duration of anesthetic effect than liposomal bupivacaine and was able to provide anesthesia twice as long as the equipotent bupivacaine-loaded medium-chain triglyceride oil, indicating that the increased viscosity of the oleogel provided enhanced controlled release over the drug-loaded oil alone.
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4
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Yang HH, Wu TJ, Suh JD, Wang MB, Holliday MA, Beswick DM, Zhang H, Wells C, McCormick J, Maxim T, Regev A, Chandy ZK, Lee JT. Postoperative Gabapentin's Effect on Opioid Consumption and Pain Control Following Sinonasal Surgery. Laryngoscope 2022; 133:1065-1072. [PMID: 35833722 DOI: 10.1002/lary.30282] [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: 05/31/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study investigates the impact of postoperative gabapentin on opioid consumption and pain control following endoscopic sinus surgery (ESS) and/or septoplasty. METHODS Patients who underwent ESS and/or septoplasty at a single institution from 2021 to 2022 were enrolled. All patients received postoperative hydrocodone-acetaminophen for pain control. Half of the patients were also prescribed gabapentin for the first postoperative day in addition to hydrocodone-acetaminophen. Subjects completed the Revised American Pain Society Patient Outcome Questionnaire 24 h and 7 days after surgery. We conducted a multivariable regression analysis to assess opioid consumption and improvement in pain scores in the first week between gabapentin and non-gabapentin groups. RESULTS A total of 102 subjects, 51 in each arm, were enrolled. The mean age was 52 years and 53% of participants were female. Controlling for important baseline demographic, clinical, and surgically related variables, the addition of postoperative gabapentin was associated with a 44% (9.5 mg from 21.6 mg) reduction in opioids consumed in the first postoperative week (B = -9.54, 95% C.I. = [-17.84, -1.24], p = 0.025). In addition, patients in both arms exhibited similar improvement in pain severity and sleep interference in the first 7 days (B = -1.59, 95% C.I. = [-5.03, 1.84], p = 0.36). CONCLUSION To the best of our knowledge, this is the first study to investigate the impact of postoperative gabapentin on opioid consumption and pain control following ESS and/or septoplasty. Our analysis demonstrated that postoperative gabapentin effectively reduced opioid use during the first postoperative week without compromising pain control. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Hong-Ho Yang
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Tara J Wu
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Marilene B Wang
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Michael A Holliday
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Daniel M Beswick
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Huan Zhang
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Christine Wells
- Office of Academic Research and Computing, University of California, Los Angeles, California, USA
| | - Justin McCormick
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Tom Maxim
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Aviva Regev
- Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Zachariah K Chandy
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Jivianne T Lee
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
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Wojtalewicz S, Vizmeg J, Erickson S, Lade C, Shea J, Sant H, Magda J, Gale B, Agarwal J, Davis B. Evaluating the influence of particle morphology and density on the viscosity and injectability of a novel long-acting local anesthetic suspension. J Biomater Appl 2022; 37:724-736. [PMID: 35649287 DOI: 10.1177/08853282221106486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Proper pain management is well understood to be one of the fundamental aspects of a healthy postoperative recovery in conjunction with mobility and nutrition. Approximately, 10% of patients prescribed opioids after surgery continue to use opioids in the long-term and as little as 10 days on opioids can result in addiction. In an effort to provide physicians with an alternative pain management technique, this work evaluates the material properties of a novel local anesthetic delivery system designed for controlled release of bupivacaine for 72 hours. The formulation utilizes solid-lipid microparticles that encapsulate the hydrophobic molecule bupivacaine in its free-base form. The lipid microparticles are suspended in a non-crosslinked hyaluronic acid hydrogel, which acts as the microparticle carrier. Two different particle manufacturing techniques, milling and hot homogenization, were evaluated in this work. The hot homogenized particles had a slower and more controlled release than the milled particles. Rheological techniques revealed that the suspension remains a viscoelastic fluid when loaded with either particle type up to 25% (w/v) particles densities. Furthermore, the shear thinning properties of the suspension media, hyaluronic acid hydrogel, were conserved when bupivacaine-loaded solid-lipid microparticles were loaded up to densities of 25% (w/v) particle loading. The force during injection was measured for suspension formulations with varying hyaluronic acid hydrogel concentrations, particle densities, particle types and particle sizes. The results indicate that the formulation viscosity is highly dependent on particle density, but hyaluronic acid hydrogel is required for lowering injection forces as well as minimizing clogging events.
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Affiliation(s)
- Susan Wojtalewicz
- Department of Mechanical Engineering, 14434University of Utah, Salt Lake City, UT, USA.,Rebel Medicine Inc., Salt Lake City, UT, USA
| | - Jonathon Vizmeg
- Rebel Medicine Inc., Salt Lake City, UT, USA.,Department of Biomedical Engineering, 14434University of Utah, Salt Lake City, UT, USA
| | | | - Caleb Lade
- Rebel Medicine Inc., Salt Lake City, UT, USA
| | - Jill Shea
- Department of Surgery, 14434University of Utah, Salt Lake City, UT, USA
| | - Himanshu Sant
- Department of Mechanical Engineering, 14434University of Utah, Salt Lake City, UT, USA
| | - Jules Magda
- Department of Chemical Engineering, 14434University of Utah, Salt Lake City, UT, USA
| | - Bruce Gale
- Department of Mechanical Engineering, 14434University of Utah, Salt Lake City, UT, USA
| | - Jayant Agarwal
- Rebel Medicine Inc., Salt Lake City, UT, USA.,Department of Surgery, 14434University of Utah, Salt Lake City, UT, USA
| | - Brett Davis
- Rebel Medicine Inc., Salt Lake City, UT, USA
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Goto T, Sapio MR, Maric D, Robinson JM, Domenichiello AF, Saligan LN, Mannes AJ, Iadarola MJ. Longitudinal peripheral tissue RNA-Seq transcriptomic profiling, hyperalgesia, and wound healing in the rat plantar surgical incision model. FASEB J 2021; 35:e21852. [PMID: 34499774 PMCID: PMC9293146 DOI: 10.1096/fj.202100347r] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023]
Abstract
Postoperative pain and delayed healing in surgical wounds, which require complex management strategies have understudied complicated mechanisms. Here we investigated temporal changes in behavior, tissue structure, and transcriptomic profiles in a rat model of a surgical incision, using hyperalgesic behavioral tests, histological analyses, and next‐generation RNA sequencing, respectively. The most rapidly (1 hour) expressed genes were the chemokines, Cxcl1 and Cxcl2. Consequently, infiltrating leukocytes were abundantly observed starting at 6 and peaking at 24 hours after incising which was supported by histological analysis and appearance of the neutrophil markers, S100a8 and S100a9. At this time, hyperalgesia was at a peak and overall transcriptional activity was most highly activated. At the 1‐day timepoint, Nppb, coding for natriuretic peptide precursor B, was the most strongly upregulated gene and was localized by in situ hybridization to the epidermal keratinocytes at the margins of the incision. Nppb was basically unaffected in a peripheral inflammation model transcriptomic dataset. At the late phase of wound healing, five secreted, incision‐specific peptidases, Mmp2, Aebp1, Mmp23, Adamts7, and Adamtsl1, showed increased expression, supporting the idea of a sustained tissue remodeling process. Transcripts that are specifically upregulated at each timepoint in the incision model may be potential candidates for either biomarkers or therapeutic targets for wound pain and wound healing. This study incorporates the examination of longitudinal temporal molecular responses, corresponding anatomical localization, and hyperalgesic behavioral alterations in the surgical incision model that together provide important and novel foundational knowledge to understand mechanisms of wound pain and wound healing.
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Affiliation(s)
- Taichi Goto
- Symptoms Biology Unit, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Matthew R Sapio
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Dragan Maric
- Flow and Imaging Cytometry Core Facility, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey M Robinson
- Translational Life Science Technology Program, University of Maryland, Baltimore County, Baltimore, MD, USA
| | - Anthony F Domenichiello
- Lipid Peroxidation Unit, Laboratory of Clinical Investigation, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Leorey N Saligan
- Symptoms Biology Unit, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Andrew J Mannes
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Michael J Iadarola
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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Mudumbai SC, Chung P, Nguyen N, Harris B, Clark JD, Wagner TH, Giori NJ, Stafford RS, Mariano ER. Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients. PAIN MEDICINE 2021; 21:595-603. [PMID: 31309970 DOI: 10.1093/pm/pnz154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization? METHODS We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed. RESULTS The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants. CONCLUSIONS Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.
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Affiliation(s)
- Seshadri C Mudumbai
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | | | | | | | - J David Clark
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Todd H Wagner
- Center for Innovation to Implementation.,Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Nicholas J Giori
- Orthopaedic Surgery Section, Surgical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Departments of Orthopaedic Surgery
| | - Randall S Stafford
- Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Hah JM, Hilmoe H, Schmidt P, McCue R, Trafton J, Clay D, Sharifzadeh Y, Ruchelli G, Hernandez Boussard T, Goodman S, Huddleston J, Maloney WJ, Dirbas FM, Shrager J, Costouros JG, Curtin C, Mackey SC, Carroll I. Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial. J Pain Res 2020; 13:2959-2970. [PMID: 33239904 PMCID: PMC7680674 DOI: 10.2147/jpr.s269370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use. Methods In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18–75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively. Results Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87–1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68–0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40–0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39–0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80–0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89–1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06–1.77; P=0.016). Conclusion Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.
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Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Heather Hilmoe
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Peter Schmidt
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Rebecca McCue
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA.,VA Program Evaluation and Resource Center, VHA Office of Mental Health Operations, Palo Alto, CA, USA
| | - Debra Clay
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Gabriela Ruchelli
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Tina Hernandez Boussard
- Department of Medicine, Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Stuart Goodman
- Department of Orthopaedic Surgery and (by Courtesy) Bioengineering, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - James Huddleston
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | | | - Joseph Shrager
- Division of Thoracic Surgery, Stanford University, Stanford, CA, USA
| | - John G Costouros
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Catherine Curtin
- Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Ian Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
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9
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McVeigh LG, Perugini AJ, Fehrenbacher JC, White FA, Kacena MA. Assessment, Quantification, and Management of Fracture Pain: from Animals to the Clinic. Curr Osteoporos Rep 2020; 18:460-470. [PMID: 32827293 PMCID: PMC7541703 DOI: 10.1007/s11914-020-00617-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Fractures are painful and disabling injuries that can occur due to trauma, especially when compounded with pathologic conditions, such as osteoporosis in older adults. It is well documented that acute pain management plays an integral role in the treatment of orthopedic patients. There is no current therapy available to completely control post-fracture pain that does not interfere with bone healing or have major adverse effects. In this review, we focus on recent advances in the understanding of pain behaviors post-fracture. RECENT FINDINGS We review animal models of bone fracture and the assays that have been developed to assess and quantify spontaneous and evoked pain behaviors, including the two most commonly used assays: dynamic weight bearing and von Frey testing to assess withdrawal from a cutaneous (hindpaw) stimulus. Additionally, we discuss the assessment and quantification of fracture pain in the clinical setting, including the use of numeric pain rating scales, satisfaction with pain relief, and other biopsychosocial factor measurements. We review how pain behaviors in animal models and clinical cases can change with the use of current pain management therapies. We conclude by discussing the use of pain behavioral analyses in assessing potential therapeutic treatment options for addressing acute and chronic fracture pain without compromising fracture healing. There currently is a lack of effective treatment options for fracture pain that reliably relieve pain without potentially interfering with bone healing. Continued development and verification of reliable measurements of fracture pain in both pre-clinical and clinical settings is an essential aspect of continued research into novel analgesic treatments for fracture pain.
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Affiliation(s)
- Luke G McVeigh
- Department of Orthopaedic Surgery, Indiana University School of Medicine, 1130 W. Michigan St, FH 115, Indianapolis, IN, 46202, USA
| | - Anthony J Perugini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, 1130 W. Michigan St, FH 115, Indianapolis, IN, 46202, USA
| | - Jill C Fehrenbacher
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fletcher A White
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Melissa A Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, 1130 W. Michigan St, FH 115, Indianapolis, IN, 46202, USA.
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
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10
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O’Hagan ET, Hübscher M, Miller CB, Gordon CJ, Gustin S, Briggs N, McAuley JH. Zolpidem reduces pain intensity postoperatively: a systematic review and meta-analysis of the effect of hypnotic medicines on post-operative pain intensity. Syst Rev 2020; 9:206. [PMID: 32883342 PMCID: PMC7472584 DOI: 10.1186/s13643-020-01458-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/14/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This systematic review aimed to investigate whether the administration of hypnotic medicines, z-drugs, melatonin or benzodiazepines, reduced pain intensity postoperatively. METHODS Medline, Embase, Cinahl, Psych info, Central and PubMed databases were searched, from inception to February 2020 to identify relevant trials. The search was extended, post hoc, to include meta-Register of Controlled Trials, the Web of Science and the conference booklets for the 14th, 15th, and 16th International Association for the Study of Pain conferences. Two independent reviewers screened titles and abstracts and cross-checked the extracted data. RESULTS The search retrieved 5546 articles. After full-text screening, 15 trials were included, which had randomised 1252 participants. There is moderate-quality evidence that in the short-term [WMD - 1.06, CI - 1.48 to - 0.64, p ≤ .01] and low-quality evidence that in the medium-term [WMD - 0.90, CI - 1.43 to - 0.37, p ≤ .01] postoperative period oral zolpidem 5/10 mg with other analgesic medicines reduced pain intensity compared to the same analgesic medicines alone. There is low-quality evidence that melatonin was not effective on postoperative pain intensity compared to placebo. The results of benzodiazepines on pain intensity were mixed. The authors reported no significant adverse events. CONCLUSIONS There is promising evidence that the hypnotic medicine zolpidem, adjuvant to other analgesics, is effective at achieving a minimally clinically important difference in pain intensity postoperatively. There is no consistent effect of melatonin or benzodiazepines on postoperative pain intensity. Readers should interpret these results with some caution due to the lack of data on safety, the small number of trials included in the pooled effects and their sample sizes. SYSTEMATIC REVIEW REGISTRATION The protocol for this systematic review was registered with PROSPERO ID= CRD42015025327 .
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Affiliation(s)
- Edel T. O’Hagan
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, NSW 2031 Australia
- Prince of Wales Clinical School, The University of New South Wales, Randwick, NSW 2031 Australia
| | - Markus Hübscher
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, NSW 2031 Australia
- Prince of Wales Clinical School, The University of New South Wales, Randwick, NSW 2031 Australia
| | - Christopher B. Miller
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, The University of Sydney, Glebe, NSW 2037 Australia
| | - Christopher J. Gordon
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, The University of Sydney, Glebe, NSW 2037 Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Sylvia Gustin
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, NSW 2031 Australia
- Gustin Pain Imaging Laboratory, School of Psychology, The University of New South Wales, Randwick, NSW 2031 Australia
| | - Nancy Briggs
- Stats Central, University of New South Wales, Randwick, NSW 2031 Australia
| | - James H. McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, NSW 2031 Australia
- School of Medical Science, University of New South Wales, Randwick, NSW 2031 Australia
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11
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Kong Q, Griffis M, Shallop BJ, Khalsa AS, Brougham K, Marchetto PA. Acute Opioid Withdrawal Mimicking Postoperative Joint Infection Following anterior cruciate ligament (ACL) Reconstruction: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923458. [PMID: 32569260 PMCID: PMC7327734 DOI: 10.12659/ajcr.923458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A short course of opioid narcotics is often prescribed for postoperative anterior cruciate ligament (ACL) reconstruction pain management. Unfortunately, there is a well-documented incidence of opioid withdrawal syndrome (OWS) following short-term use of these medications. OWS can present with symptoms such as influenza-like illness. It is important to differentiate OWS from infectious illnesses, especially after surgery. CASE REPORT We present a case of OWS in a patient who underwent ACL reconstruction 7 days prior. The patient's OWS symptoms were similar to symptoms of a postoperative infection. The knee was aspirated, and the analysis of the aspirate was not concerning for an infection. The patient's symptoms spontaneously resolved on postoperative day 10. This is the first documented case of OWS mimicking ACL reconstruction joint infection. CONCLUSIONS OWS after surgery may present with symptoms similar to joint infection. It is important to consider OWS as a potential complication after surgery and differentiate it from infection to avoid any further unnecessary invasive treatments for the patient.
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Affiliation(s)
- Qingwu Kong
- Department of Orthopedic Surgery, Albert Einstein Medical Center, Philadelphia, PA, USA.,Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Martin Griffis
- Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA.,Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Brandon J Shallop
- Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Amrit S Khalsa
- Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA.,Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kyle Brougham
- Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Paul A Marchetto
- Department of Orthopedic Surgery, Thomas Jefferson University Hospital, Rothman Institute, Philadelphia, PA, USA
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12
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Gause TM, Nunnery JJ, Chhabra AB, Werner BC. Perioperative Narcotic Use and Carpal Tunnel Release: Trends, Risk Factors, and Complications. Hand (N Y) 2020; 15:234-242. [PMID: 30067126 PMCID: PMC7076616 DOI: 10.1177/1558944718792276] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background: The goals of the study were to: (1) evaluate trends in preoperative and prolonged postoperative narcotic use in carpal tunnel release (CTR); (2) characterize risks for prolonged narcotic use; and (3) evaluate narcotic use as an independent risk factor for complications following CTR. Methods: A query of a large insurance database from 2007-2016 was conducted. Patients undergoing open or endoscopic CTR were included. Revision surgeries or patients undergoing median nerve repair at the forearm, upper extremity fasciotomies, or with distal radius fractures were excluded. Preoperative use was defined as narcotic use between 1 to 4 months prior to CTR. A narcotic prescription between 1 and 4 months after surgery was considered prolonged postoperative use. Demographics, comorbidities, and other risk factors for prolonged postoperative use were assessed using a regression analysis. Subgroup analysis was performed according to the number of preoperative narcotic prescriptions. Narcotic use as a risk factor for complications, including chronic regional pain syndrome (CRPS) and revision CTR, was assessed. Results: In total, 66 077 patients were included. A decrease in prescribing of perioperative narcotics was noted. Risk factors for prolonged narcotic use included preoperative narcotic use, drug and substance use, lumbago, and depression. Preoperative narcotics were associated with increased emergency room visits, readmissions, CRPS, and infection. Prolonged postoperative narcotic use was linked to CRPS and revision surgery. Conclusions: Preoperative narcotic use is strongly associated with prolonged postoperative use. Both preoperative and prolonged postoperative prescriptions narcotic use correlated with increased risk of complications. Preoperative narcotic use is associated with a higher risk of postoperative CRPS.
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13
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Hah J, Mackey SC, Schmidt P, McCue R, Humphreys K, Trafton J, Efron B, Clay D, Sharifzadeh Y, Ruchelli G, Goodman S, Huddleston J, Maloney WJ, Dirbas FM, Shrager J, Costouros JG, Curtin C, Carroll I. Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA Surg 2019; 153:303-311. [PMID: 29238824 DOI: 10.1001/jamasurg.2017.4915] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice. Objective To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation. Design, Setting, and Participants A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings. Interventions Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours. Main Outcomes and Measures Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year. Results Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]). Conclusions and Relevance Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research. Trial Registration clinicaltrials.gov Identifier: NCT01067144.
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Affiliation(s)
- Jennifer Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| | - Peter Schmidt
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Rebecca McCue
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Keith Humphreys
- Center for Healthcare Evaluation, Veterans Health Administration, Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
| | - Jodie Trafton
- Center for Healthcare Evaluation, Veterans Health Administration, Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California.,Veterans Administration Program Evaluation and Resource Center, Veterans Health Administration Office of Mental Health Operations, Menlo Park, California
| | - Bradley Efron
- Department of Biomedical Data Science, Stanford University, Palo Alto, California
| | - Debra Clay
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Gabriela Ruchelli
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Stuart Goodman
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California.,Department of Bioengineering, Stanford University, Palo Alto, California
| | - James Huddleston
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Frederick M Dirbas
- Department of General Surgery, Stanford University, Palo Alto, California
| | - Joseph Shrager
- Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University, Palo Alto, California
| | - John G Costouros
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Catherine Curtin
- Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Ian Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
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14
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Hofford RS, Russo SJ, Kiraly DD. Neuroimmune mechanisms of psychostimulant and opioid use disorders. Eur J Neurosci 2019; 50:2562-2573. [PMID: 30179286 PMCID: PMC6531363 DOI: 10.1111/ejn.14143] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/20/2018] [Accepted: 08/28/2018] [Indexed: 12/11/2022]
Abstract
Substance use disorders are global health problems with few effective treatment options. Unfortunately, most potential pharmacological treatments are hindered by abuse potential of their own, limited efficacy, or adverse side effects. As a consequence, there is a pressing need for the development of addiction treatments with limited abuse potential and fewer off target effects. Given the difficulties in developing new pharmacotherapies for substance use disorders, there has been growing interest in medications that act on non-traditional targets. Recent evidence suggests a role for dysregulated immune signaling in the pathophysiology of multiple psychiatric diseases. While there is evidence that immune responses in the periphery and the central nervous system are altered by exposure to drugs of abuse, the contributions of neuroimmune interactions to addictive behaviors are just beginning to be appreciated. In this review, we discuss the data on immunological changes seen in clinical populations with substance use disorders, as well as in translational animal models of addiction. Importantly, we highlight those mechanistic findings showing causal roles for central or peripheral immune mediators in substance use disorder and appropriate animal models. Based on the literature reviewed here, it is clear that brain-immune system interactions in substance use disorders are much more complex and important than previously understood. While much work remains to be done, there are tremendous potential therapeutic implications for immunomodulatory treatments in substance use disorders.
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Affiliation(s)
- Rebecca S Hofford
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Scott J Russo
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
- Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Drew D Kiraly
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
- Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York
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15
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Lederer AK, Schmucker C, Kousoulas L, Fichtner-Feigl S, Huber R. Naturopathic Treatment and Complementary Medicine in Surgical Practice. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:815-821. [PMID: 30678751 DOI: 10.3238/arztebl.2018.0815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/02/2018] [Accepted: 09/06/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Many patients in Germany use naturopathic treatments and complementary medicine. Surveys have shown that many also use them as a concomitant treatment to surgery. METHODS Multiple databases were systematically searched for systematic reviews, controlled trials, and experimental studies concerning the use of naturopathic treatments and complementary medicine in the management of typical post-operative problems (PROSPERO CRD42018095330). RESULTS Of the 387 publications identified by the search, 76 fulfilled the inclusion criteria. In patients with abnormal gastrointestinal activity, acupuncture can improve motility, ease the passing of flatus, and lead to earlier defecation. Acupuncture and acupressure can reduce postoperative nausea and vomiting, as well as pain. More-over,aromatherapy and music therapy seem to reduce pain, stress and anxiety and to improve sleep. Further studies are needed to determine whether phytotherapeutic treatments are effective for the improvement of gastrointestinal function or the reduction of stress. It also remains unclear whether surgical patients can benefit from the methods of mind body medicine. CONCLUSION Certain naturopathic treatments and complementary medical methods may be useful in postoperative care and deserve more intensive study. In the publications consulted for this review, no serious side effects were reported.
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Affiliation(s)
- Ann-Kathrin Lederer
- Center for Complementary Medicine, Institute for Infection Prevention and Hospital Epidemiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Department for General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg
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16
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Ho E, Doherty M, Thomas R, Attia J, Oldmeadow C, Clapham M. Prescription of opioids to post-operative orthopaedic patients at time of discharge from hospital: a prospective observational study. Scand J Pain 2019; 18:253-259. [PMID: 29794303 DOI: 10.1515/sjpain-2017-0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/30/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Excessive opioid prescribing can lead to adverse consequences including stockpiling, misuse, dependency, diversion and mortality. Increased prescriptions to post-operative inpatients as part of their discharge planning may be a significant contributor. Primary aims included comparing the amount of opioids prescribed, consumed, left unused and their relationship with pain and functionality. METHODS A total of 132 consecutive patients who underwent elective orthopaedic surgery were prospectively audited. Daily oral morphine equivalent (DME) of opioids prescribed was compared with opioids consumed and amount left unused 7-10 days after discharge. For analysis, patients were split into three groups: total knee replacement (TKR), hand surgery (Hands), and miscellaneous (Misc). RESULTS The mean dose of opioid prescribed per patient was 108.5 mg DME. TKR consumed 33-35% more opioids than Misc (p=0.0283) and Hands (p=0.0975). Age was a significant independent factor for opioid consumption in the 50th and 75th percentiles of Hands (p≤0.05). An average of 36 mg DME per patient was left unused with Hands having the highest median DME (37 mg) unused. In the total cohort, 26% of patients were discharged with more DME than their last 24 h as an inpatient and had at least 50% of their tablets left unused at follow-up. CONCLUSIONS Over-prescription of opioids occurs at discharge which can increase the risk of harm. New intervention is needed to optimise prescribing practises. IMPLICATIONS Changes to prescribing habits and workplace culture are required to minimise unnecessary opioid prescribing but will be challenging to implement. A multi-layered approach of electronic prescribing, opioid stewardship and targeted educational awareness programmes is recommended.
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Affiliation(s)
- Edward Ho
- Department of Anaesthesia, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia, Phone: (+61) 4921 3000
| | - Matthew Doherty
- John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia
| | - Robert Thomas
- Department of Anaesthesia, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia
| | - John Attia
- John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,University of Newcastle, Callaghan NSW, 2308, Australia
| | | | - Matthew Clapham
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
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17
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Updates on multimodal analgesia and regional anesthesia for total knee arthroplasty patients. Best Pract Res Clin Anaesthesiol 2019; 33:111-123. [DOI: 10.1016/j.bpa.2019.02.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/23/2019] [Accepted: 02/26/2019] [Indexed: 01/17/2023]
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18
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Kardell LD, Hilmer SN, Crane JA, MacPherson R, Kim TYL, Gnjidic D. Investigation of opioid prescribing in the postoperative setting among opioid-naïve surgical patients: a 6-month observational study. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1469] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Luke David Kardell
- Faculty of Medicine and Health; Sydney Pharmacy School; University of Sydney; Sydney Australia
- Department of Clinical Pharmacology; Kolling Institute of Medical Research; Royal North Shore Hospital; Sydney Australia
| | - Sarah Nicole Hilmer
- Department of Clinical Pharmacology; Kolling Institute of Medical Research; Royal North Shore Hospital; Sydney Australia
- Department of Aged Care; Kolling Institute of Medical Research; Royal North Shore Hospital; Sydney Australia
- Faculty of Medicine and Health; Sydney Medical School; University of Sydney; Sydney Australia
| | | | - Ross MacPherson
- Faculty of Medicine and Health; Sydney Medical School; University of Sydney; Sydney Australia
- Department of Anaesthesia and Pain Management; Royal North Shore Hospital; Sydney Australia
| | - Tae Yeon Lisa Kim
- Faculty of Medicine and Health; Sydney Pharmacy School; University of Sydney; Sydney Australia
| | - Danijela Gnjidic
- Faculty of Medicine and Health; Sydney Pharmacy School; University of Sydney; Sydney Australia
- Charles Perkins Centre; University of Sydney; Sydney Australia
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19
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Nolte MT, Elboghdady IM, Iyer S. Anesthesia and postoperative pain control following spine surgery. ACTA ACUST UNITED AC 2018. [DOI: 10.1053/j.semss.2018.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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First Place: A prospective, randomized controlled trial of the impact of written discharge instructions for postoperative opioids on patient pain satisfaction and on minimizing opioid risk exposure in orthopaedic surgery. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000632] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Oh JH, Seo HJ, Lee YH, Choi HY, Joung HY, Kim SH. Do Selective COX-2 Inhibitors Affect Pain Control and Healing After Arthroscopic Rotator Cuff Repair? A Preliminary Study. Am J Sports Med 2018; 46:679-686. [PMID: 29253346 DOI: 10.1177/0363546517744219] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Selective cyclooxygenase (COX)-2 inhibitors are commonly used analgesics that provide similar analgesia as that of other analgesics but with fewer adverse effects. However, few prospective studies have performed comparative analyses in this regard. PURPOSE To evaluate the efficacy of a selective COX-2 inhibitor in early postoperative pain control, satisfaction with pain management, and incidence of systemic adverse effects in patients undergoing arthroscopic rotator cuff repair. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This study included 180 patients who underwent arthroscopic rotator cuff repair between September 2011 and August 2012. The patients were randomly assigned to receive celecoxib, ibuprofen, or tramadol (n = 60 each). Visual analog scale (VAS) scores for pain intensity and satisfaction with medication, incidence of adverse effects, and use of rescue medication were recorded and compared between the 3 groups at 3 days and 2 weeks after surgery. Magnetic resonance and ultrasonography images of 82 patients were retrospectively reviewed at least 24 months after surgery, along with the range of motion and pain VAS and functional scores. RESULTS There were no significant differences among the 3 groups in terms of pain intensity, incidence of adverse effects, or dosage of rescue medication at 3 days or 2 weeks after surgery. Pain VAS and functional scores at the final follow-up were also comparable among the 3 groups. However, the retear rate in the celecoxib group (11/30 [37%]) was significantly higher than those in the ibuprofen (2/27 [7%]) and tramadol (1/25 [4%]) groups ( P = .009). CONCLUSION Despite having similar postoperative analgesic effects as other nonsteroidal anti-inflammatory drugs and opioids, selective COX-2 inhibitors should not be used for postoperative analgesia because they might negatively affect tendon-to-bone healing after surgical repair. Registration: NCT02850211 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyuk Jun Seo
- Department of Orthopaedic Surgery, Daegu Chamtntn Hospital, Daegu, Republic of Korea
| | - Ye-Hyun Lee
- Department of Orthopaedic Surgery, National Police Hospital, Seoul, Republic of Korea
| | - Hye-Yeon Choi
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, Republic of Korea
| | - Ho Yun Joung
- Department of Orthopaedic Surgery, Wonkwang University School of Medicine, Wonkwang University Sanbon Hospital, Gunpo, Republic of Korea
| | - Sae Hoon Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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22
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Sabatino MJ, Kunkel ST, Ramkumar DB, Keeney BJ, Jevsevar DS. Excess Opioid Medication and Variation in Prescribing Patterns Following Common Orthopaedic Procedures. J Bone Joint Surg Am 2018; 100:180-188. [PMID: 29406338 PMCID: PMC6818977 DOI: 10.2106/jbjs.17.00672] [Citation(s) in RCA: 223] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. Understanding prescribing habits and patient utilization of these medications following a surgical procedure is critical to establishing appropriate prescribing protocols that effectively control pain while minimizing unused opioid distribution. We evaluated prescribing habits and patient utilization following elective orthopaedic surgical procedures to identify ways of improving postoperative opioid-prescribing practices. METHODS We performed a review of prescribing data of 1,199 procedures and gathered telephone survey results from 557 patients to determine the number of opioid pills prescribed postoperatively and the number of unused pills. The data were collected from adult patients who underwent 1 of the 5 most common elective orthopaedic procedures at our institution in fiscal year 2015: total hip arthroplasty, total knee arthroplasty, endoscopic carpal tunnel release, arthroscopic rotator cuff repair, or lumbar decompression. We converted all dosages to opioid equivalents of oxycodone 5 mg and performed analyses of prescribing patterns, patient utilization, and patient disposal of unused opioids. RESULTS Prescribing patterns following the 5 orthopaedic procedures showed wide variation. The median numbers of oxycodone 5-mg equivalent opioid pills prescribed upon discharge were 90 pills (range, 20 to 330 pills) for total hip arthroplasty, 90 pills (range, 10 to 200 pills) for total knee arthroplasty, 20 pills (range, 0 to 168 pills) for endoscopic carpal tunnel release, 80 pills (range, 18 to 100 pills) for arthroscopic rotator cuff repair, and 80 pills (range, 10 to 270 pills) for lumbar decompression. Thirty-seven percent of patients overall requested and received at least 1 refill. The mean number of total pills prescribed (and standard deviation) including refills was 113.6 ± 75.7 for total hip arthroplasty, 176.4 ± 108.0 for total knee arthroplasty, 24.3 ± 29.0 for carpal tunnel release, 98.2 ± 59.6 for rotator cuff repair, and 107.4 ± 64.4 for lumbar decompression. Participants reported unused opioid medication in 61% of cases. During the study year, >43,000 unused opioid pills were prescribed. Forty-one percent of patients reported appropriate disposal of unused opioid pills. CONCLUSIONS Prescribing patterns vary widely, and a large amount of opioid medications remains unused following elective orthopaedic surgical procedures. Effective prescribing protocols are needed to limit this source of potential abuse and opioid diversion within the community.
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Affiliation(s)
- Matthew J. Sabatino
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire,E-mail address for M.J. Sabatino:
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Lam WL, Yeung WF, Wong MK, Cheung CW, Chan KKL, Ngan HYS, Wong CKH, Chen HY, Lao L. Combined electroacupuncture and auricular acupuncture for postoperative pain after abdominal surgery for gynecological diseases: study protocol for a randomized controlled trial. Trials 2018; 19:8. [PMID: 29301556 PMCID: PMC5755011 DOI: 10.1186/s13063-017-2359-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 11/28/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Postoperative pain is a major complaint following abdominal surgery for gynecological diseases. Effective postoperative pain control after abdominal surgery is particularly important for patient recovery, mobility, and satisfaction. Acupuncture has been commonly used for pain management. However, its efficacy in postoperative pain control is inconclusive and health economic evaluation is limited. METHODS A randomized, sham-controlled, patient- and- assessor-blind trial is designed to evaluate the efficacy and safety of acupuncture in managing postoperative pain following abdominal surgery of gynecological diseases. Patients who are eligible for laparotomy with a midline incision for gynecological neoplasia, including ovarian mass, uterine mass, and cervical lesions, will be recruited. Seventy-two participants will be randomly allocated to an acupuncture or non-invasive sham control in a 1:1 ratio. Treatment will be done within 2 h before operation, upon arrival to the ward and once daily for 5 days. The Pain Numerical Rating Scale (NRS) on the first 5 days during hospitalization will be the primary outcome and will be analyzed using the area-under-the-curve (AUC) method. The secondary outcome measures include frequency of rescue analgesic use during hospital stay, cumulative morphine consumption; quality of recovery as measured by time to recovery variables and the Quality of Recovery-9 (QoR-9); quality of life as measured by the Short Form-6 dimension (SF-6D) and EuroQol-5 Dimension-5 Level (EQ-5D-5 L). The incremental cost-effectiveness ratio of acupuncture vs sham acupuncture will be calculated. DISCUSSION This study protocol provides an example of integrative medicine practice in a hospital setting for the management of postoperative pain using acupuncture treatment. The acupuncture treatment protocol, if proven to be effective, can be implemented in routine settings to play a role in postoperative pain management for patients who have undergone abdominal surgery for gynecological diseases. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02851186 . Registered on 19 July 2016.
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Affiliation(s)
- Wing Lok Lam
- School of Chinese Medicine, The University of Hong Kong, 10 Sassoon Road, Pokfulam, Hong Kong, Special Administrative Region of China
| | - Wing Fai Yeung
- School of Nursing, the Hong Kong Polytechnic University, Kowloon, Hong Kong, Special Administrative Region of China
| | - Mei Kuen Wong
- School of Chinese Medicine, The University of Hong Kong, 10 Sassoon Road, Pokfulam, Hong Kong, Special Administrative Region of China
| | - Chi Wai Cheung
- Department of Anesthesiology, The University of Hong Kong, 4/F, K Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, Special Administrative Region of China
| | - Karen Kar Loen Chan
- Department of Obstetrics and Gynecology, The University of Hong Kong, 6/F, Professorial Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, Special Administrative Region of China
| | - Hextan Yuen Sheung Ngan
- Department of Obstetrics and Gynecology, The University of Hong Kong, 6/F, Professorial Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, Special Administrative Region of China
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Pokfulam, Hong Kong, Special Administrative Region of China
| | - Hai Yong Chen
- School of Chinese Medicine, The University of Hong Kong, 10 Sassoon Road, Pokfulam, Hong Kong, Special Administrative Region of China
| | - Lixing Lao
- School of Chinese Medicine, The University of Hong Kong, 10 Sassoon Road, Pokfulam, Hong Kong, Special Administrative Region of China
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Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg 2017; 125:1733-1740. [PMID: 29049117 PMCID: PMC6119469 DOI: 10.1213/ane.0000000000002458] [Citation(s) in RCA: 464] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Physicians, policymakers, and researchers are increasingly focused on finding ways to decrease opioid use and overdose in the United States both of which have sharply increased over the past decade. While many efforts are focused on the management of chronic pain, the use of opioids in surgical patients presents a particularly challenging problem requiring clinicians to balance 2 competing interests: managing acute pain in the immediate postoperative period and minimizing the risks of persistent opioid use after the surgery. Finding ways to minimize this risk is particularly salient in light of a growing literature suggesting that postsurgical patients are at increased risk for chronic opioid use. The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical- and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term. In this paper, we discuss the consequences of chronic opioid use after surgery and present an analysis of the extent to which surgery has been associated with chronic opioid use. We follow with a discussion of the risk factors that are associated with chronic opioid use after surgery and proceed with an analysis of the extent to which opioid-sparing perioperative interventions (eg, nerve blockade) have been shown to reduce the risk of chronic opioid use after surgery. We then conclude with a discussion of future research directions.
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Affiliation(s)
- Jennifer M Hah
- From the *Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California; †Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and ‡Department of Neurosurgery, §Department of Orthopaedic Surgery (by courtesy), ‖Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, ¶Department of Anesthesiology, Perioperative, and Pain Medicine, and #Department of Health Research and Policy (by courtesy), Stanford University, Stanford, California
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Gal JS, Curatolo CJ, Zerillo J, Hill B, Lonner B, Cuddihy LA, Antonacci MD, Betz RR, DeMaria S, Khelemsky Y. Anesthetic considerations for a novel anterior surgical approach to pediatric scoliosis correction. Paediatr Anaesth 2017; 27:1028-1036. [PMID: 28857329 DOI: 10.1111/pan.13216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Idiopathic scoliosis is a condition that may require surgical correction. Limitations of previous surgical modalities, however, created the need for novel methods of repair. One such technique, a newer form of anterolateral scoliosis correction, has shown considerable promise, which our center has had substantial experience performing. AIM In this article, we present the case details of our first 105 patients for the purposes of describing the evolution and details of the anesthetic management and considerations for this procedure. METHODS A retrospective review of medical records for 105 patients undergoing anterolateral instrumentation procedure for idiopathic scoliosis correction done at a single institution from May 2014 to June 2016 was performed. The details of perioperative management as well as surgical technique were reported for all patients. RESULTS The mean age for patients was 14.8 years (range 10-18); the mean weight was 49.9 kg (range 25-82). Unilateral procedures were performed on 46.7%, with bilateral and hybrid procedures performed on 50.5% and 4.7%, respectively. The median number of levels corrected was 8 (interquartile range [IQR] 7-9) for unilateral, right 7 (IQR 6-7) and left 5 (IQR 4-5) for bilateral, and 4 (IQR 4-4.5) for hybrids. The average estimated blood loss (EBL) was 310 mL±138, with cell salvaged blood transfused in 61% of patients, and allogenic blood transfusion required in only two patients. CONCLUSIONS The described anesthetic and analgesic management provides a framework for delivering perioperative care for this challenging procedure, which is gaining popularity as a modality for scoliosis correction.
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Affiliation(s)
- Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher J Curatolo
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan Hill
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Baron Lonner
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laury A Cuddihy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M D Antonacci
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Randal R Betz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yury Khelemsky
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
This review includes a summary of contemporary theories of pain processing and advocates a multimodal analgesia approach for providing perioperative care. A summary of various medication classes and anesthetic techniques is provided that highlights evidence emerging from neurosurgical literature. This summary covers opioid management, acetaminophen, nonsteroidal antiinflammatories, ketamine, lidocaine, dexmedetomidine, corticosteroids, gabapentin, and regional anesthesia for neurosurgery. At present, there is not enough investigation into these areas to describe best practices for treating or preventing chronic pain in neurosurgery; but providers can identify a wider range of options available to personalize perioperative care strategies.
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Affiliation(s)
- Samuel Grodofsky
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street 5th Floor Dulles, Philadelphia, PA 19104, USA.
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Shulman BS, Marcano AI, Davidovitch RI, Karia R, Egol KA. Nature's wrath-The effect of weather on pain following orthopaedic trauma. Injury 2016; 47:1841-6. [PMID: 27318614 DOI: 10.1016/j.injury.2016.05.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 05/29/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite frequent complaints by orthopaedic trauma patients, to our knowledge there is no data regarding weather's effect on pain and function following acute and chronic fracture. The aim of our study was to investigate the influence of daily weather conditions on patient reported pain and functional status. METHODS We retrospectively examined prospectively collected data from 2369 separate outpatient visits of patients recovering from operative management of acute tibial plateau fractures, acute distal radius fractures, and chronic fracture nonunions. Pain and functional status were assessed using a visual analogue scale (VAS) and the DASH and SMFA functional indexes. For each visit date, the mean temperature, difference between mean temperature and expected temperature, dew point, mean humidity, amount of rain, amount of snow, and barometric pressure were recorded. Statistical analysis was run to search for associations between weather data and patient reported pain and function. RESULTS Low barometric pressure was associated with increased pain across all patient visits (p=0.007) and for patients at 1-year follow-up only (p=0.005). At 1-year follow-up, high temperature (p=0.021) and high humidity (p=0.030) were also associated with increased pain. No significant association was noted between weather data and patient reported functional status at any follow-up interval. CONCLUSIONS Patient complaints of weather influencing pain after orthopaedic trauma are valid. While pain in the immediate postoperative period is most likely dominated by incisional and soft tissue injuries, as time progresses barometric pressure, temperature, and humidity impact patient pain levels. Affirming and counseling that pain may vary based on changing weather conditions can help manage patient expectations and improve satisfaction.
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Affiliation(s)
- Brandon S Shulman
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003, USA.
| | - Alejandro I Marcano
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003, USA.
| | - Roy I Davidovitch
- Center for Musculoskeletal Care, 33 East 38th Street, New York, NY 10016, USA.
| | - Raj Karia
- NYU Langone Medical Center, 380 2nd Ave. Suite 606, New York, NY 10010, USA.
| | - Kenneth A Egol
- NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003, USA.
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Majuta LA, Longo G, Fealk MN, McCaffrey G, Mantyh PW. Orthopedic surgery and bone fracture pain are both significantly attenuated by sustained blockade of nerve growth factor. Pain 2015; 156:157-165. [PMID: 25599311 DOI: 10.1016/j.pain.0000000000000017] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The number of patients suffering from postoperative pain due to orthopedic surgery and bone fracture is projected to dramatically increase because the human life span, weight, and involvement in high-activity sports continue to rise worldwide. Joint replacement or bone fracture frequently results in skeletal pain that needs to be adequately controlled for the patient to fully participate in needed physical rehabilitation. Currently, the 2 major therapies used to control skeletal pain are nonsteroidal anti-inflammatory drugs and opiates, both of which have significant unwanted side effects. To assess the efficacy of novel therapies, mouse models of orthopedic and fracture pain were developed and evaluated here. These models, orthopedic surgery pain and bone fracture pain, resulted in skeletal pain-related behaviors that lasted 3 weeks and 8 to 10 weeks, respectively. These skeletal pain behaviors included spontaneous and palpation-induced nocifensive behaviors, dynamic weight bearing, limb use, and voluntary mechanical loading of the injured hind limb. Administration of anti-nerve growth factor before orthopedic surgery or after bone fracture attenuated skeletal pain behaviors by 40% to 70% depending on the end point being assessed. These data suggest that nerve growth factor is involved in driving pain due to orthopedic surgery or bone fracture. These animal models may be useful in developing an understanding of the mechanisms that drive postoperative orthopedic and bone fracture pain and the development of novel therapies to treat these skeletal pains.
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Affiliation(s)
- Lisa A Majuta
- Department of Pharmacology, University of Arizona, Tucson, AZ 85724, USA Arizona Cancer Center, University of Arizona, Tucson, AZ 85724, USA
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Loxoprofen sodium and celecoxib for postoperative pain in patients after spinal surgery: a randomized comparative study. J Orthop Sci 2015; 20:617-23. [PMID: 25911562 DOI: 10.1007/s00776-015-0726-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/07/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to treat inflammation, pain, and fever, but no criterion standard exists for the management of postoperative pain following spinal surgery. In the present study, we compared the analgesic efficacy of loxoprofen sodium (loxoprofen) and celecoxib for the management of postoperative pain following spinal surgery. METHODS One-hundred forty-one patients (mean age 62.2 years) were randomly assigned to two groups before spinal surgery: a loxoprofen group (n = 73, 180 mg/day) and a celecoxib group (n = 68, 200 mg/day). The drugs were administered from 1 day until 7 days after surgery. A numeric rating scale (NRS) was used to evaluate pain at nine predefined times every day and the findings were compared between the two groups. Laboratory data and adverse events were also recorded. RESULTS There was no significant difference in the maximum and mean NRS scores on each day between loxoprofen and celecoxib, suggesting a comparable analgesic effect for these two NSAIDs. Greater improvement in the NRS score between preadministration (baseline) and 30 min or 2 h after administration was obtained for loxoprofen. This tendency was shown for both slight (NRS score <5 at baseline) and severe pain (NRS score ≥ 5 at baseline). Loxoprofen was discontinued in one patient on day 4 because of renal dysfunction. Celecoxib was discontinued in one patient on day 2 at the patient's request. CONCLUSIONS Both loxoprofen sodium and celecoxib were well tolerated for the relief of acute postoperative pain after spinal surgery. A single administration of loxoprofen showed superior and rapid effectiveness compared with celecoxib for both slight and severe postoperative pain.
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Devin CJ, McGirt MJ. Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. J Clin Neurosci 2015; 22:930-8. [DOI: 10.1016/j.jocn.2015.01.003] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 01/16/2015] [Indexed: 01/05/2023]
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Roberts MJ, Perera M, Lawrentschuk N, Romanic D, Papa N, Bolton D. Globalization of continuing professional development by journal clubs via microblogging: a systematic review. J Med Internet Res 2015; 17:e103. [PMID: 25908092 PMCID: PMC4424319 DOI: 10.2196/jmir.4194] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 02/21/2015] [Accepted: 02/23/2015] [Indexed: 11/16/2022] Open
Abstract
Background Journal clubs are an essential tool in promoting clinical evidence-based medical education to all medical and allied health professionals. Twitter represents a public, microblogging forum that can facilitate traditional journal club requirements, while also reaching a global audience, and participation for discussion with study authors and colleagues. Objective The aim of the current study was to evaluate the current state of social media–facilitated journal clubs, specifically Twitter, as an example of continuing professional development. Methods A systematic review of literature databases (Medline, Embase, CINAHL, Web of Science, ERIC via ProQuest) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of Twitter, the followers of identified journal clubs, and Symplur was also performed. Demographic and monthly tweet data were extracted from Twitter and Symplur. All manuscripts related to Twitter-based journal clubs were included. Statistical analyses were performed in MS Excel and STATA. Results From a total of 469 citations, 11 manuscripts were included and referred to five Twitter-based journal clubs (#ALiEMJC, #BlueJC, #ebnjc, #urojc, #meded). A Twitter-based journal club search yielded 34 potential hashtags/accounts, of which 24 were included in the final analysis. The median duration of activity was 11.75 (interquartile range [IQR] 19.9, SD 10.9) months, with 7 now inactive. The median number of followers and participants was 374 (IQR 574) and 157 (IQR 272), respectively. An overall increasing establishment of active Twitter-based journal clubs was observed, resulting in an exponential increase in total cumulative tweets (R2=.98), and tweets per month (R2=.72). Cumulative tweets for specific journal clubs increased linearly, with @ADC_JC, @EBNursingBMJ, @igsjc, @iurojc, and @NephJC, and showing greatest rate of change, as well as total impressions per month since establishment. An average of two tweets per month was estimated for the majority of participants, while the “Top 10” tweeters for @iurojc showed a significantly lower contribution to overall tweets for each month (P<.005). A linearly increasing impression:tweet ratio was observed for the top five journal clubs. Conclusions Twitter-based journal clubs are free, time-efficient, and publicly accessible means to facilitate international discussions regarding clinically important evidence-based research.
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Hah JM, Mackey S, Barelka PL, Wang CKM, Wang BM, Gillespie MJ, McCue R, Younger JW, Trafton J, Humphreys K, Goodman SB, Dirbas FM, Schmidt PC, Carroll IR. Self-loathing aspects of depression reduce postoperative opioid cessation rate. PAIN MEDICINE 2015; 15:954-64. [PMID: 24964916 DOI: 10.1111/pme.12439] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE We previously reported that increased preoperative Beck Depression Inventory II (BDI-II) scores were associated with a 47% (95% CI 24%-64%) reduction in the rate of opioid cessation following surgery. We aimed to identify the underlying factors of the BDI-II (affective/cognitive vs somatic) associated with a decreased rate of opioid cessation after surgery. METHODS We conducted a secondary analysis of the data from a previously reported prospective, longitudinal, observational study of opioid use after five distinct surgical procedures (total hip replacement, total knee replacement, thoracotomy, mastectomy, and lumpectomy) in 107 patients. The primary endpoint was time to opioid cessation. After exploratory factor analysis of the BDI-II, mean summary scores were calculated for each identified factor. These scores were evaluated as predictors of time to opioid cessation using Cox proportional hazards regression. RESULTS The exploratory factor analysis produced three factors (self-loathing symptoms, motivational symptoms, emotional symptoms). All three factors were significant predictors in univariate analysis. Of the three identified factors of the BDI-II, only preoperative self-loathing symptoms (past failure, guilty feelings, self-dislike, self-criticalness, suicidal thoughts, worthlessness) independently predicted a significant decrease in opioid cessation rate after surgery in the multivariate analysis (HR 0.86, 95% CI 0.75-0.99, P value 0.037). CONCLUSIONS Our results identify a set of negative cognitions predicting prolonged time to postoperative opioid cessation. Somatic symptoms captured by the BDI-II were not primarily responsible for the association between preoperative BDI-II scores and postoperative prolonged opioid use.
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Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Stanford University, Palo Alto, California, USA
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Abstract
Opioids are commonly used for the management of pain in patients with musculoskeletal disorders; however, national attention has highlighted the potential adverse effects of the use of opioid analgesia in this and other nonmalignant pain settings. Chronic opioid users undergoing orthopaedic surgery represent a particularly challenging patient population in regard to their perioperative pain control and outcomes. Preoperative evaluation provides an opportunity to estimate a patient's preoperative opioid intake, discuss pain-related fears, and identify potential psychiatric comorbidities. Patients using high levels of opioids may also require referral to an addiction specialist. Various regional blockade and pharmaceutical options are available to help control perioperative pain, and a multimodal pain management approach may be of particular benefit in chronic opioid users undergoing orthopaedic surgery.
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Current views on acute to chronic pain transition in post-traumatic patients: risk factors and potential for pre-emptive treatments. J Trauma Acute Care Surg 2014; 76:1142-50. [PMID: 24662883 DOI: 10.1097/ta.0000000000000188] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sia DIT, Chalmers A, Singh V, Malhotra R, Selva D. General anaesthetic considerations for haemostasis in orbital surgery. Orbit 2013; 33:5-12. [PMID: 24144180 DOI: 10.3109/01676830.2013.842250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Orbital surgery is often conducted in areas with limited exposure where vital structures are tightly crowded together. A bloodless field is paramount in orbital surgery for the proper identification of normal and pathologic tissue and even minimal bleeding can obscure the surgical field, making surgery more difficult and increasing the risk of complications. Surgery for highly vascular orbital lesions is an additional situation where maintaining an adequate surgical field is often challenging but paramount. The role of the anaesthetist in controlling surgical blood loss has been increasingly recognized in the last few decades. Various techniques including hypotensive anaesthesia have been described, but the control of intraoperative bleeding does not rely on a single particular technique, but a series of well-designed interventions that result in optimal conditions. An understanding of the anaesthetic considerations pertinent to haemostasis is invaluable for oculoplastic surgeons. Additionally, with the growing use of endonasal approaches to medial wall decompression and accessing the medial orbit, it has become increasingly important that orbital surgeons understand the anaesthetic requirements of their colleagues in other disciplines.
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Affiliation(s)
- David Ik Tuo Sia
- South Australian Institute of Ophthalmology , Adelaide , Australia
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Ousey K, Edward KL, Lui S. Identifying and exploring physical and psychological morbidity and patient and family caregiver resilience following acute wound development and/or wound blistering post orthopaedic surgery: a systematic review. Int Wound J 2013; 12:63-9. [PMID: 23489286 DOI: 10.1111/iwj.12054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 01/16/2013] [Accepted: 01/28/2013] [Indexed: 11/29/2022] Open
Abstract
The aim of this article was to identify the literature that examined and explored physical and psychological morbidity and patient and family caregiver resilience following acute wound development and/or wound blistering post orthopaedic surgery. A systematic review of the literature using the databases MEDLINE, CINAHL and EMBASE was undertaken. The papers were examined using title and abstract for relevance to the primary and secondary outcomes. The primary outcome of interest was family caregiver resilience following acute wound development and/or wound blistering post orthopaedic surgery. The search yielded 275 records after removing any duplicates; eight studies were considered eligible and were reviewed as full text. Following full review, none of the studies was included in this article. To conclude, there were no papers that investigated or examined the concept of resilience in relation to the management of acute post-surgical orthopaedic wounds. Four of the papers identified, following the review process, did discuss quality of life outcomes and how these may be improved following wound development; most papers focused on the management of chronic wounds. It is apparent from the review that there is no evidence currently available that explores patient and family caregiver resilience following acute wound development and/or wound blistering post orthopaedic surgery.
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Affiliation(s)
- Karen Ousey
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
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