Opioid versus opioid-free analgesia after surgical discharge: protocol for a systematic review and meta-analysis

Effect of oral pre-emptive analgesia on pain management after total knee arthroplasty: a protocol for systematic review and meta-analysis

INTRODUCTION

Total knee arthroplasty (TKA) is currently regarded as an effective treatment for knee osteoarthritis, relieving patients' pain and significantly enhancing their quality of life and activity levels, allowing them to return to work and daily life after surgery. However, some TKA patients suffer from varying degrees of postoperative residual pain and opioid abuse, which negatively impacts their recovery and quality of life. It has been reported that preoperative treatment with multimodal analgesics improves postoperative pain and reduces opioid consumption. However, there is no conclusive evidence that pre-emptive analgesia provides the same benefits in TKA. In order to inform future research, this protocol focuses on the efficacy and safety of oral analgesics used in TKA pre-emptive analgesia.

METHODS AND ANALYSIS

We will search the literature on the involvement of pre-emptive analgesia in the management of pain in TKA from the PubMed, EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews, from their inception to 1 February 2023. Additionally, clinical registry platforms will be investigated to collect data for ongoing studies. Using the Cochrane Risk of Bias Tool, the quality assessment will be conducted. RevMan V.5.4 will be used for the meta-analysis. The statistic I 2 will be used to measure the percentage of total variability due to heterogeneity between studies. Where appropriate, subgroup and sensitivity analyses, assessment of evidence quality and publication bias will be conducted.

ETHICS AND DISSEMINATION

No ethical approval and consent is required for this systematic review. Moreover, the results of this systematic review will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022380782.

Shared decision-making for postoperative opioid prescribing and preoperative pain management education decreases excess opioid burden

INTRODUCTION

Managing postoperative pain requires an individualized approach in order to balance adequate pain control with risk of persistent opioid use and narcotic abuse associated with inappropriately outsized narcotic prescriptions. Shared decision-making has been proposed to address individual pain management needs. We report here the results of a quality improvement initiative instituting prescribing guidelines using shared decision-making and preoperative pain expectation and management education to decrease excess opioid pills after surgery and improve patient satisfaction.

METHODS

Pre-intervention prescribing habits were obtained by retrospective review perioperative pharmacy records for patients undergoing general surgeries in the 24 months prior to initiation of intervention. Patients scheduled to undergo General Surgery procedures were given a survey at their preoperative visit. Preoperative education was performed by the surgical team as a part of the Informed Consent process using a standardized handout and patients were asked to choose the number of narcotic pills they wished to obtain within prescribing recommendations. Postoperative surveys were administered during or after their 2-week postoperative visit.

RESULTS

131 patients completed pre-intervention and post-intervention surveys. The average prescription size decreased from 12.29 oxycodone pills per surgery prior to institution of pathway to 6.80 pills per surgery after institution of pathway (p < 0.001). The percentage of unused pills after surgery decreased from an estimated 70.5% pre-intervention to 48.5% (p < 0.001) post-intervention. 61.1% of patients with excess pills returned or planned to return medication to the pharmacy with 16.8% of patients reporting alternative disposal of excess medication. Patient-reported satisfaction was higher with current surgery compared to prior surgeries (p < 0.001).

CONCLUSION

Institution of procedure-specific prescribing recommendations and preoperative pain management education using shared decision-making between patient and provider decreases opioid excess burden, resulting in fewer unused narcotic pills entering the community. Furthermore, allowing patients to participate in decision-making with their provider results in increased patient satisfaction.

Standard opioid-containing versus opioid-sparing anesthesia on early postoperative recovery after video-assisted thoracic surgery: A propensity-weighted analysis

PURPOSE

Opioids have several adverse effects. At present, there are no large clinical studies on the effects of opioid-sparing anesthesia on early postoperative recovery after thoracoscopic surgery. This study was to investigate the effects of opioid-sparing anesthesia on early postoperative recovery after thoracoscopic surgery.

METHODS

Adult patients who underwent video-assisted thoracic surgery from 1 January 2019 to 28 February 2021 were enrolled by reviewing the electronic medical records. Participants were divided into opioid-sparing anesthesia (OSA group) and opioid-containing anesthesia (STD group) based on intraoperative opioid usage. The propensity-score analysis was to compare the early postoperative recovery of two groups. The outcome measurements included the incidence of postoperative nausea and vomiting (PONV) during an entire hospital stay, need for rescue antiemetic medication, postoperative-pain episodes within 48 h after surgery, need for rescue analgesia 48 h postoperatively, duration of postoperative hospital stay, length of PACU stay, postoperative fever, postoperative shivering, postoperative atrial fibrillation, postoperative pulmonary infection, postoperative hypoalbuminemia, postoperative hypoxemia, intraoperative blood loss, and intraoperative urine output.

RESULTS

A total of 1,975 patients were identified. No significant difference was observed in patient characteristics between the OSA and STD groups after adjusting for propensity score-based inverse probability treatment weighting. The incidence of postoperative nausea and vomiting was significantly lower in the OSA group than in the STD group (14.7% vs. 18.9%, p = 0.041). The rescue antiemetic use rate was lower in the OSA group than in the STD group (7.5% vs.12.2%; p = 0.002). PACU duration was longer in the OSA group than in the STD group (70.8 ± 29.0 min vs. 67.3 ± 22.7 min; p = 0.016). The incidence of postoperative fever was higher in the STD group than that in the OSA group (11.0% vs.7.7%; p = 0.032). There were no differences between the groups in terms of other outcomes.

CONCLUSIONS

Our results suggest that opioid-sparing anesthesia has a lower incidence of postoperative complications than opioid-based anesthetic techniques.

Comparison of weight loss and adverse events of obesity drugs in children and adolescents: a systematic review and meta-analysis

BACKGROUND

The global incidence of childhood obesity is increasing. Currently, there are only few established drugs for treating adolescent obesity. Randomized clinical trials (RCTs) comparing pharmacological interventions in children with obesity are scarce; therefore, we aimed to analyze the relative efficacy and adverse reactions of these drugs and compare the effects of each drug on body mass index (BMI).

RESEARCH DESIGN AND METHODS

This meta-analysis focused on the slimming effect, safety, and correlation of metformin, orlistat, exenatide, liraglutide, and topiramate in children with obesity. Several international databases were searched and clinical trials on the treatment of obesity in children in which the drug was administered for ≥ 6 months were included. Changes in BMI before and after treatment were analyzed using a Bayes framework, and the surface under the cumulative ranking was calculated.

RESULTS

Of 2102 relevant articles retrieved, 21 RCTs were included in the study. Compared to other drugs, liraglutide reduced BMI the most in children with obesity. However, it was most associated with drug withdrawal due to adverse events while topiramate was least.

CONCLUSIONS

Liraglutide had a higher probability of achieving clinically significant weight loss compared with other drugs while topiramate was superior in safety.

Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials

BACKGROUND

Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050).

FINDINGS

47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes.

INTERPRETATION

Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field.

FUNDING

The Canadian Institutes of Health Research.

Bupivacaine liposome use reduces length of post-anesthesia care unit stay and postoperative narcotic use following robotic inguinal herniorrhaphy

In the current opioid crisis, multimodal analgesic protocols should be considered to reduce or eliminate narcotic usage in the postoperative period. We assess the impact of bupivacaine liposome used along with a standard analgesia protocol following robotic inguinal hernia repair. A retrospective review of a prospectively maintained data including robotic inguinal hernia repairs (IHR) by two surgeons in the United States was performed. Within a multimodal analgesic protocol, local anesthetic was administered intraoperatively. One group received a mix of bupivacaine and bupivacaine liposome (BL), and one received standard bupivacaine (SB). Recovery room and home opiate doses were recorded. Primary outcomes included length of stay (LOS) and postoperative medication requirements. Statistical analysis was performed using Chi-square or Fisher's exact test and Mann-Whitney U test as appropriate. 122 robotic IHRs were included; 55 received BL and 67 received SB. Hospital LOS (hours) was reduced in the BL group (2.8 ± 1.1 vs 3.5 ± 1.2; p = 0.0003). There was no significant difference in recovery room parenteral MME requirements between the groups; however, BL group had less oral MME requirements (5.0 ± 6.5 MME vs. 8.1 ± 6.9 MME, p = 0.02). The BL group had a higher rate of zero opiate doses at home (44% vs 5%, p = 0.0005). Of those that did require opiates at home, there was a significant reduction in number of narcotic pills used by the BL compared to the SB group (median 1 vs 5, respectively; p < 0.0001). Intraoperative administration of BL as part of a pain management protocol may decrease length of hospital stay, and reduce or eliminate the need for narcotic analgesic use at home.