Risk Factors and Prevention Strategies for Postoperative Opioid Abuse

Clinical and surgical factors associated with opioid refill rates following septorhinoplasty

BACKGROUND

Septorhinoplasty is one the most common class of procedures performed worldwide, and opioids are frequently prescribed for post-operative pain [1].

OBJECTIVE

The objective of this study was to examine the rate of post-operative opioid prescription refills following septorhinoplasty.

METHODS

This study was a case-control study of patients who underwent septoplasty and other secondary concomitant procedures.

RESULTS

Of the 249 patients included in this study, the majority of patients (94.8%) were prescribed 12 tablets of hydrocodone-acetaminophen 5 mg - 325 mg and only 31 patients (13.3%) received refills. The presence of osteotomies and history of prior opioid use were associated with refills. Nasal valve repair type, open versus closed approach, and presence of autologous auricular cartilage graft harvest were not.

DISCUSSION

Our study highlights factors that surgeons should consider when prescribing opioids after septorhinoplasty. Twelve tablets of an opioid are likely sufficient for the majority of patients, but if osteotomies are performed or the patient has a history of prior opioid use, more may be indicated to avoid the need for refills. Additional narcotics are not necessary for an open approach or for patients in which auricular cartilage is needed.

A Machine Learning Application to Classify Patients at Differing Levels of Risk of Opioid Use Disorder: Clinician-Based Validation Study

Background

Despite restrictive opioid management guidelines, opioid use disorder (OUD) remains a major public health concern. Machine learning (ML) offers a promising avenue for identifying and alerting clinicians about OUD, thus supporting better clinical decision-making regarding treatment.

Objective

This study aimed to assess the clinical validity of an ML application designed to identify and alert clinicians of different levels of OUD risk by comparing it to a structured review of medical records by clinicians.

Methods

The ML application generated OUD risk alerts on outpatient data for 649,504 patients from 2 medical centers between 2010 and 2013. A random sample of 60 patients was selected from 3 OUD risk level categories (n=180). An OUD risk classification scheme and standardized data extraction tool were developed to evaluate the validity of the alerts. Clinicians independently conducted a systematic and structured review of medical records and reached a consensus on a patient's OUD risk level, which was then compared to the ML application's risk assignments.

Results

A total of 78,587 patients without cancer with at least 1 opioid prescription were identified as follows: not high risk (n=50,405, 64.1%), high risk (n=16,636, 21.2%), and suspected OUD or OUD (n=11,546, 14.7%). The sample of 180 patients was representative of the total population in terms of age, sex, and race. The interrater reliability between the ML application and clinicians had a weighted kappa coefficient of 0.62 (95% CI 0.53-0.71), indicating good agreement. Combining the high risk and suspected OUD or OUD categories and using the review of medical records as a gold standard, the ML application had a corrected sensitivity of 56.6% (95% CI 48.7%-64.5%) and a corrected specificity of 94.2% (95% CI 90.3%-98.1%). The positive and negative predictive values were 93.3% (95% CI 88.2%-96.3%) and 60.0% (95% CI 50.4%-68.9%), respectively. Key themes for disagreements between the ML application and clinician reviews were identified.

Conclusions

A systematic comparison was conducted between an ML application and clinicians for identifying OUD risk. The ML application generated clinically valid and useful alerts about patients' different OUD risk levels. ML applications hold promise for identifying patients at differing levels of OUD risk and will likely complement traditional rule-based approaches to generating alerts about opioid safety issues.

Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study

INTRODUCTION

In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients.

METHODS

This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption.

RESULTS

We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]).

CONCLUSION

This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.

Acute Pain and Development of Opioid Use Disorder: Patient Risk Factors

PURPOSE OF REVIEW

Pharmacological therapy for acute pain carries the risk of opioid misuse, with opioid use disorder (OUD) reaching epidemic proportions worldwide in recent years. This narrative review covers the latest research on patient risk factors for opioid misuse in the treatment of acute pain. In particular, we emphasize newer findings and evidence-based strategies to reduce the prevalence of OUD.

RECENT FINDINGS

This narrative review captures a subset of recent advances in the field targeting the literature on patients' risk factors for OUD in the treatment for acute pain. Besides well-recognized risk factors such as younger age, male sex, lower socioeconomic status, White race, psychiatric comorbidities, and prior substance use, additional challenges such as COVID-19 further aggravated the opioid crisis due to associated stress, unemployment, loneliness, or depression. To reduce OUD, providers should evaluate both the individual patient's risk factors and preferences for adequate timing and dosing of opioid prescriptions. Short-term prescription should be considered and patients at-risk closely monitored. The integration of non-opioid analgesics and regional anesthesia to create multimodal, personalized analgesic plans is important. In the management of acute pain, routine prescription of long-acting opioids should be avoided, with implementation of a close monitoring and cessation plan.

Comparison of three analgesic regimens in women undergoing cervical brachytherapy

PURPOSE

Effective periprocedural analgesia is an important aspect of cervical brachytherapy delivery, with implications for patient comfort and attendance for subsequent fractions. We compared the efficacy and safety of three analgesic modalities: intravenous patient-controlled analgesia (IV-PCA), continuous epidural infusion (CEI) and programmed-intermittent epidural bolus with patient-controlled epidural analgesia (PIEB-PCEA).

METHODS AND MATERIALS

Ninety-seven brachytherapy episodes involving 36 patients between July 2016 and June 2019 in a single tertiary center were retrospectively reviewed. Episodes were divided into two key phases: Phase 1 (while applicator remained in situ) and Phase 2 (following applicator removal until discharge or 4 h). For the primary endpoint, pain scores were retrieved and analyzed by analgesic modality with respect to median score and an internally defined "unacceptable" pain experience (>20% of scores being ≥4/10; i.e., moderate or greater). Total nonepidural oral morphine equivalent dose (OMED) and toxicity/complication events were reported as secondary endpoints.

RESULTS

In Phase 1, there was a significantly higher median pain score (p < 0.001) and more episodes with unacceptable pain scores (46%) in the IV-PCA group compared with either epidural modality (6-14%; p < 0.001). In Phase 2, we observed a greater median pain score (p = 0.007) and higher proportion of patient episodes with unacceptable pain scores (38%) in the CEI group compared with both the IV-PCA (13%) and PIEB-PCEA (14%) groups (p = 0.001). There was a significant difference in median OMED used throughout all phases across the PIEB-PCEA (0 mg), IV-PCA (70 mg), and CEI (15 mg) groups (p < 0.001).

CONCLUSIONS

PIEB-PCEA is safe and offers superior analgesia compared to IV-PCA or CEI for pain control after applicator placement in cervical brachytherapy.

Evaluating the impact of metabolic surgery on patients with prior opioid use

BACKGROUND

Metabolic surgery is the most effective treatment for obesity and may improve obesity-related pain syndromes. However, the effect of surgery on the persistent use of opioids in patients with a history of prior opioid use remains unclear.

OBJECTIVE

To determine the effect of metabolic surgery on opioid use behaviors in patients with prior opioid use.

SETTING

A consortium of public and private hospitals in Michigan.

METHODS

Using a statewide metabolic-specific data registry, we identified 16,820 patients who self-reported opioid use before undergoing metabolic surgery between 2006 and 2020 and analyzed the 8506 (50.6%) patients who responded to 1-year follow-up. We compared patient characteristics, risk-adjusted 30-day postoperative outcomes, and weight loss between patients who self-reported discontinuing opioid use 1 year after surgery and those who did not.

RESULTS

Among patients who self-reported using opioids before metabolic surgery, 3864 (45.4%) discontinued use 1 year after surgery. Predictors of persistent opioid use included an annual income of <$10,000 (odds ratio [OR] = 1.24; 95% confidence interval [CI], 1.06-1.44; P = .006), Medicare insurance (OR = 1.48; 95% CI, 1.32-1.66; P < .0001), and preoperative tobacco use (OR = 1.36; 95% CI, 1.16-1.59; P = .0001). Patients with persistent use were more likely to have a surgical complication (9.6% versus 7.5%, P = .0328) and less percent excess weight loss (61.6% versus 64.4%, P < .0001) than patients who discontinued opioids after surgery. There were no differences in the morphine milligram equivalents prescribed within the first 30 days following surgery between groups (122.3 versus 126.5, P = .3181).

CONCLUSIONS

Nearly half of patients who reported taking opioids before metabolic surgery discontinued use at 1 year. Targeted interventions aimed at high-risk patients may increase the number of patients who discontinue opioid use after metabolic surgery.

Association of a Statewide Opioid Legislation with Opioid Prescribing Patterns in Facial Plastic and Reconstructive Procedures

Background: The Michigan Opioid Laws are legislation enacted between 2017 and 2018 as a strategy to combat the growing opioid crisis. Objective: To compare opioid prescription rates and morphine milligram equivalents (MMEs) of opioid prescribed to patients undergoing various facial plastic and reconstructive surgery (FPRS) procedures before, during, and after legislation enactment. Materials and Methods: This is a cross-sectional retrospective review of subjects undergoing any of 10 FPRS procedures between July 2016 and November 2019 at a tertiary care hospital with analysis of demographic factors, opioid prescription rates, and MMEs over time. Results: Of 863 patients included, 107 and 575 patients were prescribed postoperative opioids before and after opiate legislation enactment, respectively, with no difference in baseline demographics between groups. Regression analysis showed no change in MME prescribing in the year before legislation (p = 0.70), followed by a decrease of 0.13 MME per day (p = 0.00), with a subsequent stabilization of MME at a reduced rate for the remainder of the study period (p = 0.74). Conclusion: Enactment of the Michigan Opioid Laws was temporally associated with a decrease in opioid prescriptions for common facial plastic surgery procedures.

Postoperative opioid-prescribing practices in otolaryngology: Evidence-based guideline outcomes

Objectives

We previously reported that >50% of postoperative opioids prescribed at our institution went unused for common otolaryngologic procedures. Based on these findings, we instituted multimodal, evidence-based guidelines for postoperative pain management. In the second part of our multiphasic study, we evaluated the effects of these guidelines on (1) quantity of unused opioids, (2) patient satisfaction, and (3) institutional perceptions toward the opioid epidemic and prescribing guidelines.

Methods

Standardized, procedure-specific opioid prescription guidelines were created using prospective data from the first phase of our study and evidence from current literature. Again, we examined sialendoscopy, parotidectomy, parathyroidectomy/thyroidectomy, and transoral robotic surgery (TORS). Patients were surveyed at their first postoperative appointment. Groups from Phases I and II were compared. Attending physicians were surveyed before the start of the multiphasic project and after prescribing guidelines were implemented.

Results

Prescribing guidelines led to an average reduction in prescribed morphine milligram equivalents (MME) per patient by: 48% (sialendoscopy), 63% (parotidectomy), 60% (para/thyroidectomy), and 42% (TORS). Average used MME per patient for parotidectomy was significantly reduced (64%). The proportion of unused MME per patient and patient satisfaction scores did not significantly change after guidelines were implemented.

Conclusion

Implementation of opioid-prescribing guidelines and the use of multimodal analgesia substantially reduced the amount of opioids prescribed across all procedures without impacting patient satisfaction.

Level of Evidence

2.

Preoperative Patient-Reported Data Indicate the Risk of Prolonged Opioid Use After Hand and Upper Extremity Surgeries

PURPOSE

Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery.

METHODS

We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve.

RESULTS

We included 2,114 patients. In our final model on the 2018-2019 electronic health records and PRD data (n = 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit.

CONCLUSIONS

We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Randomized Trial of Bupivacaine Versus Liposomal Bupivacaine in Minimally Invasive Lobectomy

BACKGROUND

The objective of this single-blind randomized study is to compare local infiltration of bupivacaine or liposomal bupivacaine (LipoB) in narcotic naïve patients undergoing minimally invasive lobectomy for early stage lung cancer.

METHODS

Adult patients without previous lung surgery undergoing minimally invasive lobectomy (robotic or thoracoscopic) for early stage lung cancer were randomly assigned to bupivacaine (with epinephrine 0.25%, 1:200 000) or LipoB 1.3%. Pain level was documented using the visual analog scale and morphine equivalents for narcotic pain medications. Inhospital treatment cost and pharmacy cost were compared.

RESULTS

The study enrolled 50 patients (bupivacaine, 24; LipoB, 26). The mean age of patients was 66 years, 94% were non-Hispanic white, and 48% were male. There was no difference in baseline characteristics and comorbidities. Duration of surgery (105 vs 137 minutes, P = .152), chest tube duration (49 vs 55 hours, P = .126), and length of stay (2.45 vs 3.28 days, P = .326) were similar between treatments. Inhospital morphine equivalents were 42.7 mg vs 48 mg (P = .714), and the median pain score was 5.2 vs 4.75 (P = .602) for bupivacaine vs LipoB, respectively. There was no difference in narcotic use at 2 to 4 weeks (57.1% [12 of 21] vs 54.5% [12 of 22], P = 1.00), and at 6 months (5.9% [1 of 17] vs 9.5% [2 of 21], P = 1.00) after surgery. The overall cost ($20 252 vs $22 775, P = .225) was similar; however, pharmacy cost for LipoB was higher ($1052 vs $596, P = .0001).

CONCLUSIONS

In narcotic naïve patients undergoing minimally invasive lobectomy, short-term narcotic use, postoperative pain scores, length of stay, and long-term narcotic use were similar between bupivacaine and LipoB.

Identifying Patients Vulnerable to Inadequate Pain Resolution After Cardiac Surgery

Acute postoperative pain (APOP) is often evaluated through granular parameters, though monitoring postoperative pain using trends may better describe pain state. We investigated acute postoperative pain trajectories in cardiac surgical patients to identify subpopulations of pain resolution and elucidate predictors of problematic pain courses. We examined retrospective data from 2810 cardiac surgical patients at a single center. The k-means algorithm for longitudinal data was used to generate clusters of pain trajectories over the first 5 postoperative days. Patient characteristics were examined for association with cluster membership using ordinal and multinomial logistic regression. We identified 3 subgroups of pain resolution after cardiac surgery: 37.7% with good resolution, 44.2% with moderate resolution, and 18.2% exhibiting poor resolution. Type I diabetes (2.04 [1.00-4.16], p = 0.05), preoperative opioid use (1.65 [1.23-2.22], p = 0.001), and illicit drug use (1.89 [1.26-2.83], p = 0.002) elevated risk of membership into worse pain trajectory clusters. Female gender (1.72 [1.30-2.27], p < 0.001), depression (1.60 [1.03-2.50], p = 0.04) and chronic pain (3.28 [1.79-5.99], p < 0.001) increased risk of membership in the worst pain resolution cluster. This study defined 3 APOP resolution subgroups based on pain score trend after cardiac surgery and identified factors that predisposed patients to worse resolution. Patients with moderate or poor pain trajectory consumed more opioids and received them for longer before discharge. Future studies are warranted to determine if altering postoperative pain monitoring and management improve postoperative course of patients at risk of moderate or poor pain resolution.

Persistent opioid use in cataract surgery pain management and the role of nonopioid alternatives

Cataracts are a leading cause of preventable blindness globally. Although care varies between developing and industrialized countries, surgery is the single effective approach to treating cataracts. From the earliest documented primitive cataract removals to today's advanced techniques, cataract surgery has evolved dramatically. As surgical techniques have developed, so have approaches to surgical pain management. With current cataract surgical procedures and advanced technology, anesthesia and intraoperative pain management have shifted to topical/intracameral anesthetics, with or without low-dose systemic analgesia and anxiolysis. Despite this, pain and discomfort persist in some patients and are underappreciated in modern cataract surgery. Although pain management has progressed, opioids remain a mainstay intraoperatively and, to a lesser extent, postoperatively. This article discusses the evolution of pain management in cataract surgery, particularly the use of opioids and the associated risks as well as how ophthalmology can have a positive impact on the opioid crisis.

Effect of Perioperative Opioid Use on Patients Undergoing Hip Arthroscopy

Background

Opioids are commonly used to treat postoperative pain; however, guidelines vary regarding safe opioid use after hip arthroscopy.

Purpose/Hypothesis

The purposes were to (1) identify risk factors for persistent opioid use, (2) assess the effect of opioid use on outcomes, and (3) describe common opioid prescribing patterns after hip arthroscopy. It was hypothesized that preoperative opioid use would affect complication rates and result in greater postoperative opioid use.

Study Design

Case-control study; Level of evidence 3.

Methods

The Utah State All Payer Claims Database was queried for patients who underwent hip arthroscopy between January 2013 and December 2017. Included were patients ≥14 years of age at index surgery with continuous insurance. Patients were separated into acute (<3 months) and chronic (≥3 months) postoperative opioid use groups. Primary outcomes included revision surgery, complications (infection, pulmonary embolism/deep venous thrombosis, death), emergency department (ED) visits, and hospital admissions. Multivariate logistic regression was utilized to identify factors associated with the outcomes.

Results

Included were 2835 patients (mean age, 47 years; range, 14-64 years), of whom 2544 were in the acute opioid use and 291 were in the chronic opioid use group. Notably, 91% of the patients in the chronic group took opioid medications preoperatively, and they were more than twice as likely to carry a mental health diagnosis (P < .01). Patients in the acute group had a significantly shorter initial prescription duration, took fewer opioid pills, and had fewer refills than those in the chronic group (P < .01 for all). Patients in the chronic group had a significantly higher risk of postoperative ED visits (odds ratio [OR], 2.76; P = .008), hospital admission (OR, 3.02; P = .002), and additional surgery (P = .003), as well as infection (OR, 2.55; P < .001) and hematoma (OR, 2.43; P = .030). Patients who had used opioids before hip arthroscopy were more likely to need more refills (P < .01). A formal opioid use disorder diagnosis correlated significantly with postoperative hospital admissions (OR, 3.83; P = .044) and revision hip arthroscopy (OR, 4.72; P = .003).

Conclusion

Mental health and substance use disorders were more common in patients with chronic postoperative opioid use, and chronic postoperative opioid use was associated with greater likelihood of postoperative complications. Preoperative opioid use was significantly correlated with chronic postoperative opioid use and with increased refill requests after index arthroscopy.

Serratus Anterior Block for Long-Term Post-Thoracoscopy Pain Management

Purpose

Neuropathic, chronic pain is a common and severe complication following thoracic surgery, known as post-thoracotomy pain syndrome (PTPS). Here we evaluated the efficacy of an ultrasound-guided serratus anterior plane block (SAPB) on pain control compared to traditional pain management with intravenous opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) six months after thoracic surgery.

Patients and Methods

In this retrospective observational study, we analyzed data from a questionnaire survey. We interviewed all patients who underwent elective video-assisted thoracoscopy surgery (VATS) at Soroka University Medical Center between December 2016 and January 2018. The responses of ninety-one patients were included.

Results

Participants reported PTPS in both groups, 43% of patients in the SAPB group and 57% of patients in the standard group, which failed to reach significance. However, we demonstrated that the percentage of pain occurrence trended lower in the SAPB group. There was significantly less burning/stitching or shooting, shocking, pressure-like, and aching pain in SAPB patients compared to the standard protocol group. Patients in the SAPB group had significantly less pain located in the upper and lower posterior thorax anatomical regions compared to the standard protocol group. Moreover, we found a significant difference in occurrence of PTPS depending on the type of thoracic surgery. From both study groups, 69% of patients who underwent lobectomy reported pain, compared with 41.9% of those in the segmental (wedge resection) procedure, and 42.1% of patients in other procedures.

Conclusion

While the present study did not demonstrate a statistically significant reduction of PTPS after SAPB concerning postoperative pain control, there was a trend of a decrease. We also found significance in the type of pain and location of pain after thoracic surgery between the two groups, as well as a significant difference between pain occurrence in types of thoracic surgeries from both groups.

Effect of Preoperative Chronic Opioid Use on Mortality and Morbidity in Vascular Surgical Patients

Introduction

Opioid derivates are an essential part of everyday clinical pain management practice. They have excellent analgesic, sedative, and sympatholytic effects and are widely used in various conditions. Beyond advantageous aspects, there are numerous problems with the chronic use of these agents. Dependency and life-threatening complications are the biggest problems with both illegal and prescribed opioid derivates. In our current study, effects of chronic opioid use were observed on mortality and life quality in the case of vascular surgery.

Methods

This prospective, observational study was conducted between 2014 and 2017. After obtaining informed consent, all participants were asked to fill a questionnaire containing different psychological tests. Perioperative data, chronic medical therapy, and anthropometric data were also collected. Opioid user and non-user patients’ psychological results were compared with non-parametrical tests. The effect of chronic opioid administration was investigated with logistic regression method with bootstrapping.

Results

Finally, the data of 164 patients were analyzed. 64.0% of participants were male, the mean age was 67.05 years, and the standard deviation was 9.48 years. The median follow-up time was 1312 days [interquartile range (IQR): 930-1582 days]. During the follow-up time, 42 patients died (25.6%). In the examined patient cohort, the frequency of opioid derivate use was 3.7% (only six patients). In the non-survived group, opioid use was significantly higher (1.6% vs. 9.5%, p=0.019). Significant differences were found in the aspect of cognitive performance measured by Mini-Mental State Examination (MMSE), opioid users have had lower points [25.5 (IQR: 24.5-26.0) vs. 28.0 (IQR: 27.0-29.0) p=0.008]. Opioid users have showed higher score on Beck Depression Inventory (BDI) [15.5 (IQR: 10.0-18.0) vs. 6.0 (IQR: 3.0-11.0), p=0.030). In a multivariate Cox regression model built up from registered preoperative medical treatment, opioids were found as a risk factor for all-cause mortality [adjusted hazard ratio (AHR): 4.31, 95% CI: 1.77-10.55, p=0.001].

Conclusion

Our current findings suggest that chronic, preoperative use of opioids could associate with increased mortality. Furthermore, both decrease in cognitive performance and increased depression symptoms were found in the opioid user cohorts which emphasize the importance of further risk stratification of these patients.

More Than 1 in 3 Patients With Chronic Low Back Pain Continue to Use Opioids Long-term After Spinal Fusion: A Systematic Review

OBJECTIVE

A common expectation for patients after elective spine surgery is that the procedure will result in pain reduction and minimize the need for pain medication. Most studies report changes in pain and function after spine surgery, but few report the extent of opioid use after surgery. This systematic review aims to identify the rates of opioid use after lumbar spine fusion.

MATERIALS AND METHODS

PubMed, CINAHL, Cochrane Central Register of Controlled Trials, and Ovid Medline were searched to identify studies published between January 1, 2005 and June 30, 2020 that assessed the effectiveness of lumbar fusion for the management of low back pain.

RESULTS

Of 6872 abstracts initially identified, 329 studies met the final inclusion criteria, and only 32 (9.7%) reported any postoperative opioid use. Long-term opioid use after surgery persists for more than 1 in 3 patients with usage ranging from 6 to 85.9% and a pooled mean of 35.0% based on data from 21 studies (6.4% of all lumbar fusion studies).

DISCUSSION

Overall, opioid use is not reported in the majority of lumbar fusion trials. Patients may expect a reduced need for opioid-based pain management after surgery, but the limited data available suggests long-term use is common. Lack of consistent reporting of these outcomes limits definitive conclusions regarding the efficacy of spinal fusion for reducing long-term opioid. Patient decisions about undergoing surgery may be altered if they had realistic expectations about rates of postsurgical opioid use. Spine surgery trials should track opioid utilization out to a minimum of 6 months after surgery as a core outcome.

High-dose steroids in high pain responders undergoing total knee arthroplasty: a randomised double-blind trial

Background

Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking.

Methods

A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kg⁻¹ or intermediate-dose dexamethasone 0.3 mg kg⁻¹ in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications.

Results

Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P<0.01), along with pain at leg raise at 24 and 48 h (14% vs 29%, P=0.02 and 12% vs 31%, P=0.03, respectively). C-reactive protein was reduced in the high-dose group at both 24 and 48 h (both P<0.01). Quality of Recovery-15 was also improved (P<0.01).

Conclusions

When compared with preoperative dexamethasone 0.3 mg kg⁻¹ i.v., dexamethasone 1 mg kg⁻¹ reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects.

Clinical trial registration

NCT03763734.

Effects of Patient and Surgery Characteristics on Persistent Postoperative Pain: A Mediation Analysis

OBJECTIVE

Acute postoperative pain intensity is associated with persistent postsurgical pain (PPP) risk. However, it remains unclear whether acute postoperative pain intensity mediates the relationship between clinical factors and persistent pain.

MATERIALS AND METHODS

Participants from a mixed surgical population completed the Brief Pain Inventory and Pain Catastrophizing Scale before surgery, and the Brief Pain Inventory daily after surgery for 7 days and at 30 and 90 days after surgery. We considered mediation models using the mean of the worst pain intensities collected daily on each of postoperative days (PODs) 1 to 7 against outcomes of worst pain intensity at the surgical site endpoints reflecting PPP (POD 90) and subacute pain (POD 30).

RESULTS

The analyzed cohort included 284 participants for the POD 90 outcome. For every unit increase of maximum acute postoperative pain intensity through PODs 1 to 7, there was a statistically significant increase of mean POD 90 pain intensity by 0.287 after controlling for confounding effects. The effects of female versus male sex (m=0.212, P=0.034), pancreatic/biliary versus colorectal surgery (m=0.459, P=0.012), thoracic cardiovascular versus colorectal surgery (m=0.31, P=0.038), every minute increase of anesthesia time (m=0.001, P=0.038), every unit increase of preoperative average pain score (m=0.012, P=0.015), and every unit increase of catastrophizing (m=0.044, P=0.042) on POD 90 pain intensity were mediated through acute PODs 1 to 7 postoperative pain intensity.

DISCUSSION

Our results suggest the mediating relationship of acute postoperative pain on PPP may be predicated on select patient and surgical factors.

Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial

BACKGROUND

This study aimed to compare postoperative pain and patient satisfaction in patients undergoing primary arthroscopic labral surgery managed with either a nonopioid alternative pain regimen or a traditional opioid pain regimen.

METHODS

Sixty consecutive patients undergoing primary arthroscopic shoulder labral surgery were assessed for participation. In accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement, a prospective randomized controlled trial was performed. The 2 arms of the study were a multimodal nonopioid analgesic protocol as the experimental group and a standard opioid regimen as the control group. The primary outcome was postoperative pain scores (on a visual analog scale [VAS]) for the first 10 days postoperatively. Secondary outcomes included patient satisfaction, patient-reported outcomes, and complications. Randomization was performed with a random number generator, and all data were collected by blinded observers. Patients were not blinded.

RESULTS

Twelve patients did not meet the inclusion criteria or declined to participate. Thus, 48 patients were included in the final analysis: 24 in the nonopioid group and 24 in the opioid group. There was no significant difference in VAS or PROMIS (Patient-Reported Outcomes Measurement Information System) scores between patients in the 2 cohorts on any postoperative day (P > .05). When we controlled for confounding factors with repeated-measures mixed models, the nonopioid cohort reported significantly lower VAS and PROMIS (Patient-Reported Outcomes Measurement Information System) Pain Interference scores (P < .01) at all time points. No difference was found in reported adverse events (constipation, diarrhea, drowsiness, nausea, and upset stomach) between cohorts at any time point (P > .05).

CONCLUSION

This study found that a multimodal nonopioid pain regimen provided, at the minimum, equivalent pain control, an equivalent adverse reaction profile, and equivalent patient satisfaction when compared with a standard opioid-based regimen following arthroscopic shoulder labral surgery.

Clinical Outcomes of Symptomatic Neuroma Resection and Reconstruction with Processed Nerve Allograft

Background:

Neuromas causing sensory disturbance can substantially affect nerve function and quality of life. Historically, passive termination of the nerve end and proximal relocation to muscle or bone has been performed after neuroma resection, but this method does not allow for neurologic recovery or prevent recurrent neuromas. The use of processed nerve allografts (PNAs) for intercalary reconstruction of nerve defects following neuroma resection is reasonable for neuroma management, although reported outcomes are limited. The purpose of this study was to assess the outcomes of pain reduction and functional recovery following neuroma resection and intercalary nerve reconstruction using PNA.

Methods:

Data on outcomes of PNA use for peripheral nerve reconstruction were collected from a multicenter registry study. The registry database was queried for upper extremity nerve reconstruction with PNA after resection of symptomatic neuroma. Patients completing both pain and quantitative sensory assessments were included in the analysis. Improvement in pain-related symptoms was determined via patient self-reported outcomes and/or the visual analog scale. Meaningful sensory recovery was defined as a score of at least S3 on the Medical Research Council Classification scale.

Results:

Twenty-five repairs involving 21 patients were included in this study. The median interval from injury to reconstruction was 386 days, and the average nerve defect length was 31 mm. Pain improved in 80% of repairs. Meaningful sensory recovery was achieved in 88% of repairs.

Conclusion:

Neuroma resection and nerve reconstruction using PNA can reduce or eliminate chronic peripheral nerve pain and provide meaningful sensory recovery.

Identifying risk factors that increase analgesic requirements at discharge among patients with burn injuries

Patients with burn injuries require large doses of opioids and gabapentinoids to achieve pain control and are often discharged from hospital with similar amounts. This study aimed to identify patient risk factors that increase analgesic requirements among patients with burn injuries and to determine the relationship between opioid and gabapentinoid use. Patient charts from July 1, 2015 - 2018 were reviewed retrospectively to determine analgesic requirements 24 hours before discharge. Linear mixed regression models were performed to determine patient risk factors (age, gender, history of substance misuse, total body surface area of burn, length of stay in hospital, history of psychiatric illness, or surgical treatment) that may increase analgesic requirements. This study found that patients with a history of substance misuse (p = 0.01) or who were managed surgically (p = 0.01) required higher doses of opioids at discharge. Similarly, patients who had undergone surgical debridement required more gabapentinoids (p < 0.001). For every percent increase in TBSA, patients also required 14 mg more gabapentinoids (p = 0.01). In contrast, older patients (p = 0.006) and those with a longer hospital stay (p = 0.009) required fewer amounts of gabapentinoids before discharge. By characterizing factors that increase analgesic requirements at discharge, burn care providers may have a stronger understanding of which patients are at greater risk of developing chronic opioid or gabapentinoid misuse. The quantity and duration of analgesics prescribed at discharge may then be tailored according to these patient specific risk factors.

Multimodal Nonopioid Pain Protocol Provides Equivalent Pain Versus Opioid Control Following Meniscus Surgery: A Prospective Randomized Controlled Trial

PURPOSE

To assess the effectiveness of a nonopioid pain regimen in controlling postoperative pain as compared with a traditional opioid pain control following primary meniscectomy or meniscal repair.

METHODS

Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the Consolidated Standards of Reporting Trials 2010 statement. The 2 arms of the study included a multimodal nonopioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for the first 10 days postoperatively. Secondary outcomes included patient-reported outcomes, complications, and patient satisfaction. Randomization was achieved using a random-number generator. Patients were not blinded. Data collection was done by a blinded observer.

RESULTS

Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen and 31 randomized to the nonopioid regimen. Patients receiving the nonopioid regimen demonstrated noninferior visual analog scale scores compared with patients who received opioid pain medication (P > .05). No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, P = .724) or postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, P = .064) Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form scores. No difference was found in recorded side effects between both groups at any given time point: constipation, nausea, diarrhea, upset stomach, and drowsiness (P > .05).

CONCLUSIONS

This study found that a multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Opioid Use After Orbital, Eyelid, or Lacrimal Surgery

PURPOSE

Opioids may be indicated to mitigate pain after oculofacial surgery. The opioid crisis prompted attention to how these medications are dispensed and disposed. This study aims to characterize opioid usage and handling of patients undergoing oculofacial plastic surgery.

METHODS

Eighty-nine adult patients were surveyed on their opioid usage after undergoing orbital, lacrimal, or eyelid (including esthetic) surgery at a tertiary oculofacial plastic surgery practice. Each patient was prescribed 10 tablets of hydrocodone/acetaminophen 5 mg/325 mg; one tablet taken orally as needed every 6 hours for pain not relieved by acetaminophen. Subset analysis was performed for type of surgery, age, and gender.

RESULTS

Patients consumed an average of 3 ± 0.4 tablets. In the subsets, the averages were 2.1 ± 0.5 (n = 38) tablets after eyelid surgery, 1.6 ± 0.6 (n = 24) after lacrimal surgery, and 5.6 ± 0.9 (n = 27) after orbital surgery. Greater opioid usage was observed after orbital versus eyelid surgery (p = 0.0007) and orbital versus lacrimal surgery (p = 0.0005) but not eyelid versus lacrimal surgery (p = 0.8604). Forty-six patients (51.7%) used no opioids. Over half (57.3%; n = 51) filled their prescription. Thirty-three patients (37.1%) had unused medications, of which 21 patients did not properly dispose of their medications. The mean age of patients who used opioids was less than the mean age of those who needed no opioids (p = 0.024). There were no gender differences in opioid usage use versus not (p = 0.62).

CONCLUSIONS

Opioid needs after oculofacial plastic surgeries, especially eyelid and lacrimal, were minimal in this cohort. For most patients, the prescription exceeded needs. Younger age but not gender was associated with opioid use versus not. Most did not properly discard these medications. Quality improvement in both the dispensing and disposal of opioids in oculofacial surgical practice may be warranted.

Older Patients More Accurately Predict Pain Tolerance After Lumbar Spine Fusion Compared with Their Younger Peers

OBJECTIVE

Patients undergoing spine surgery often inaccurately estimate their pain tolerance and postoperative analgesic requirement. We sought to identify an association between patients' self-perceived pain tolerance and postoperative opioid consumption (POC).

METHODS

We included adult patients undergoing elective lumbar spine decompression and fusion between 2014 and 2018. Patients with cognitive delay, psychiatric comorbidities, and perioperative complications were excluded. Demographic data, mean daily postoperative morphine milligram equivalents (MME), and pain tolerance scores were recorded.

RESULTS

Eighty-four patients met inclusion criteria. The median pain tolerance score was 8, which was used to defined a cutoff for high (≥8) and low (<8) pain tolerance. The average preoperative visual analog scale (VAS) pain score was higher in the high pain tolerance group (μ = 5.3) compared with the low pain tolerance group (μ = 4.0) (P = 0.01). Multivariate regression revealed pain tolerance was not predictive of mean daily postoperative MME use (P = 0.19). Age and preoperative VAS pain score were found to be negative (P < 0.0001) and positive (P = 0.027) independent predictors, respectively, of mean postoperative MME use. Patients 61 years and younger who reported high pain tolerance had higher POC compared with patients older than 61 years of age, who reported low (P = 0.036) pain tolerance.

CONCLUSIONS

Self-perceived pain tolerance does not appear to predict POC, while younger age and higher preoperative VAS pain scores are related to increased POC. Younger patients who report high pain tolerance appear to consume higher levels of opioids compared with older patients.

Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial

STUDY OBJECTIVE

Opioid administration for pain in general care floor patients remains common, and can lead to adverse outcomes, including respiratory compromise. The PRODIGY trial found that among ward patients receiving parenteral opioids, 46% experienced ≥1 respiratory depression episode. The objective of this analysis was to evaluate the geographic differences of opioid administration and examine the association between opioid administration characteristics and the occurrence of respiratory depression.

DESIGN

Prospective observational trial.

SETTING

16 general care medical and surgical wards in Asia, Europe, and the United States.

PATIENTS

1335 patients receiving parenteral opioids.

INTERVENTIONS

Blinded, alarm-silenced continuous capnography and pulse oximetry monitoring.

MEASUREMENTS

Opioid-induced respiratory depression, defined as respiratory rate ≤ 5 bpm, SpO₂ ≤ 85%, or ETCO₂ ≤ 15 or ≥ 60 mmHg for ≥3 min; apnea episode lasting >30 s; or any respiratory opioid-related adverse event.

RESULTS

Across all patients, 58% received only long-acting opioids, 16% received only short-acting (<3 h) opioids, and 21% received a combination of short- and long-acting (≥3 h) opioids. The type and median total morphine milligram equivalent (MME) of opioid administered varied significantly by region, with 31.5 (12.5-76.7) MME, 31.0 (6.2-99.0) MME, and 7.2 (1.7-18.7) MME in the United States, Europe, and Asia, respectively (p < 0.001). Considering only postoperative opioids, 54% (N = 119/220) and 45% (N = 347/779) of patients receiving only short-acting opioids or only long-acting opioids experienced ≥1 episode of opioid-induced respiratory depression, respectively. Multivariable analysis identified post-procedure tramadol (OR 0.62, 95% CI 0.424-0.905, p = 0.0133) and post-procedure epidural opioids (OR 0.485, 95% CI 0.322-0.731, p = 0.0005) being associated with a significant reduction in opioid-induced respiratory depression.

CONCLUSIONS

Despite varying opioid administration characteristics between Asia, Europe, and the United States, opioid-induced respiratory depression remains a common global problem on general care medical and surgical wards. While the use of post-procedure tramadol or post-procedure epidural opioids may reduce the incidence of respiratory depression, continuous monitoring is also necessary to ensure patient safety when receiving postoperative opioids. REGISTRATION NUMBER: www.clinicaltrials.gov, ID: NCT02811302.

Health(care) in the Crisis: Reflections in Science and Society on Opioid Addiction

Opioid abuse and misuse have led to an epidemic which is currently spreading worldwide. Since the number of opioid overdoses is still increasing, it is becoming obvious that current rather unsystematic approaches to tackle this health problem are not effective. This review suggests that fighting the opioid epidemic requires a structured public health approach. Therefore, it is important to consider not only scientific and biomedical perspectives, but societal implications and the lived experience of groups at risk as well. Hence, this review evaluates the risk factors associated with opioid overdoses and investigates the rates of chronic opioid misuse, particularly in the context of chronic pain as well as post-surgery treatments, as the entrance of opioids in people's lives. Linking pharmaceutical biology to narrative analysis is essential to understand the modulations of the usual themes of addiction and abuse present in the opioid crisis. This paper shows that patient narratives can be an important resource in understanding the complexity of opioid abuse and addiction. In particular, the relationship between chronic pain and social inequality must be considered. The main goal of this review is to demonstrate how a deeper transdisciplinary-enriched understanding can lead to more precise strategies of prevention or treatment of opioid abuse.

Deceptology in cancer and vaccine sciences: Seeds of immune destruction-mini electric shocks in mitochondria: Neuroplasticity-electrobiology of response profiles and increased induced diseases in four generations - A hypothesis

From Rockefeller's support of patent medicine to Gates' patent vaccines, medical establishment invested a great deal in intellectual ignorance. Through the control over medical education and research it has created a public illusion to prop up corporate profit and encouraged the lust for money and power. An overview of data on cancer and vaccine sciences, the status of Americans' health, a survey of repeated failed projects, economic toxicity, and heavy drug consumption or addiction among young and old provide compelling evidence that in the twentieth century nearly all classic disease categories (congenital, inheritance, neonatal, or induced) shifted to increase induced diseases. Examples of this deceptology in ignoring or minimizing, and mocking fundamental discoveries and theories in cancer and vaccine sciences are attacks on research showing that (a), effective immunity is responsible for defending and killing pathogens and defective cancerous cells, correcting and repairing genetic mutations; (b) viruses cause cancer; and (c), abnormal gene mutations are often the consequences of (and secondary to) disturbances in effective immunity. The outcomes of cancer reductionist approaches to therapies reveal failure rates of 90% (+/-5) for solid tumors; loss of over 50 million lives and waste of $30-50 trillions on too many worthless, out-of-focus, and irresponsible projects. Current emphasis on vaccination of public with pathogen-specific vaccines and ingredients seems new terms for drugging young and old. Cumulative exposures to low level carcinogens and environmental hazards or high energy electronic devices (EMF; 5G) are additional triggers to vaccine toxicities (antigen-mitochondrial overload) or "seeds of immune destruction" that create mini electrical shocks (molecular sinks holes) in highly synchronized and regulated immune network that retard time-energy-dependent biorhythms in organs resulting in causes, exacerbations or consequences of mild, moderate or severe immune disorders. Four generations of drug-dependent Americans strongly suggest that medical establishment has practiced decades of intellectual deception through its claims on "war on cancer"; that cancer is 100, 200, or 1000 diseases; identification of "individual" genetic mutations to cure diseases; "vaccines are safe". Such immoral and unethical practices, along with intellectual harassment and bullying, censoring or silencing of independent and competent professionals ("Intellectual Me Too") present grave concerns, far greater compared with the sexual harassment of 'Me Too' movement that was recently spearheaded by NIH. The principal driving forces behind conducting deceptive and illogical medical/cancer and vaccine projects seem to be; (a) huge return of investment and corporate profit for selling drugs and vaccines; (b) maintenance of abusive power over public health; (c) global control of population growth via increased induction of diseases, infertility, decline in life-span, and death. An overview of accidental discoveries that we established and extended since 1980s, on models of acute and chronic ocular inflammatory diseases, provides series of the first evidence for a direct link between inflammation and multistep immune dysfunction in tumorigenesis and angiogenesis. Results are relevant to demonstrate that current emphasis on vaccinating the unborn, newborn, or infant would induce immediate or long-term immune disorders (eg, low birth weight, preterm birth, fatigue, autism, epilepsy/seizures, BBB leakage, autoimmune, neurodegenerative or digestive diseases, obesity, diabetes, cardiovascular problems, or cancers). Vaccination of the unborn is likely to disturb trophoblast-embryo-fetus-placenta biology and orderly growth of embryo-fetus, alter epithelial-mesenchymal transition or constituent-inducible receptors, damage mitochondria, and diverse function of histamine-histidine pathways. Significant increased in childhood illnesses are likely due to toxicities of vaccine and incipient (eg, metals [Al, Hg], detergents, fetal tissue, DNA/RNA) that retard bioenergetics of mitochondria, alter polarization-depolarization balance of tumoricidal (Yin) and tumorigenic (Yang) properties of immunity. Captivated by complex electobiology of immunity, this multidisciplinary perspective is an attempt to initiate identifying bases for increased induction of immune disorders in three to four generations in America. We hypothesize that (a) gene-environment-immune biorhythms parallel neuronal function (brain neuroplasticity) with super-packages of inducible (adaptive or horizontal) electronic signals and (b) autonomic sympathetic and parasympathetic circuitry that shape immunity (Yin-Yang) cannot be explained by limited genomics (innate, perpendicular) that conventionally explain certain inherited diseases (eg, sickle cell anemia, progeria). Future studies should focus on deep learning of complex electrobiology of immunity that requires differential bioenergetics from mitochondria and cytoplasm. Approaches to limit or control excessive activation of gene-environment-immunity are keys to assess accurate disease risk formulations, prevent inducible diseases, and develop universal safe vaccines that promote health, the most basic human right.

Procedure-specific and patient-specific pain management for ambulatory surgery with emphasis on the opioid crisis

PURPOSE OF REVIEW

Postoperative pain is frequent while, on the other hand, there is a grooving general concern on using effective opioid pain killers in view of the opioid crisis and significant incidence of opioid abuse. The present review aims at describing nonopioid measures in order to optimize and tailor perioperative pain management in ambulatory surgery.

RECENT FINDINGS

Postoperative pain should be addressed both preoperatively, intraoperatively and postoperatively. The management should basically be multimodal, nonopioid and procedure-specific. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis, and then limited to a few days at maximum, unless strict control is applied. The individual patient should be screened preoperatively for any risk factors for severe postoperative pain and/or any abuse potential.

SUMMARY

Basic multimodal analgesia should start preoperatively or peroperatively and include paracetamol, cyclo-oxygenase (COX)-2 specific inhibitor or conventional nonsteroidal anti-inflammatory drug (NSAID) and in most cases dexamethasone and local anaesthetic wound infiltration. If any of these basic analgesics are contraindicated or there is an extra risk of severe postoperative pain, further measures may be considered: nerve-blocks or interfascial plane blocks, gabapentinnoids, clonidine, intravenous lidocaine infusion or ketamine infusion. In the abuse-prone patient, a preferably nonopioid perioperative approach should be aimed at.

Can We Eliminate Opioid Medications for Postoperative Pain Control? A Prospective, Surgeon-Blinded, Randomized Controlled Trial in Knee Arthroscopic Surgery

BACKGROUND

Orthopaedic surgeons have a responsibility to develop responsible opioid practices. Growing evidence has helped define an optimal number of opioids to prescribe after surgical procedures, but little evidence-based guidance exists to support specific practice patterns to decrease opioid utilization.

HYPOTHESIS

After knee arthroscopic surgery with partial meniscectomy, patients who were provided a prescription for opioids and instructed to only fill the prescription if absolutely necessary for pain control would take fewer opioids than patients with opioids automatically included as part of a multimodal approach to pain control prescribed at discharge.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Patients undergoing arthroscopic partial meniscectomy were provided multimodal pain control with aspirin, acetaminophen, and naproxen and randomized to receive oxycodone as either included with their multimodal pain medications (group 1) or given an optional prescription to fill (group 2). Patients were contacted at time points up to 1 month after surgery to assess opioid utilization and medication side effects. The mean number of tablets utilized was the primary outcome measure, with a 50% reduction defined as a successful outcome.

RESULTS

A total of 105 patients were initially enrolled, and 95 (91%; 48 in group 1 and 47 in group 2) successfully completed the study. There was no significant reduction in the number of tablets utilized between groups 1 and 2 (3.5 vs 4.5, respectively; P = .45), days that opioids were required (2.2 vs 3.2, respectively; P = .20), or postoperative pain at any time point. The group with the option to fill their prescription had significantly fewer unused tablets remaining than the group with opioids included as part of the multimodal pain control regimen (75% of potentially prescribed tablets vs 82% of prescribed tablets; P < .001). Overall, 37% of patients did not require any opioids after surgery, and 86% used ≤8 tablets.

CONCLUSION

Patients required a minimal number of opioids after knee arthroscopic surgery with partial meniscectomy. There was no difference in the number of tablets utilized whether the opioid prescription was included in a multimodal pain control regimen or patients were given an option to fill the prescription. Offering optional opioid prescriptions in the setting of a multimodal approach to pain control can significantly reduce the number of unused opioids circulating in the community.

REGISTRATION

NCT03876743 (ClinicalTrials.gov identifier).

Preoperative Opioids Associated With Increased Postoperative Opioid Use in Pediatric Appendicitis

BACKGROUND

In light of current opioid-minimization efforts, we aimed to identify factors that predict postoperative opioid requirement in pediatric appendicitis patients.

METHODS

A single-center retrospective cohort study was conducted of children (<18 y) who underwent laparoscopic appendectomy for acute appendicitis between January 1, 2018 and April 30, 2019. Patients who underwent open or interval appendectomies were excluded. The primary outcome was morphine milliequivalents (MMEs) per kilogram administered between 2 and 24 h after surgery. Multivariable analyses were performed to evaluate predictors of postoperative opioid use. Clinically sound covariates were chosen a priori: age, weight, simple versus complicated appendicitis, preoperative opioid administration, and receipt of regional or local anesthesia.

RESULTS

Of 546 patients, 153 (28%) received postoperative opioids. Patients who received postoperative opioids had a longer median preadmission symptom duration (48 versus 24 h, P < 0.001) and were more likely to have complicated appendicitis (55% versus 21%, P < 0.001). Patients who received postoperative opioids were more likely to have received preoperative opioids (54% versus 31%, P < 0.001). Regional and local anesthesia use was similar between groups. Nearly all patients (99%) received intraoperative opioids. Each preoperative MME per kilogram that a patient received was associated with receipt of 0.29 additional MMEs per kilogram postoperatively (95% confidence interval, 0.19-0.40).

CONCLUSIONS

Preoperative opioid administration was independently associated with increased postoperative opioid use in pediatric appendicitis. These findings suggest that preoperative opioids may potentiate increased postoperative pain. Limiting preoperative opioid exposure, through strategies such as multimodal analgesia, may be an important facet of efforts to reduce postoperative opioid use.