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Segebarth PB, Schallmo M, Odum S, Hietpas K, Michalek C, Chapman TM, Leas D, Milam RA, Hamid N. Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial. Clin Spine Surg 2024; 37:138-148. [PMID: 38553433 DOI: 10.1097/bsd.0000000000001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/28/2024] [Indexed: 05/07/2024]
Abstract
STUDY DESIGN Randomized controlled trial (RCT). OBJECTIVE Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures. SUMMARY OF BACKGROUND DATA Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures. METHODS This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC). RESULTS Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively. CONCLUSIONS A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.
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Araujo-Duran J, Kopac O, Montalvo Campana M, Bakal O, Sessler DI, Hofstra RL, Shah K, Turan A, Ayad S. Virtual Reality Distraction for Reducing Acute Postoperative Pain After Hip Arthroplasty: A Randomized Trial. Anesth Analg 2024; 138:751-759. [PMID: 37678233 PMCID: PMC10909914 DOI: 10.1213/ane.0000000000006642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Relaxation and distraction provided by virtual reality presentations might be analgesic and reduce the need for opioid analgesia. We tested the hypothesis that a virtual reality program (AppliedVR) decreases acute postoperative pain and opioid requirements in patients recovering from hip arthroplasty. We also evaluated whether virtual reality distraction improves patient mobility and reduces the need for antiemetics. METHODS We evaluated 106 adults who were recovering from elective primary total hip arthroplasty. Participating patients were randomized to 2- to 8-minute-long 3-dimensional immersive virtual reality relaxation and distraction video presentations (eg, guided breathing exercises, games, mindfulness) or to 2-dimensional presentations of nature short films (eg, forest wildlife) with neutral music that was chosen to be neither overly relaxing nor distracting, presented through identical headsets. Our primary outcome was pain after virtual reality or sham video presentations, adjusted for pretreatment scores. Secondary outcomes included total opioid consumption, pain scores obtained per routine by nurse staff, perception of video system usability, and pain 1 week after hospital discharge. RESULTS Fifty-two patients were randomized to virtual reality distraction and relaxation, and 54 were assigned to 2-dimensional sham presentations. Virtual reality presentations were not found to affect pain scores before and after presentations, with an estimated difference in means (virtual reality minus sham video) of -0.1 points (95% confidence interval [CI], -0.5 to 0.2; P = .391) on a 0 to 10 scale, with 10 being the worst. The mean (standard error [SE]) after-intervention pain score was estimated to be 3.4 (0.3) in the virtual reality group and 3.5 (0.2) in the reference group. Virtual reality treatment was not found to affect postoperative opioid consumption in morphine milligram equivalents, with an estimated ratio of geometric means (virtual reality/sham video) of 1.2 (95% CI, 0.6-2.1; P = .608). Virtual reality presentations were not found to reduce pain scores collected every 4 hours by nursing staff, with an estimated difference in means of 0.1 points (95% CI, -0.9 to 0.7; P = .768). CONCLUSIONS We did not observe statistically significant or clinically meaningful reductions in average pain scores or opioid consumption. As used in our trial, virtual reality did not reduce acute postoperative pain.
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Affiliation(s)
| | | | | | - Omer Bakal
- From the Department of Outcomes Research
| | | | | | - Karan Shah
- Department of Quantitative Health Sciences
| | - Alparslan Turan
- From the Department of Outcomes Research
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Sabry Ayad
- From the Department of Outcomes Research
- Department of Regional Practice, Anesthesiology Institute, Cleveland Clinic/Fairview Hospital, Cleveland, Ohio
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Rim F, Liu SS, Kelly M, Kim D, Sideris A, Langford DJ. Preoperative pain screening and optimisation by a perioperative pain service to support complex surgical patients: no patient left behind. Br J Anaesth 2024; 132:437-439. [PMID: 38087742 DOI: 10.1016/j.bja.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 01/21/2024] Open
Affiliation(s)
- Faye Rim
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Spencer S Liu
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Mary Kelly
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA
| | - Dae Kim
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Alexandra Sideris
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Dale J Langford
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology & Perioperative Medicine, University of Rochester, Rochester, NY, USA; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA.
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Combalia A, Sanchez-Vives MV, Donegan T. Immersive virtual reality in orthopaedics-a narrative review. INTERNATIONAL ORTHOPAEDICS 2024; 48:21-30. [PMID: 37566225 PMCID: PMC10766717 DOI: 10.1007/s00264-023-05911-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 07/23/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE This narrative review explores the applications and benefits of immersive virtual reality (VR) in orthopaedics, with a focus on surgical training, patient functional recovery, and pain management. METHODS The review examines existing literature and research studies on immersive VR in orthopaedics, analyzing both experimental and clinical studies. RESULTS Immersive VR provides a realistic simulation environment for orthopaedic surgery training, enhancing surgical skills, reducing errors, and improving overall performance. In post-surgical recovery and rehabilitation, immersive VR environments can facilitate motor learning and functional recovery through virtual embodiment, motor imagery during action observation, and virtual training. Additionally VR-based functional recovery programs can improve patient adherence and outcomes. Moreover, VR has the potential to revolutionize pain management, offering a non-invasive, drug-free alternative. Virtual reality analgesia acts by a variety of means including engagement and diverting patients' attention, anxiety reduction, and specific virtual-body transformations. CONCLUSION Immersive virtual reality holds significant promise in orthopaedics, demonstrating potential for improved surgical training, patient functional recovery, and pain management but further research is needed to fully exploit the benefits of VR technology in these areas.
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Affiliation(s)
- A Combalia
- Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain.
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Clínic de Barcelona, Universitat de Barcelona (UB), c. Villarroel, 170, 08036, Barcelona, Spain.
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), c. Villarroel, 170, 08036, Barcelona, Spain.
| | - M V Sanchez-Vives
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), c. Villarroel, 170, 08036, Barcelona, Spain.
- Institución Catalana de Investigación y Estudios Avanzados (ICREA), Passeig de Lluís Companys, 23, 08010, Barcelona, Spain.
| | - T Donegan
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), c. Villarroel, 170, 08036, Barcelona, Spain
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Bovonratwet P, Vaishnav AS, Mok JK, Urakawa H, Dupont M, Melissaridou D, Shahi P, Song J, Shinn DJ, Dalal SS, Araghi K, Sheha ED, Gang CH, Qureshi SA. Association Between Patient Reported Outcomes Measurement Information System Physical Function With Postoperative Pain, Narcotics Consumption, and Patient-Reported Outcome Measures Following Lumbar Microdiscectomy. Global Spine J 2024; 14:225-234. [PMID: 35623628 PMCID: PMC10676173 DOI: 10.1177/21925682221103497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine association between preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scores with postoperative pain, narcotics consumption, and patient-reported outcome measures (PROMs) following single-level lumbar microdiscectomy. METHODS Consecutive patients who underwent single-level lumbar microdiscectomy were identified from May 2017-May 2020. Patients were grouped by their preoperative PROMIS-PF scores: mild disability (score≥40), moderate disability (score 30-39.9), and severe disability (score<30). Preoperative PROMIS-PF subgroups were tested for association with inpatient postoperative pain, total inpatient narcotics consumption, time to narcotic use cessation as well as improvements in postoperative PROMIS-PF, ODI, VAS-Leg Pain, VAS-Back Pain, SF-12 Physical Component Score (PCS), SF-12 Mental Component Score (MCS) at 2-, 6-, 12-weeks, 6-month, 1-year, 2-year follow-up. RESULTS A total of 127 patients were included. Patients with greater disability reported higher inpatient maximum Visual Analog Scale (VAS) pain scores (P = .023) and total inpatient narcotics consumption (P = .008) but no difference in time to narcotic cessation after surgery (P = .373). However, patients with greater preoperative disability also demonstrated greater improvement from baseline in PROMIS-PF, ODI, SF-12 PCS, and SF-12 MCS at 2-week follow-up (P < .05). These higher improvements from baseline for patients with greater preoperative disability were sustained for PROMIS-PF, ODI, and VAS-Leg Pain at 2-year follow-up (P < .05). CONCLUSIONS Patients with greater preoperative disability, as measured by PROMIS-PF, had increased inpatient postoperative pain and narcotics consumption, but also higher improvement from baseline in long-term PROMs. This data can be utilized for patient counseling and setting expectations.
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Affiliation(s)
- Patawut Bovonratwet
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Avani S. Vaishnav
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jung K. Mok
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Hikari Urakawa
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Marcel Dupont
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Pratyush Shahi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Junho Song
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Daniel J. Shinn
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sidhant S. Dalal
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Kasra Araghi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Evan D. Sheha
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Catherine H. Gang
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sheeraz A. Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
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Kevas Y, Kaveeshwar S, Pitsenbarger L, Hughes M, Schneider MB, Hahn A, Honig EL, Pensy RA, Langhammer CG, Henn RF. Preoperative Factors Associated With Worse PROMIS Pain Interference 2 Years After Hand and Wrist Surgery. Hand (N Y) 2023:15589447231218301. [PMID: 38156464 DOI: 10.1177/15589447231218301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
BACKGROUND The purpose of this study was to identify preoperative factors associated with worse postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores 2 years after hand and wrist surgery. We hypothesized that older age, more comorbidities, increased substance use, and lower socioeconomic status would correlate with worse 2-year PROMIS PI scores. METHODS This study was a retrospective review of prospectively acquired data on 253 patients. Surveys were administered within 1 week of surgery and 2 years postoperatively. Bivariate and multivariable analyses were conducted to identify significant predictors of worse 2-year PROMIS PI scores and change in PROMIS PI scores. RESULTS Older age, higher body mass index, more comorbidities, lower preoperative expectations, more prior surgeries, unemployment, smoking, higher American Society of Anesthesiologists (ASA) score, and multiple other socio-demographic factors were correlated with worse 2-year PROMIS PI scores (P ≤ .018). Similar factors were also correlated with less improvement in 2-year PROMIS PI scores (P ≤ .048). Worse scores on all preoperative patient-reported outcome measures correlated with worse 2-year PROMIS PI scores (P ≤ .007). Multivariable analysis identified smoking history, less frequent alcohol consumption, worse preoperative PROMIS social satisfaction and Numeric Pain Scale whole body scores, and higher ASA scores as independent predictors of worse 2-year PROMIS PI. The same factors in addition to better baseline PROMIS PI were predictive of less improvement in 2-year PROMIS PI. CONCLUSION Numerous preoperative factors were predictive of worse postoperative 2-year PROMIS PI and less improvement in 2-year PROMIS PI for patients undergoing hand and wrist surgery.
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Affiliation(s)
- Yanni Kevas
- University of Maryland School of Medicine, Baltimore, USA
| | | | | | - Meghan Hughes
- University of Maryland School of Medicine, Baltimore, USA
| | | | - Alexander Hahn
- University of Maryland School of Medicine, Baltimore, USA
| | - Evan L Honig
- University of Maryland School of Medicine, Baltimore, USA
| | | | | | - R Frank Henn
- University of Maryland School of Medicine, Baltimore, USA
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Yanik JM, Glass NA, Caldwell LS, Buckwalter V JA, Fowler TP, Lawler EA. A Novel Prescription Method Reduces Postoperative Opioid Distribution and Consumption: A Randomized Clinical Trial. Hand (N Y) 2023; 18:1314-1322. [PMID: 35656851 PMCID: PMC10617470 DOI: 10.1177/15589447221096709] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prescription opioid abuse in the United States has risen substantially over the past 2 decades. Narcotic prescription refill restrictions may paradoxically be contributing to this epidemic. We investigated a novel, refill-based opioid prescription method to determine whether it would alter postoperative narcotic distribution or consumption. METHODS In this randomized controlled trial, patients undergoing internal fixation of distal radius fractures or thumb carpometacarpal joint arthroplasty received either a single prescription for all postoperative narcotics (control arm) or the same amount of pain medication divided into 3 equal prescriptions to be filled as needed (experimental arm). Outcomes included total narcotics dispensed, measured in morphine milligram equivalents (MME) through a prescription monitoring program, patient-reported opioid consumption versus opioid not consumed, and a satisfaction survey. RESULTS Forty-eight participants were enrolled; 25 were randomized to the control arm and 23 to the experimental arm. At 8 weeks post-op, fewer opioids had been dispensed to the experimental arm (177 ± 94 vs 287 ± 123 MME, P = .0025). At 6-week follow-up, the experimental arm reported lower narcotic consumption (124 ± 105 vs 214 ± 110 MME, P = .0131). Subanalysis of the independent surgeries yielded similar results. Some patients reported insurance issues when filling subsequent prescriptions. Consequently, although 100% of control arm patients reported good pain control, only 82.6% of experimental arm patients said likewise (P = .0455). CONCLUSIONS This randomized clinical trial demonstrated that patients obtained and consumed fewer narcotics when postoperative opioids were given in a refill-based prescription method. More research is needed to determine whether this opioid distribution method is reproducible, translatable, and feasible.
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Affiliation(s)
- John M. Yanik
- University of Iowa Hospitals and Clinics, Iowa City, USA
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Ruckle DE, Chang AC, Wongworawat MD. The Effect of Upper Extremity Tourniquet Time on Postoperative Pain and Opiate Consumption. Hand (N Y) 2023; 18:1152-1155. [PMID: 35321573 PMCID: PMC10798213 DOI: 10.1177/15589447221084009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is widespread use of pneumatic tourniquet for both upper and lower extremity orthopedic surgeries. Tourniquet use improves visualization, decreases blood loss, and as a result, decreases operative time. Exceeding a certain amount of tourniquet time can cause lasting neuromuscular damage. Orthopedic procedures cause significant pain, and the perioperative narcotic prescriptions after orthopedic surgery have been identified as one of the major contributors to the opioid epidemic. Our aim was to determine whether increasing tourniquet time had a negative impact on immediate postoperative opiate usage in the upper extremity, and to determine other factors associated with increased immediate postoperative opiate usage. METHODS A retrospective medical record review was performed on patients who underwent volar pleading for fracture fixation between January 2014 and December 2019 at a single institution. Postoperative pain, morphine equivalent dose (MED) usage, and demographic variables were collected. Multivariable analysis was performed, with P < .05 considered significant. RESULTS Immediate postoperative MED consumed was not correlated with operative time, tourniquet time, preoperative substance usage, or sex. However, postoperative MED consumed was correlated with preoperative narcotic use, high body mass index (BMI), and fracture surgery complexity. CONCLUSIONS Tourniquet usage under current guidelines does not appear to have an effect on postoperative pain and narcotic usage. Preoperative narcotic usage, BMI, and surgery complexity are significant factors for postoperative opiate consumption.
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Xu AL, Humbyrd CJ. Strategies for Reducing Perioperative Opioid Use in Foot and Ankle Surgery: Education, Risk Identification, and Multimodal Analgesia. Orthop Clin North Am 2023; 54:485-494. [PMID: 37718087 DOI: 10.1016/j.ocl.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
There remains a high prevalence and substantial risks of opioid utilization amongst orthopedic patients. The goal of this review is to discuss strategies for responsible opioid use in the perioperative setting following foot and ankle orthopedic surgeries. We will highlight 1) education interventions, 2) risk identification, and 3) non-opioid alternatives for postoperative pain management.
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Affiliation(s)
- Amy L Xu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Casey Jo Humbyrd
- Orthopedic Surgery, University of Pennsylvania, 230 West Washington Square, 5th Floor, Philadelphia, PA 19107, USA.
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Wang CG, Zhang ZQ, Yang Y, Long YB, Wang XL, Ding YL. A randomized controlled trial of iliopsoas plane block vs. femoral nerve block for hip arthroplasty. BMC Anesthesiol 2023; 23:197. [PMID: 37291487 PMCID: PMC10249315 DOI: 10.1186/s12871-023-02162-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Iliopsoas plane block (IPB) is a novel analgesic technique for hip surgery that retains quadriceps strength. However, evidence from randomized controlled trial is remains unavailable. We hypothesized that IPB, as a motor-sparing analgesic technique, could match the femoral nerve block (FNB) in pain management and morphine consumption, providing an advantage for earlier functional training in patients underwent hip arthroplasty. METHODS We recruited ninety patients with femoral neck fracture, femoral head necrosis or hip osteoarthritis who were scheduled for unilateral primary hip arthroplasty were recruited and received either IPB or FNB. Primary outcome was the pain score during hip flexion at 4 h after surgery. Secondary outcomes included quadriceps strength and pain scores upon arrival at post anesthesia care unit (PACU) and at 2, 4, 6, 24, 48 h after surgery, the first time out of bed, total opioids consumption, patient satisfaction, and complications. RESULTS There was no significant difference in terms of pain score during hip flexion at 4 h after surgery between the IPB group and FNB group. The quadriceps strength of patients receiving IPB was superior to those receiving FNB upon arrival at PACU and at 2, 4, 6 and 24 h after surgery. The IPB group showed a shorter first time out of bed compared to the FNB group. However, there were no significant differences in terms of pain scores within 48 h after surgery, total opioids consumption, patient satisfaction and complications between the two groups. CONCLUSION IPB was not superior to FNB in terms of postoperative analgesia for hip arthroplasty. However, IPB could serve as an effective motor-sparing analgesic technique for hip arthroplasty, which would facilitate early recovery and rehabilitation. This makes IPB worth considering as an alternative to FNB. TRIAL REGISTRATION The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry (ChiCTR2200055493; registration date: January 10, 2022; enrollment date: January 18, 2022; https://www.chictr.org.cn/searchprojEN.html ).
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Affiliation(s)
- Chun-Guang Wang
- Department of Anesthesiology, The First Central Hospital of Baoding, Northern Great Wall Street 320#, Baoding, 071000, Hebei, China.
| | - Zhi-Qiang Zhang
- Department of Cardio-Thoracic Surgery, The First Central Hospital of Baoding, Baoding, 071000, China
| | - Yang Yang
- Department of Anesthesiology, The First Central Hospital of Baoding, Northern Great Wall Street 320#, Baoding, 071000, Hebei, China
| | - Yu-Bin Long
- Department of Orthopedics, The First Central Hospital of Baoding, Baoding, 071000, Hebei, China
| | - Xiu-Li Wang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Yan-Ling Ding
- Department of Anesthesiology, The First Central Hospital of Baoding, Northern Great Wall Street 320#, Baoding, 071000, Hebei, China
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11
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Gailey AD, Ostrum RF. The use of liposomal bupivacaine in fracture surgery: a review. J Orthop Surg Res 2023; 18:267. [PMID: 37005638 PMCID: PMC10068181 DOI: 10.1186/s13018-023-03583-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Historically, opioids have played a major role in the treatment of postoperative pain in orthopedic surgery. A multitude of adverse events have been associated with opioid use and alternative approaches to pain relief are being investigated, with particular focus on multimodal pain management regimens. Liposomal bupivacaine (EXPAREL) is a component of some multimodal regimens. This formulation of bupivacaine encapsulates the local anesthetic into a multivesicular liposome to theoretically deliver a consistent amount of drug for up to 72 hours. Although the use of liposomal bupivacaine has been studied in many areas of orthopedics, there is little evidence evaluating its use in patients with fractures. This systematic review of the available data identified a total of eight studies evaluating the use of liposomal bupivacaine in patients with fractures. Overall, these studies demonstrated mixed results. Three studies found no difference in postoperative pain scores on postoperative days 1-4, while two studies found significantly lower pain scores on the day of surgery. Three of the studies evaluated the quantity of narcotic consumption postoperatively and failed to find a significant difference between control groups and groups treated with liposomal bupivacaine. Further, significant variability in comparison groups and study designs made interpretation of the available data difficult. Given this lack of clear evidence, there is a need for prospective, randomized clinical trials focused on fully evaluating the use of liposomal bupivacaine in fracture patients. At present, clinicians should maintain a healthy skepticism and rely on their own interpretation of the available data before widely implementing the use of liposomal bupivacaine.
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Affiliation(s)
- Andrew D Gailey
- Department of Orthopaedic Surgery, University of Tennessee Health Science Center-Campbell Clinic and University of North Carolina Health Care, 1584 Forrest Ave, Memphis, TN, 38112, USA.
- Department of Orthopaedic Surgery, Campbell Clinic/University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Robert F Ostrum
- Department of Orthopaedic Surgery, University of Tennessee Health Science Center-Campbell Clinic and University of North Carolina Health Care, 1584 Forrest Ave, Memphis, TN, 38112, USA
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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12
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Impact of State Opioid Regulation on Postoperative Opioid Prescribing Patterns for Total Knee Arthroplasty: A Retrospective Analysis. J Am Acad Orthop Surg 2023; 31:258-264. [PMID: 36727692 DOI: 10.5435/jaaos-d-22-00651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/23/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Limited studies have assessed the impact of state regulations on opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA). This study evaluates how Florida House Bill 21 (FL-HB21) affected postoperative opioid prescribing for patients after TKA. METHODS Institutional review board approval was obtained to retrospectively review all patients who underwent TKA during 3 months of 2017 (pre-law) and 2018 (post-law) by five arthroplasty surgeons in Florida. Prescribed opioid quantity in morphine milligram equivalents (MME), quantity of refills, and number of prescribers were recorded for each patient's 90-day postsurgical episode. The differences between pre-law and post-law prescription data and short-term postoperative pain levels were compared. RESULTS The average total MME was notably reduced by over 30% for all time periods for the post-law group. The average MME per patient decreased by 169 MME at the time of discharge, by 245 MME during subsequent postoperative visits, and by 414 MME for the 90-day postsurgical episode ( P < 0.001 for all). The quantity of refills was unchanged (1.6 vs. 1.6, P = 0.885). The total number of prescribers per patient for the 90-day postsurgical episode was unchanged (1.31 vs. 1.24 prescribers/patient, P = 0.16). Postoperative pain levels were similar at discharge (3.6 pre-law vs. 3.3 post-law, P = 0.272). DISCUSSION Restrictive opioid legislation was associated with notably reduced postoperative opioid (MME) prescribed per patient after TKA at the time of discharge and for the entire 90-day postsurgical episode. There was no increase in the number of prescribers or refills required by patients. LEVEL OF EVIDENCE Level III retrospective cohort.
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Levy HA, Karamian BA, Canseco JA, Henstenburg J, Larwa J, Haislup B, Kaye ID, Woods BI, Radcliff KE, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Does a High Postoperative Opioid Dose Predict Chronic Use After ACDF? World Neurosurg 2023; 171:e686-e692. [PMID: 36566977 DOI: 10.1016/j.wneu.2022.12.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The purpose of this study is to determine if increased postoperative prescription opioid dosing is an isolated predictor of chronic opioid use after anterior cervical diskectomy and fusion (ACDF). METHODS A retrospective cohort analysis of patients undergoing ACDF for degenerative diseases from 2016-2019 at a single institution was performed. Preoperative and postoperative opioid and benzodiazepine prescriptions, including morphine milligram equivalents (MMEs) and duration of use, were obtained from the Pennsylvania Prescription Drug Monitoring Program. Univariate analysis compared patient demographics and surgical factors across groups on the basis of postoperative opioid dose (high: MME ≥90, low: MME <90) and chronicity of use (chronic: ≥120 days or >10 prescriptions). Logistic regressions identified predictors of high opioid dose and chronic use. RESULTS A total of 385 patients were included. Preoperative opioid tolerance and tobacco use were associated with high postoperative opioid dose and chronic usage. Younger age correlated with high-dose prescriptions. Increased body mass index and preoperative benzodiazepine use were associated with chronic opioid use. Chronic postoperative opioid use correlated with high-dose prescriptions, change in opioid prescribed, private pay scripts, and more than 1 prescriber and pharmacy. Logistic regression identified high postoperative opioid dose, opioid tolerance, increased body mass index, and no prior cervical surgery as predictors of chronic opioid use. Regression analysis determined younger age, increased medical comorbidities, and opioid tolerance to be predictors for high MME prescriptions. CONCLUSIONS High postoperative opioid dose independently predicted chronic opioid use after ACDF regardless of preoperative opioid tolerance.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA.
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffrey Henstenburg
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph Larwa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brett Haislup
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kris E Radcliff
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Seilern und Aspang J, Schenker ML, Port A, Leslie S, Giordano NA. A systematic review of patient-centered interventions for improving pain outcomes and reducing opioid-related risks in acute care settings. OTA Int 2023; 6:e226. [PMID: 36760660 PMCID: PMC9904190 DOI: 10.1097/oi9.0000000000000226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 09/17/2022] [Indexed: 02/05/2023]
Abstract
Objectives This systematic review evaluates the literature for patient-oriented opioid and pain educational interventions that aim to optimize pain management using opioid-sparing approaches in the orthopaedic trauma population. The study protocol was registered with PROSPERO (CRD42021234006). Data Sources A review of English-language publications in CINAHL (EBSCO), MEDLINE through PubMed, Embase.com, PsycInfo (EBSCO), and Web of Science Core Collection literature databases published between 1980 and February 2021 was conducted using PRISMA guidelines. Study Selection Only studies implementing patient-oriented opioid and/or pain education in adult patients receiving acute orthopaedic care were eligible. Outcomes were required to include postinterventional opioid utilization, postoperative analgesia and amount, or patient-reported pain outcomes. Data Extraction A total of 480 abstracts were reviewed, and 8 publications were included in the final analysis. Two reviewers independently extracted data from selected studies using a standardized data collection form. Disagreements were addressed by a third reviewer. Quality of studies was assessed using the Cochrane Risk of Bias Tool. Data Synthesis Descriptive statistics characterized study findings, and content analysis was used to discern themes across studies. Conclusion Our findings indicate the merit for patient-centered educational interventions including verbal/written/audio-visual trainings paired with multimodal approaches to target opioid-sparing pain management and reduce short-term pain scores in urgent and acute care settings after acute orthopaedic injuries. The scarcity of published literature warrants further rigorously designed studies to substantiate the benefit of patient-centric education in reducing prolonged opioid utilization and associated risks after orthopaedic trauma. Level of Evidence Therapeutic level III.
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Affiliation(s)
- Jesse Seilern und Aspang
- Emory University School of Medicine, Department of Orthopaedic Surgery, Grady Memorial Hospital, Atlanta, GA
| | - Mara L. Schenker
- Emory University School of Medicine, Department of Orthopaedic Surgery, Grady Memorial Hospital, Atlanta, GA
| | - Ada Port
- Christopher Wolf Crusade, Atlanta, GA
| | - Sharon Leslie
- Emory University, Woodruff Health Sciences Center Library, 1462 Clifton Road NE, Atlanta, GA
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15
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Kukushliev VV, Sherman KA, Kurylo CM, Ortmann SD, Scheidt RA, Scheidt KB. Tapered Dose Postoperative Opioid Prescriptions Following Inpatient Total Hip and Knee Arthroplasty: Quality Improvement Study and Retrospective Review. J Arthroplasty 2023; 38:239-244. [PMID: 36075313 DOI: 10.1016/j.arth.2022.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Overprescription of pain medications directly fuels the opioid epidemic. Veterans are profoundly impacted. Tapered dose protocols may reduce excessive prescribing. METHODS A retrospective study of adult veterans who presented to our institution for primary total knee arthroplasty or total hip arthroplasty (THA) was performed. Postdischarge opioid use was reviewed before and after an opioid taper prescription protocol. The preprotocol and postprotocol groups had 299 and 89 veterans, respectively. Total Morphine Milligram Equivalent (MME) prescribed postdischarge, number of tablets prescribed, number of refills issued, 30-day emergency department visits, and 30-day readmissions were compared. Opioid naïve and chronic opioid users were both included. RESULTS Preprotocol and postprotocol implementation group, in combination with surgery type (total knee arthroplasty versus THA) and opioid naïve status, predicted MME. On average, the postprotocol group received 224 MME less, THA patients received 177 MME less, and nonopioid naïve patients received 152 MME more. CONCLUSION The opioid taper protocol led to less opioid administration after discharge. Taper protocols should be considered for postoperative pain management. LEVEL OF EVIDENCE III, retrospective comparison study.
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Affiliation(s)
- Vasil V Kukushliev
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Christopher M Kurylo
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stephen D Ortmann
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert A Scheidt
- Washington University in St. Louis School of Medicine, Saint Louis, Missouri
| | - Karl B Scheidt
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
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16
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Walczak BE, Bernardoni ED, Steiner Q, Baer GS, Donnelly MJ, Shepler JA. Effects of General Anesthesia Plus Multimodal Analgesia on Immediate Perioperative Outcomes of Hamstring Tendon Autograft ACL Reconstruction. JB JS Open Access 2023; 8:JBJSOA-D-22-00144. [PMID: 36999048 PMCID: PMC10043574 DOI: 10.2106/jbjs.oa.22.00144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Anterior cruciate ligament reconstruction with hamstring tendon autograft (H-ACLR) is a standard ambulatory procedure with the potential for considerable postoperative pain. We hypothesized that general anesthesia combined with a multimodal analgesia regimen would reduce postoperative opioid use associated with H-ACLR. Methods This study was a single-center, surgeon-stratified, double-blinded, placebo-controlled, randomized clinical trial. The primary end point was the total postoperative opioid use during the immediate postoperative period, and secondary outcomes included postoperative knee pain, adverse events, and ambulatory discharge efficiency. Results One hundred and twelve subjects, 18 to 52 years of age, were randomized to placebo (57 subjects) or combination multimodal analgesia (MA) (55 subjects). The MA group required fewer opioids postoperatively (mean ± standard deviation, 9.81 ± 7.58 versus 13.88 ± 8.49 morphine milligram equivalents; p = 0.010; effect size = -0.51). Similarly, the MA group required fewer opioids within the first 24 hours postoperatively (mean ± standard deviation, 16.56 ± 10.77 versus 22.13 ± 10.66 morphine milligram equivalents; p = 0.008; effect size = -0.52). The subjects in the MA group reported lower posteromedial knee pain (median [interquartile range, IQR]: 3.0 [0.0 to 5.0] versus 4.0 [2.0 to 5.0]; p = 0.027) at 1 hour postoperatively. Nausea medication was required for 10.5% of the subjects receiving the placebo versus 14.5% of the subjects receiving MA (p = 0.577). Pruritis was reported for 17.5% of subjects receiving the placebo versus 14.5% receiving MA (p = 0.798). The median time to discharge was 177 minutes (IQR, 150.5 to 201.0 minutes) for subjects receiving placebo versus 188 minutes (IQR, 160.0 to 222.0 minutes) for those receiving MA (p = 0.271). Conclusions A combination of general anesthesia and local, regional, oral, and intravenous multimodal analgesia appears to reduce postoperative opioid requirements after H-ACLR compared with placebo. Adding preoperative patient education and focusing on donor-site analgesia may maximize perioperative outcomes. Level of Evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brian E. Walczak
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin
- Castle Orthopedics & Sports Medicine, Rush Copley Medical Center, Rush University Health, Aurora, Illinois
- Email for corresponding author:
| | - Eamon D. Bernardoni
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin
| | - Quinn Steiner
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Geoffrey S. Baer
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - John A. Shepler
- Department of Anesthesia, University of Wisconsin-Madison, Madison, Wisconsin
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17
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Heller S, Shemesh S, Rukinglaz O, Cohen N, Velkes S, Fein S. Efficacy of single-shot adductor canal block before Versus after primary total knee arthroplasty - Does timing make a difference? A randomized controlled trial. J Orthop Surg (Hong Kong) 2022; 30:10225536221132050. [PMID: 36189733 DOI: 10.1177/10225536221132050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with severe postoperative pain. Multimodal analgesia, including peripheral nerve block, is recommended for post-operative pain relief. Administration of some pain medications prior to surgery has shown to be more effective than after the operation. This is a prospective, randomized controlled trial designed to compare the analgesic efficacy of the adductor canal block (ACB) performed immediately before or immediately after primary total knee arthroplasty (TKA). We hypothesized that ACB before the surgery will reduce postoperative pain and improve knee function. METHODS A total of 50 patients were enrolled and randomized into 2 groups, with 26 patients receiving a preoperative ACB and 24 receiving a postoperative ACB. RESULTS Treatment groups were similar in terms of gender (p = .83), age (p = 0.61) weight (p = .39) and ASA score. Average visual analogue scale (VAS) on arrival to the post-anesthesia care unit (PACU) were 4.9 ± 3.2 in the preoperative ACB versus 3.4 ± 2.8 for the postoperative ACB (p = .075). VAS scores at different time points as well as the mean, minimal and maximal reported VAS scores were not significantly different between the two groups. The cumulative quantities of Fentanyl administered by the anesthesia team was comparable between the groups. Similarly, the dosage of Morphine, Tramadol, Acetaminophen and Dipyrone showed only small variations. The Quality of Recovery Score, Knee Society Scores and knee range of motion did not differ between the groups. CONCLUSIONS Our findings demonstrate no significant differences in patient total narcotics consumption, pain scores and functional scores, between preoperative and postoperative ACB in patients undergoing TKA. TRIAL REGISTRATION The trial was registered at www.clinicaltrials.gov and was assigned the registration number NCT02908711. LEVEL OF EVIDENCE level I randomized controlled trial.
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Affiliation(s)
- Snir Heller
- Department of Orthopaedic Surgery, 36632Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Shai Shemesh
- Department of Orthopaedic Surgery, 36632Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Oleg Rukinglaz
- Sackler Faculty of Medicine, Tel Aviv University, Israel.,Department of Anesthesiology, Rabin Medical Center, Petach Tikva Israel
| | - Nir Cohen
- Department of Orthopaedic Surgery, 36632Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Steven Velkes
- Department of Orthopaedic Surgery, 36632Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Shai Fein
- Department of Anesthesiology, 511918Assuta Ashdod University Hospital, Israel.,Ben-Gurion University Joyce and Irving Goldman Medical School,Beer-Sheva, Israel
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18
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Postoperative Pain Medication Utilization in Pediatric Patients Undergoing Sports Orthopaedic Surgery: Characterizing Patient Usage Patterns and Opioid Retention. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202210000-00010. [PMID: 36734649 PMCID: PMC9592445 DOI: 10.5435/jaaosglobal-d-22-00206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Opioid overprescribing is a problem in orthopaedic surgery, with many patients having leftover opioid medications after surgery. The purpose of our study was to capture utilization patterns of opioids in pediatric patients undergoing orthopaedic sports medicine surgery, in addition to evaluating patient practices surrounding unutilized opioid medication. Our hypothesis was that there would be low utilization of opioids in this patient population and would in turn contribute to notable overprescribing of opioids and opioid retention in this population. METHODS Pediatric patients undergoing orthopaedic surgery for knee and hip pathology were prospectively enrolled. A survey was administered 14 days postoperatively, with questions centered on the patient-reported number of opioids prescribed, number of opioids used, number of days opioids were used, and incidences of leftover opioid medication and disposal of leftover medication. The magnitude of opioid overprescribing was calculated using the reported prescribed and reported used number of opioid pills. Linear regression was used to examine associations between opioids and NSAIDs prescribed. RESULTS One hundred fourteen patients reported a mean prescription of 12.0 ± 5.0 pills, with utilization of 4.4 ± 6.1 pills over 2.7 ± 5.1 days. Patients were prescribed 2.73 times the number of opioid pills required on average. One hundred patients (87.7%) reported having unused opioid medication after their surgery, with 71 (71.0%) reporting opioid retention. Regression results showed an association with opioids used and prescribed opioid amount (β = 0.582, R = 0.471, P < 0.001). DISCUSSION Overall, our study results help characterize the utilization patterns of opioid medications in the postsurgical pediatric sports orthopaedic population and suggest that orthopaedic surgeons may be able to provide smaller quantities of opioid pills for analgesia than is typically prescribed, which in turn may help reduce the amount of prescription opioid medications present in the community. LEVEL OF EVIDENCE Level IV.
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19
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Ladich EM, Zhou KQ, Spence DL, Moore CB. Opioid-Sparing Anesthesia: Gabapentin and Postoperative Pain. J Perianesth Nurs 2022; 37:966-970. [PMID: 36100525 DOI: 10.1016/j.jopan.2022.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/04/2022] [Accepted: 04/24/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Nonopioid analgesics are commonly used to augment or replace opioids in the perioperative setting. Perianesthesia nurses must consider timing and appropriateness when administering these medications to patients in the preoperative area or the postanesthesia care unit, particularly when other medications with sedative effects are being given. Gabapentin, originally proposed as an anticonvulsant medication, promotes analgesia and reduces risk for postoperative nausea and vomiting. This review examines the effect of gabapentin on postoperative pain. DESIGN A systematic review. METHODS CINAHL, PubMed, and Cochrane Review databases were searched to find a total of 93 sources that examined gabapentin and postoperative pain. After applying inclusion and exclusion criteria, four randomized controlled trials (RCT) were reviewed. Postoperative pain within the 24 hours of surgery was measured as the primary outcome using the visual analog scale in all sources FINDINGS: Three of the four reviewed RCTs determined gabapentin was both statistically and clinically significant in reducing postoperative pain, and all four sources showed a reduction in opioid consumption during the immediate postoperative period, which promoted patient satisfaction. CONCLUSIONS Further study of gabapentin and postoperative pain is needed employing rigorous and robust methodology and diversity of the sample selections.
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Affiliation(s)
- Elaine M Ladich
- Department of Anesthesiology, Paso Del Norte Surgical Center, El Paso, TX.
| | - Kelly Q Zhou
- Department of Anesthesiology, Los Angelas County Medical Center, Keck School of Medicine, University of Southern California, Los Angelas, CA
| | - Dennis L Spence
- Doctor of Nurse Anesthesia Practice Program, TexasWesleyan University, Fort Worth, TX
| | - Chad B Moore
- Nurse Anesthesia Program, Uniformed Services University of the Health Sciences, Jacksonville, FL
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20
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The difficulty of choosing the method of analgesia after total replacement of the lower limb large joints (case report, literature review). ACTA BIOMEDICA SCIENTIFICA 2022. [DOI: 10.29413/abs.2022-7.4.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A case of successful treatment of a patient with a periprosthetic fracture of the femur is described. The fracture occurred one day after total hip replacement as a result of a fall, possibly associated with postoperative conduction analgesia. Lower limb large joints total replacement may become the most frequently performed type of elective surgery already in the current decade. The increasing prevalence of osteoporosis, osteoarthritis, rheumatic diseases and hip fractures is an objective prerequisite for it. Despite of all efforts, the problem of postoperative pain control during these surgical interventions currently remains unresolved. There is currently no “gold standard” for pain relief after total hip and knee replacement surgeries. An excellent ratio of effectiveness and safety is demonstrated by multimodal pain relief programs based on peripheral nerve blocks. However, while having undeniable advantages, conduction anesthesia/analgesia has a critically important drawback. The cornerstone of postoperative rehabilitation for patients undergoing total hip or knee replacement is their early activation. All methods of conduction anesthesia are associated with motor blockade. In particular, femoral nerve block causes weakness of quadriceps muscle of thigh, inducing patients’ inadvertent falling when attempting to stand or walk. The situation with the choice of the method of anesthesia after total replacement of the lower limb large joints can be described as “a long way to go”.
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21
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Efficacy and Durability of Opioid Restrictive State Legislation Two Years After Implementation for Total Knee Arthroplasty. J Arthroplasty 2022; 37:1771-1775. [PMID: 35429615 DOI: 10.1016/j.arth.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To curtail the U.S. opioid crisis, many states have instituted regulations that mandate time and/or dosage limits for opioid prescriptions. This study evaluates the impact of one such law, Florida House Bill 21, on postoperative opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA) and the durability of the law's impact over time. METHODS All patients who underwent TKA at a single institution during the same three-month period in 2017 (pre-law), 2018 (post-law), and 2020 (2 years post-law) were identified. Outcomes and measures included: prescribed morphine milligram equivalents (MME) at discharge and for the 90-day surgical episode, refill quantity with associated MME, and quantity of opioid prescribers. Patients with established chronic pain or those who underwent contralateral TKA during the 90-day window were excluded. Data was compared using a one-way analysis of variance. Significance was set at alpha <0.05. RESULTS The average MME of filled opioid prescriptions per patient during the 90-day post-surgical episode decreased from 1310 MME in 2017 to 891 MME in 2018 (P < .001). The average MME in 2020 was 814 MME, which was significantly lower than the average in 2017 (P < .001), and statistically stable compared to the average in 2018 (P = .215). CONCLUSION Restrictive opioid state policy implementation was associated with reduced overall MME prescription to patients undergoing TKA at discharge and for the 90-day surgical episode. There was no increase in the number of opioid refills or opioid prescribers. Durable change and continued improvement were observed 2 years after implementation of law.
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22
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Vij N, Newgaard O, Norton M, Tolson H, Kaye AD, Viswanath O, Urits I. Liposomal Bupivacaine Decreases Post-Operative Opioid Use after Anterior Cruciate Ligament Reconstruction: A Review of Level I Evidence. Orthop Rev (Pavia) 2022; 14:37159. [DOI: 10.52965/001c.37159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/21/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Anterior Cruciate Ligament tears are common after a non-contact injury and several thousand reconstructions (ACLR) occur yearly in the United States. Multimodal pain management has evolved greatly to include nerve blocks to minimize physical therapy losses post-operatively, pericapsular and wound injections, and other adjunctive measures. However, there is a surprisingly high use of opioid use after ACLR. Objective The purpose of present investigation is to summarize the current state of knowledge regarding opioid use after ACLR and to synthesize the literature regarding the use of liposomal bupivacaine and its potential to reduce post-operative opioid use in ACLR patients. Methods The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. A full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by three authors until an agreement was reached. Results Eighteen articles summarized the literature around the opioid epidemic in ACL surgery and the current context of multimodal pain strategies in ACLR. Five primary articles directly studied the use of liposomal bupivacaine as compared to reasonable control options. There remains to be over prescription of opioids within orthopedic surgery. Patient and prescriber education are effective methods at decreasing opioid prescriptions. Many opioid pills prescribed for ACLR are not used for the correct purpose. Several risk factors have been identified for opioid overuse in ACLR: American Society of Anesthesiologists score, concurrent meniscal/cartilage injury, preoperative opioid use, age < 50, COPD, and substance abuse disorder. Liposomal bupivacaine is effective in decreasing post-operative opioid use and reducing post-operative pain scores as compared to traditional bupivacaine. LB may also be effective as a nerve block, though the data on this is more limited and the effects on post-operative therapy need to be weighed against the potential therapeutic benefit. LB is associated with significantly greater costs than traditional bupivacaine. Discussion The role for opioid medications in ACLR should continue to decrease over time. Liposomal bupivacaine is a powerful tool that can reduce post-operative opioid consumption in ACLR.
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Affiliation(s)
- Neeraj Vij
- University of Arizona College of Medicine - Phoenix
| | | | - Matt Norton
- Louisiana State University Health Shreveport School of Medicine
| | | | - Alan D. Kaye
- Louisiana State University Health Sciences Center
| | - Omar Viswanath
- Louisiana State University Health Shreveport; Creighton University School of Medicine; Innovative Pain and Wellness
| | - Ivan Urits
- Louisiana State University Health Shreveport
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23
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Vij N, Supra R, Vanvalkenburg D, Comardelle N, Kaye AD, Viswanath O, Urits I. The role for high volume local infiltration analgesia with liposomal bupivacaine in total hip arthroplasty: A scoping review. Orthop Rev (Pavia) 2022; 14:37101. [DOI: 10.52965/001c.37101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/21/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Liposomal bupivacaine has been integrated into clinical practice within many surgical disciplines to reduce post-operative pain and opioid consumption. This novel agent has been utilized in this regard in many subdisciplines of orthopedic surgery. Total hip arthroplasty has significant opioid use post-operatively as compared to many other orthopedic disciplines. Objectives The purpose of the present investigation is to summarize the current use of liposomal bupivacaine after total hip arthroplasty and to shed light on the prospect of liposomal bupivacaine to reduce opioid use after total hip arthroplasty. A tertiary purpose is to identify future areas of adjunctive pain measures that can assist in the reduction of opioid use after total hip arthroplasty. Methods This IRB-exempt scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist strictly. The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by three authors until an agreement was reached. Results A total of 21 articles were included for qualitative description of the opioid epidemic, opioid overuse in total hip arthroplasty, and risk factors for opioid overuse in total hip arthroplasty. A total of 9 articles were included regarding the use of liposomal bupivacaine in total hip arthroplasty. Several risk factors have been identified for opioid overuse after total hip arthroplasty. These include younger age, an opioid risk tool score of > 7, a higher body mass index, chronic obstructive pulmonary disease, immunodeficiency syndromes, preexisting pain syndromes, peripheral vascular disease, anxiety and mood disorders, and substance abuse disorders. Liposomal bupivacaine reduces postoperative opioid use, patient-reported outcomes, length of stay, and time to ambulation, yet is more expensive than traditional bupivacaine. Conclusions Liposomal bupivacaine represents a useful adjunct for multimodal pain strategies in total hip arthroplasty with sufficient evidence to suggest that it may be useful in decreasing postoperative opioid use. The high costs of LB represent a barrier to institutional acceptance of LB into standardized multimodal pain strategies. Further efforts should be aimed toward better understanding the current state of integration of LB into academic and private practice settings, industry movements to decrease the cost, and the role other adjunctive measures may have in reducing post-operative opioid use.
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Affiliation(s)
- Neeraj Vij
- University of Arizona College of Medicine - Phoenix
| | | | | | | | - Alan D. Kaye
- Louisiana State University Health Sciences Center
| | | | - Ivan Urits
- Louisiana State University Health Shreveport
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Alexander McIntyre J, Pagani N, Van Schuyver P, Puzzitiello R, Moverman M, Menendez M, Kavolus J. Public Perceptions of Opioid Use Following Orthopedic Surgery: A Survey. HSS J 2022; 18:328-337. [PMID: 35846268 PMCID: PMC9247590 DOI: 10.1177/15563316221097698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023]
Abstract
Background: The United States accounts for the majority of prescription opioids consumed worldwide. Recent literature has focused on opioid prescribing patterns among orthopedic surgeons; however, public and patient expectations about postoperative opioid use remain understudied. Purpose: We sought to explore public perceptions of opioid use after elective orthopedic surgery. Methods: We posted a 32-question survey on Amazon Mechanical Turk (MTurk), an online platform with over 500,000 unique registered users that is a validated tool for collecting survey responses in medical research. The survey asked about attitudes regarding opioid use after elective orthopedic surgery and sociodemographic factors, as well as validated assessments of health literacy and patient engagement. Results: Of 727 respondents who completed surveys, nearly half (46%) said they would prefer nonopioid pain medication after elective orthopedic surgery, although 86% said they would expect to be prescribed opioids for 1 week to 1 month postoperatively. About half said they would expect to be prescribed extra opioid medication in case of unexpected pain following surgery, and 50% reported that they would save their pills to treat future pain. Approximately 63% said they would understand their surgeon's opioid weaning, but over ⅓ said weaning would lead to decreased satisfaction with their surgeon. Roughly ⅔ reported that pain control after surgery would directly affect their opinion of the surgeon. Conclusions: Our survey found that some members of the general public reported expectations regarding postoperative opioid prescribing that could lead to decreased patient satisfaction. These findings suggest the need for further research on the value of preoperative patient education in pain management, on patient expectations of pain control after elective surgery, and on the use of opioids following orthopedic surgery.
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Affiliation(s)
- James Alexander McIntyre
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA,James Alexander McIntyre, MD, Department of
Orthopedic Surgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111,
USA.
| | - Nicholas Pagani
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA
| | | | | | - Michael Moverman
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA
| | - Mariano Menendez
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA
| | - Joseph Kavolus
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA
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Sutherland AM, Clarke HA. The role of anesthesiologists in reducing opioid harm. Can J Anaesth 2022; 69:917-922. [DOI: 10.1007/s12630-022-02274-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 01/04/2023] Open
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Frenkel Rutenberg T, Izchak H, Rosenthal Y, Barak U, Shemesh S, Heller S. Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty. J Knee Surg 2022; 35:933-939. [PMID: 33167053 DOI: 10.1055/s-0040-1721034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively, P = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%, p = 0.013) and POD 4 (81% vs 66%, p = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.
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Affiliation(s)
- Tal Frenkel Rutenberg
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Izchak
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Rosenthal
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Barak
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Shemesh
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Snir Heller
- Orthopedic Department, Rabin Medical Center, HaSharon Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Duprey MS, Devlin JW, Griffith JL, Travison TG, Briesacher BA, Jones R, Saczynski JS, Schmitt EM, Gou Y, Marcantonio ER, Inouye SK. Association Between Perioperative Medication Use and Postoperative Delirium and Cognition in Older Adults Undergoing Elective Noncardiac Surgery. Anesth Analg 2022; 134:1154-1163. [PMID: 35202006 PMCID: PMC9124692 DOI: 10.1213/ane.0000000000005959] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative delirium is frequent in older adults and is associated with postoperative neurocognitive disorder (PND). Studies evaluating perioperative medication use and delirium have generally evaluated medications in aggregate and been poorly controlled; the association between perioperative medication use and PND remains unclear. We sought to evaluate the association between medication use and postoperative delirium and PND in older adults undergoing major elective surgery. METHODS This is a secondary analysis of a prospective cohort study of adults ≥70 years without dementia undergoing major elective surgery. Patients were interviewed preoperatively to determine home medication use. Postoperatively, daily hospital use of 7 different medication classes listed in guidelines as risk factors for delirium was collected; administration before delirium was verified. While hospitalized, patients were assessed daily for delirium using the Confusion Assessment Method and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. The association between prehospital medication use and postoperative delirium was assessed using a generalized linear model with a log link function, controlling for age, sex, type of surgery, Charlson comorbidity index, and baseline cognition. The association between daily postoperative medication use (when class exposure ≥5%) and time to delirium was assessed using time-varying Cox models adjusted for age, sex, surgery type, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation (APACHE)-II score, and baseline cognition. Mediation analysis was utilized to evaluate the association between medication use, delirium, and cognitive change from baseline to 1 month. RESULTS Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. The multivariable analyses revealed no significant association between prehospital benzodiazepine (relative risk [RR], 1.44; 95% confidence interval [CI], 0.85-2.44), beta-blocker (RR, 1.38; 95% CI, 0.94-2.05), NSAID (RR, 1.12; 95% CI, 0.77-1.62), opioid (RR, 1.22; 95% CI, 0.82-1.82), or statin (RR, 1.34; 95% CI, 0.92-1.95) exposure and delirium. Postoperative hospital benzodiazepine use (adjusted hazard ratio [aHR], 3.23; 95% CI, 2.10-4.99) was associated with greater delirium. Neither postoperative hospital antipsychotic (aHR, 1.48; 95% CI, 0.74-2.94) nor opioid (aHR, 0.82; 95% CI, 0.62-1.11) use before delirium was associated with delirium. Antipsychotic use (either presurgery or postsurgery) was associated with a 0.34 point (standard error, 0.16) decrease in general cognitive performance at 1 month through its effect on delirium (P = .03), despite no total effect being observed. CONCLUSIONS Administration of benzodiazepines to older adults hospitalized after major surgery is associated with increased postoperative delirium. Association between inhospital, postoperative medication use and cognition at 1 month, independent of delirium, was not detected.
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Affiliation(s)
| | - John W. Devlin
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - John L. Griffith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Thomas G. Travison
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Becky A. Briesacher
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Richard Jones
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Departments of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Eva M. Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sharon K. Inouye
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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O'Brien PE, Mears SC, Siegel ER, Barnes CL, Stambough JB. Does In-Hospital Opioid Use Affect Opioid Consumption After Total Joint Arthroplasty? J Arthroplasty 2022; 37:824-830. [PMID: 35114319 DOI: 10.1016/j.arth.2022.01.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Preoperative opioid use strongly correlates with greater postoperative opioid use and complications following total joint arthroplasty (TJA). However, there is a lack of information regarding the effect of opioid consumption during the hospital stay and within the operating room on postoperative opioid use. METHODS We retrospectively reviewed 369 consecutive patients undergoing primary TJA at an academic center over a 9-month period. Ninety-day preoperative and postoperative opioid prescriptions were obtained from the state's drug monitoring database. In-hospital opioid consumption data was obtained from the preoperative unit, operating room, postanesthesia care unit (PACU), and hospital floor. Multivariate analysis was utilized to compare patients' total in-hospital opioid consumption with their preoperative and postoperative use, along with opioid use throughout the hospitalization. RESULTS Total in-hospital opioid consumption was independently associated with postoperative opioid use (rs = 0.17, P = .0010). Opioids consumed on the hospital floor correlated with opioid use in the preoperative unit (rs = 0.11, P = .0338) and PACU (rs = 0.15, P = .0032). Increased preoperative opioid consumption was the greatest risk factor for excessive postoperative use (rs = 0.44, P < .0001). A greater proportion of patients <65 years of age were high posthospital opioid consumers (P = .0146) and significantly more TKA patients were in the higher use groups (P = .0006). CONCLUSION In-hospital opioid use is independently associated with preoperative and postoperative consumption. Preoperative opioid use remains the greatest risk factor for increased opioid consumption after TJA. Multimodal approaches to decrease reliance on opioids for pain control during hospitalization may offer hope to further decrease postoperative usage. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Patrick E O'Brien
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
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Reisener MJ, Hughes AP, Okano I, Zhu J, Arzani A, Kostas J, Shue J, Sama AA, Cammisa FP, Girardi FP, Soffin EM. Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients. J Neurosurg Spine 2022; 36:713-721. [PMID: 34861648 DOI: 10.3171/2021.8.spine21599] [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: 04/25/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses. RESULTS In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.
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Affiliation(s)
- Marie-Jacqueline Reisener
- 1Department of Orthopaedic Surgery, Spine Care Institute
- 4Centrum für Muskuloskeletale Chirurgie (CMSC), Charité University Hospital, Berlin, Germany
| | | | - Ichiro Okano
- 1Department of Orthopaedic Surgery, Spine Care Institute
| | - Jiaqi Zhu
- 2Epidemiology & Biostatistics Department, and
| | - Artine Arzani
- 1Department of Orthopaedic Surgery, Spine Care Institute
| | | | - Jennifer Shue
- 1Department of Orthopaedic Surgery, Spine Care Institute
| | - Andrew A Sama
- 1Department of Orthopaedic Surgery, Spine Care Institute
| | | | | | - Ellen M Soffin
- 3Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York; and
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Translation of legislation: Effect Analysis of Michigan Opioid Law on Clinical Practice. Ann Thorac Surg 2022; 114:2016-2022. [DOI: 10.1016/j.athoracsur.2022.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/11/2022] [Accepted: 03/22/2022] [Indexed: 11/23/2022]
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Mou Z, Chau H, Kalavacherla S, Radgoudarzi N, Soliman SI, Zhao B, Mekeel K. Tailored order set in the electronic health record decreases postoperative opioid prescriptions. Surgery 2022; 172:677-682. [DOI: 10.1016/j.surg.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/22/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
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Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review. BMC Musculoskelet Disord 2022; 23:238. [PMID: 35277150 PMCID: PMC8917706 DOI: 10.1186/s12891-022-05044-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 01/18/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.
Methods
This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.
Results
A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.
Conclusions
This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.
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Discharge Opioid Prescribing Patterns in an Academic Orthopaedic Setting: Level of Training and Subspecialty Patterns. J Am Acad Orthop Surg 2022; 30:e361-e370. [PMID: 34844260 DOI: 10.5435/jaaos-d-21-00895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/22/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Despite increased research on opioids in the orthopaedic literature, little is known of the prescribing practices of orthopaedic providers based on their level of training. The purpose of this study was to describe the discharge opioid prescribing patterns of orthopaedic providers, stratifying by level of training and orthopaedic subspecialty, within a single medical system. METHODS A retrospective review of orthopaedic surgical encounters was performed over a 1-year period for adults who received a discharge opioid prescription. Patient demographics and prescriber characteristics were collected, including the provider's level of training (attending, fellow, resident, physician assistant [PA], and nurse practitioner [NP]) and surgical subspecialty. Junior residents were postgraduate year 1 to 3, whereas senior residents/fellows were postgraduate year 4 to 6. Discharge opioids were converted to milligram morphine equivalents (MMEs). Overprescribing was defined as a prescribing more than a seven-day supply or >45 MMEs per day. Multivariable linear regression analysis determined the factors associated with discharge MMEs, whereas logistic regression determined the factors associated with overprescribing opioids. RESULTS Of the 3,786 patients reviewed, 1,500 met the criteria for inclusion in the study. The greatest proportion of opioid prescriptions was written by junior residents (33.9%), followed by NPs (30.1%), PAs (24.1%), senior residents/fellows (10.6%), and attendings (1.2%). Compared with junior residents, senior residents prescribed -59.4 MMEs, NPs prescribed +104 MMEs, and attendings prescribed +168 MMEs (P < 0.05), whereas PAs prescribed similar amounts (P > 0.05). Orthopaedic subspecialty was also predictive of discharge MMEs (P < 0.05). Senior residents and attendings were more likely to prescribe more than seven days of opioids (P < 0.05), whereas NPs and PAs were more likely to prescribe >45 MMEs per day (P < 0.05). DISCUSSION This study demonstrates significant variability in opioid prescribing practices according to provider level of training and subspecialty. National guidelines for opioid prescribing practices and educational programs may help reduce such variability. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Xu AL, Dunham AM, Enumah ZO, Humbyrd CJ. Patient understanding regarding opioid use in an orthopaedic trauma surgery population: a survey study. J Orthop Surg Res 2021; 16:736. [PMID: 34952626 PMCID: PMC8709537 DOI: 10.1186/s13018-021-02881-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prior studies have assessed provider knowledge and factors associated with opioid misuse; similar studies evaluating patient knowledge are lacking. The purpose of this study was to assess the degree of understanding regarding opioid use in orthopaedic trauma patients. We also sought to determine the demographic factors and clinical and personal experiences associated with level of understanding. METHODS One hundred and sixty-six adult orthopaedic trauma surgery patients across two clinical sites of an academic institution participated in an internet-based survey (2352 invited, 7.1% response rate). Demographic, clinical, and personal experience variables, as well as perceptions surrounding opioid use were collected. Relationships between patient characteristics and opioid perceptions were identified using univariate and multivariable logistic regressions. Alpha = 0.05. RESULTS Excellent recognition (> 85% correct) of common opioids, side effects, withdrawal symptoms, and disposal methods was demonstrated by 29%, 10%, 30%, and 2.4% of patients; poor recognition (< 55%) by 11%, 56%, 33%, and 52% of patients, respectively. Compared with white patients, non-white patients had 7.8 times greater odds (95% confidence interval [CI] 1.9-31) of perceiving addiction discrepancy (p = 0.004). Employed patients with higher education levels were less likely to have excellent understanding of side effects (adjusted odds ratio [aOR] 0.06, 95% CI 0.006-0.56; p = 0.01) and to understand that dependence can occur within 2 weeks (aOR 0.28, 95% CI 0.09-0.86; p = 0.03) than unemployed patients. Patients in the second least disadvantaged ADI quartile were more knowledgeable about side effects (aOR 8.8, 95% CI 1.7-46) and withdrawal symptoms (aOR 2.7, 95% CI 1.0-7.2; p = 0.046) than those in the least disadvantaged quartile. Patients who knew someone who was dependent or overdosed on opioids were less likely to perceive addiction discrepancy (aOR 0.24, 95% CI 0.07-0.76; p = 0.02) as well as more likely to have excellent knowledge of withdrawal symptoms (aOR 2.6, 95% CI 1.1-6.5, p = 0.03) and to understand that dependence can develop within 2 weeks (aOR 3.8, 95% CI 1.5-9.8, p = 0.005). CONCLUSIONS Level of understanding regarding opioid use is low among orthopaedic trauma surgery patients. Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history.
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Affiliation(s)
- Amy L Xu
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alexandra M Dunham
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Zachary O Enumah
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Casey J Humbyrd
- Department of Orthopaedic Surgery, The University of Pennsylvania, 230 West Washington Square, 5th Floor Farm Journal Building,, Philadelphia, PA, 19106, USA.
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Guo EW, Yedulla NR, Cross AG, Hessburg LT, Elhage KG, Koolmees DS, Makhni EC. Older, Male Orthopaedic Surgeons From Southern Geographies Prescribe Higher Doses of Post-Operative Narcotics Than do their Counterparts: A Medicare Population Study. Arthrosc Sports Med Rehabil 2021; 3:e1577-e1583. [PMID: 34977609 PMCID: PMC8689220 DOI: 10.1016/j.asmr.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 06/29/2021] [Indexed: 11/01/2022] Open
Abstract
Purpose Methods Results Conclusion Level of Evidence
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Mallow PJ, Belk KW. Cost-utility analysis of single nucleotide polymorphism panel-based machine learning algorithm to predict risk of opioid use disorder. J Comp Eff Res 2021; 10:1349-1361. [PMID: 34672212 DOI: 10.2217/cer-2021-0115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To conduct a cost-utility analysis of a novel genetic diagnostic test (OUDTEST) for risk of developing opioid use disorder for elective orthopedic surgery patients. Materials & Methods: A simulation model assessed cost-effectiveness and quality-adjusted life-years (QALYs) for OUDTEST from private insurer and self-insured employer perspectives over a 5-year time horizon for a hypothetical patient population. Results: OUDTEST was found to cost less and increase QALYs, over a 5-year period for private insurance (savings US$2510; QALYs 0.02) and self-insured employers (-US$2682; QALYs 0.02). OUDTEST was a dominant strategy in 71.1% (private insurance) and 72.7% (self-insured employer) of model iterations. Sensitivity analyses revealed robust results except for physician compliance. Conclusion: OUDTEST was expected to be a cost-effective solution for personalizing postsurgical pain management in orthopedic patients.
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Affiliation(s)
- Peter J Mallow
- Department of Health Services Administration, Xavier University, 3800 Victory Parkway, Cincinnati, OH 45207, USA
| | - Kathy W Belk
- Health Clarity Solutions, LLC, Mooresville, NC 28115, USA
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Mariano ER, Dickerson DM, Szokol JW, Harned M, Mueller JT, Philip BK, Baratta JL, Gulur P, Robles J, Schroeder KM, Wyatt KEK, Schwalb JM, Schwenk ES, Wardhan R, Kim TS, Higdon KK, Krishnan DG, Shilling AM, Schwartz G, Wiechmann L, Doan LV, Elkassabany NM, Yang SC, Muse IO, Eloy JD, Mehta V, Shah S, Johnson RL, Englesbe MJ, Kallen A, Mukkamala SB, Walton A, Buvanendran A. A multisociety organizational consensus process to define guiding principles for acute perioperative pain management. Reg Anesth Pain Med 2021; 47:118-127. [PMID: 34552003 DOI: 10.1136/rapm-2021-103083] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/09/2021] [Indexed: 12/22/2022]
Abstract
The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.
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Affiliation(s)
- Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA .,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA.,Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Beverly K Philip
- American Society of Anesthesiologists, Schaumburg, Illinois, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Robles
- Department of Urology, Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Kristopher M Schroeder
- Department of Anesthesiology, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richa Wardhan
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Todd S Kim
- Department of Orthopedic Surgery, Palo Alto Medical Foundation, Burlingame, California, USA
| | - Kent K Higdon
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.,Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Gary Schwartz
- AABP Integrative Pain Care, Brooklyn, New York, USA.,Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Stephen C Yang
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Vikas Mehta
- Department of Otolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California Irvine School of Medicine, Orange, California, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amanda Kallen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
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Bolia IK, Haratian A, Bell JA, Hasan LK, Saboori N, Palmer R, Petrigliano FA, Weber AE. Managing Perioperative Pain After Anterior Cruciate Ligament (ACL) Reconstruction: Perspectives from a Sports Medicine Surgeon. Open Access J Sports Med 2021; 12:129-138. [PMID: 34512045 PMCID: PMC8426642 DOI: 10.2147/oajsm.s266227] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022] Open
Abstract
Anterior cruciate ligament reconstructions (ACLR) are a relatively common procedure in orthopedic sports medicine with an estimated 130,000 arthroscopic operations performed annually. Most procedures are carried out on an outpatient basis, and though success rates of ACLR are as high as 95%, pain remains the most common postoperative complication delaying patient discharge, and thereby increasing the costs associated with patient care. Despite the success and relative frequency of ACLR surgery, optimal and widely accepted strategies and regimens for controlling perioperative pain are not well established. In recent years, the paradigm of pain control has shifted from exclusively utilizing opiates and opioid medications in the acute postoperative period to employing other agents and techniques including nerve blocks, intra-articular and periarticular injections of local anesthetic agents, NSAIDs, and less commonly, ketamine, tranexamic acid (TXA), sedatives, gabapentin, and corticosteroids. More often, these agents are now used in combination and in synergy with one another as part of a multimodal approach to pain management in ACLR, with the goal of reducing postoperative pain, opioid consumption, and the incidence of delayed hospital discharge. The purpose of this review is to consolidate current literature on various agents involved in the management of postoperative pain following ACLR, including the role of classically used opiate and opioid medications, as well as to describe other drugs currently utilized in practice either individually or in conjunction with other agents as part of a multimodal regimen in pain management in ACLR.
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Affiliation(s)
- Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Jennifer A Bell
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Nima Saboori
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ryan Palmer
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Chrencik MT, Ventimiglia DJ, Schneider MB, Zhang T, Fisher KJ, Hahn A, Gilotra MN, Hasan SA, Henn RF. Preoperative characteristics predictive of PROMIS Pain Interference two years after shoulder surgery. J Orthop 2021; 27:49-55. [PMID: 34483550 DOI: 10.1016/j.jor.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/28/2021] [Accepted: 08/15/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction The objective of this study was to identify preoperative characteristics associated with worse Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) two years after shoulder surgery. Methods This was a retrospective analysis of prospectively collected data on 293 patients who underwent elective shoulder surgery. Survey questionnaires were collected within one week of surgery and then two years postoperatively. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables. Results Worse two-year PROMIS PI was significantly correlated with older age, higher BMI, greater comorbidities, more prior surgeries, and multiple socio-demographic factors. Less improvement in PROMIS PI was significantly correlated with greater comorbidities, more previous surgeries, unemployment, prior orthopaedic surgery on the operative joint, and a higher American Society of Anesthesiologists (ASA) score. Better scores on all preoperative patient-reported outcome measures correlated with better two-year PROMIS PI. Multivariable analysis demonstrated that worse two-year PROMIS PI was independently predicted by the following preoperative factors: Workers' Compensation claim, opioid use, worse whole body Numeric Pain Score, and worse PROMIS PI. Less improvement in two-year PROMIS PI was predicted by the same preoperative factors. Conclusion Worse PROMIS PI after shoulder surgery was associated with older age, greater comorbidities, mental health impairment, and lower socioeconomic status. Preoperative predictors of worse pain interference two years after shoulder surgery included Workers' Compensation, opioid use, worse whole body pain, and worse PROMIS PI. Level of evidence III.
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Affiliation(s)
- Matthew T Chrencik
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dominic J Ventimiglia
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matheus B Schneider
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tina Zhang
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kalin J Fisher
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alexander Hahn
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mohit N Gilotra
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S Ashfaq Hasan
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - R Frank Henn
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Pannu TS, Villa JM, Fleites J, Patel PD, Higuera CA, Riesgo AM. Florida State Opioid Prescription Restriction Law: Impact on Opioid Utilization After Total Joint Arthroplasty. J Arthroplasty 2021; 36:2742-2745. [PMID: 33888387 DOI: 10.1016/j.arth.2021.03.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/22/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In response to the opioid epidemic, Florida recently passed the opioid prescription limiting law, effective since July 1st, 2018. However, its impact on opioid prescription after total joint arthroplasty (TJA) has not been elucidated. Thus, our objective was to assess if this new law led to reduced opioid prescription after TJA and to determine its impact on perioperative clinical outcomes. METHODS A retrospective chart review was conducted on a consecutive series of 658 primary TJAs (618 patients), performed by four surgeons in a single institution [1/2/2018-10/23/2018]. Based on effective date of the law, cases were divided into: prelaw (327 cases; 168 hips/159 knees) and postlaw (331 cases; 191 hips/140 knees) phases. Baseline demographics and surgical characteristics were compared. The effect of the law on perioperative outcomes: length of stay, complications, emergency department/office visits, patient phone calls, reoperation or readmission (90 days), and total morphine equivalents prescribed was investigated. Independent sample t-tests and chi-square analyses were performed. RESULTS Prelaw and postlaw phases had no significant difference in baseline demographics and characteristics. No difference was found in length of stay. Opioid law implementation led to significantly lower total oral morphine equivalents after TJAs [Prelaw: 1059.9 ± 825.4 vs postlaw: 942.8 ± 691.7; P = .04], but did not result in a significant increase in 90-day complications, patient visits (office or emergency) or phone calls, and reoperation or readmission. CONCLUSION Our data suggest that Florida state opioid prescription limiting law has resulted in a marked decline in opioid prescription without any increase in rates of patient visits, phone calls, or readmission after TJA.
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Affiliation(s)
- Tejbir S Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Jorge Fleites
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Preetesh D Patel
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Aldo M Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
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Rim F, Donofrio J, Peterson C, Liu S. Impact of Structured Patient-Centered Preoperative Pain Consult and Interventions From a Dedicated Perioperative Pain Service: A Case Series of 4 Patients. A A Pract 2021; 14:e01279. [PMID: 32909722 DOI: 10.1213/xaa.0000000000001279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Opioid-tolerant individuals have greater risk of perioperative complications and worse clinical outcomes. A preoperative screening process and structured approach to opioid-tolerant patients was developed to identify and optimize these patients before elective surgery.
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Affiliation(s)
- Faye Rim
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York.,Department of Rehabilitation Medicine, Weill Cornell Medical College, New York, New York
| | - Justin Donofrio
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Christine Peterson
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Spencer Liu
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York
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Patzkowski MS, Scott MSC, Patzkowski JC, Highland KB. Femoral Nerve Blockade Does Not Lead to Subjective Functional Deficits After Anterior Cruciate Ligament Reconstruction. Mil Med 2021; 187:e644-e648. [PMID: 34244804 DOI: 10.1093/milmed/usab269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/14/2021] [Accepted: 06/25/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Anterior cruciate ligament reconstruction (ACLR) ranks among the most common surgeries performed in civilian as well as military orthopedic settings. Regional anesthesia, and the femoral nerve block (FNB) in particular, has demonstrated efficacy in reducing postoperative pain and opioid use after ACLR, however concerns linger about possible impaired functional outcomes. The purpose of the current investigation was to assess International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores at 6 to 12 months after ACLR in patients who did (FNB) and did not (NoFNB) receive a perioperative FNB. MATERIALS AND METHODS All patients undergoing unilateral ACLR in the study period were reviewed in this institutional process improvement analysis. The primary outcome was prospectively collected IKDC-SKF scores obtained at 6-12 months post-surgery. Demographic and surgical information collected as potential covariates included age, sex, body mass index (BMI), preoperative IKDC-SKF score, use of an FNB, use of another (not femoral nerve) block, American Society of Anesthesiologists (ASA) score, graft type (auto vs. allograft), concomitant meniscus or cartilage procedures, tobacco use, tourniquet time, and primary vs. revision surgery. Assuming a 1:2 ratio of patients who did not vs. did receive FNBs and a clinically meaningful difference of 7 points on the IKDC-SKF, 112 patients were required for 80% power. A regression model averaging approach examined the relationships between covariates and postoperative IKDC-SKF scores. RESULTS One hundred nineteen patients met inclusion criteria (FNB 79 and NoFNB 40). The cohorts were significantly different in several factors including BMI, ASA level, graft type, and other peripheral nerve blocks, which were controlled for through regression modeling. Regressions with model averaging examined the relationship between treatment groups and postoperative IKDC-SKF scores, along with other potential predictor variables. Estimated adjusted marginal differences in postoperative IKDC-SKF scores from the best-fitting model revealed a very small 0.66-point mean (P = .86) difference between NoFNB and FNB groups that was not statistically significant. Those who reported tobacco use had a 10.51 point (P = .008) lower mean postoperative IKDC-SKF score than those who did not report tobacco use. Every 1-point increase in the preoperative IKDC-SKF score was associated with a 0.28-point (P = .02) increase in the postsurgical IKDC-SKF score. CONCLUSIONS Active tobacco use may negatively impact short-term subjective patient-reported outcomes after ACLR, as reported by the IKDC-SKF. Lower preoperative scores are also associated with significantly lower postoperative IKDC-SKF scores while the use of a FNB was not associated with lower postoperative scores. The negative association between tobacco use and patient-reported functional outcomes after ACLR lends further support to tobacco cessation programs within the military.
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Affiliation(s)
- Michael S Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Maj Summer C Scott
- Department of Anesthesia, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Jeanne C Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation Inc, Rockville, MD 20852, USA
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Lovecchio F, Steinhaus M, Elysee JC, Huang A, Ang B, Lafage R, Yang J, Soffin E, Craig C, Lafage V, Schwab F, Kim HJ. Factors Associated With Short Length of Stay After Long Fusions for Adult Spinal Deformity: Initial Steps Toward Developing an Enhanced Recovery Pathway. Global Spine J 2021; 11:866-873. [PMID: 32787569 PMCID: PMC8258808 DOI: 10.1177/2192568220941448] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The identification of case types and institutional factors associated with reduced length of stay (LOS) is a key initial step to inform the creation of clinical care pathways that can assist hospitals to maximize the benefit of value-based payment models. The objective of this study was to identify preoperative, intraoperative, and postoperative factors associated with shorter than expected LOS after adult spinal deformity (ASD) surgery. METHODS A retrospective cohort study was performed of 82 patients with ASD who underwent ≥5 levels of fusion to the pelvis between 2013 and 2018. A LOS <6 days was determined as a basis for comparison, as 5.7 days was the "expected LOS" generated through Poisson regression modeling of the sample. Clinical, radiographic, surgical, and postoperative factors were compared between those staying ≥6 days (L group) and <6 days (S group). Logistic regression was used to identify factors associated with LOS <6 days. RESULTS A total of 35 patients were in group S (42.7%). Gender, age, body mass index, ASA (American Society of Anesthesiologists) class, and use of preoperative narcotics, revision surgery, day of admission, and surgical complications did not vary between the cohorts (P > .05). Mild-moderate preoperative sagittal deformity (sagittal Schwab modifiers 0 or +), lower estimated blood loss (<1200 mL), fewer levels fused (7 vs 10 levels), shorter operating room time, procedure end time before 15:00, and no intensive care unit stay, were associated with short LOS (P < .05). Only 1 major medical complication occurred in the short LOS group (P < .05). CONCLUSIONS This study identifies the ASD "case phenotype," intra-, and postoperative benchmarks associated with shorter LOS, providing targets for pathways designed to reduce LOS.
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Affiliation(s)
| | | | | | - Alex Huang
- Hospital for Special Surgery, New York, NY, USA
| | - Bryan Ang
- Hospital for Special Surgery, New York, NY, USA
| | | | | | | | - Chad Craig
- Hospital for Special Surgery, New York, NY, USA
| | | | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA,Han Jo Kim, MD, Hospital for Special Surgery, 541 East 71st Street, New York, NY 10021, USA.
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Adalbert JR, Ilyas AM. Implementing Prescribing Guidelines for Upper Extremity Orthopedic Procedures: A Prospective Analysis of Postoperative Opioid Consumption and Satisfaction. Hand (N Y) 2021; 16:491-497. [PMID: 31441326 PMCID: PMC8283100 DOI: 10.1177/1558944719867122] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: A lack of established opioid-prescribing guidelines has prompted recent studies to propose preliminary guidelines to mitigate inadvertent overprescribing, diversion, and abuse. The purpose of our study was to assess the efficacy of a specific set of opioid-prescribing guidelines by prospective evaluation of patient consumption and satisfaction. Methods: During a consecutive period, all patients undergoing outpatient upper extremity surgical procedures were postoperatively prescribed opioids based on published guidelines that were specific to the anatomical location and procedure being performed. At the first postoperative visit, surgical details, opioid consumption patterns, and prescription efficacy and satisfaction were recorded. Results: A total of 201 patients reported any amount of prescription use, resulting in a mean consumption of 5.5 pills. Patients who underwent soft tissue procedures reported the lowest requirement (4.2 pills) compared with those who underwent fracture repairs (6.7 pills) or arthroscopy and arthroplasty/fusion procedures (8.7 pills). Patients undergoing hand procedures consumed fewer opioids (3.9 pills) compared with those undergoing wrist (6.3 pills) or elbow (8.1 pills) procedures. Of the patients requiring opioids, 82% reported being satisfied or at least neutral to the prescribed quantity (P < .001), and 92% reported being satisfied or at least neutral to the prescribed opioid analgesic efficacy (P < .001). Overall, the study refill request rate was 13%. Conclusions: Although the proposed guidelines tended to exceed patient need, the study confirmed strong patient satisfaction and an overall refill request rate of only 13%. We conclude that following anatomical and procedure-specific opioid-prescribing guidelines is an effective method of prescribing opioids postoperatively after upper extremity.
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Affiliation(s)
| | - Asif M. Ilyas
- Thomas Jefferson University, Philadelphia, PA, USA,Asif M. Ilyas, Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA.
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Abstract
BACKGROUND Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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46
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Acuña AJ, Jella TK, Samuel LT, Cwalina TB, Kim TS, Kamath AF. A Work in Progress: National Opioid Prescription Reductions Across Orthopaedic Subspecialties in a Contemporary Medicare Sample of 5,026,911 Claims. J Am Acad Orthop Surg Glob Res Rev 2021; 5:01979360-202105000-00015. [PMID: 34014856 PMCID: PMC8140777 DOI: 10.5435/jaaosglobal-d-21-00080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION As the opioid epidemic continues in the United States, efforts by orthopaedic surgeons to reduce opioid prescriptions remain critical. Although previous studies have demonstrated reductions in prescriptions across surgical specialties, there is limited information regarding contemporary trends in opioid prescriptions across orthopaedic subspecialties. Our analysis sought to estimate the frequency and trends of opioid prescriptions among Medicare Part D enrollees. METHODS The Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from Centers of Medicare and Medicare from 2014 to 2018 were analyzed. These data were merged with the National Provider Identifier Registry to identify the subspecialty of providers. Prescriber opioid prescription rate, days per claim, and claims per patient were calculated. Temporal trends were tested using linear regression. Poisson regression was used to calculate annual adjusted incidence rate ratios while controlling for year, surgeon sex, average patient comorbidity risk score, and average patient age. RESULTS We analyzed 5,026,911 opioid claims prescribed to 2,661,762 beneficiaries. Among all orthopaedic surgeons, the opioid prescription rate per 100 beneficiaries significantly decreased over the study period from 52.99 (95% CI, 52.6 to 53.37) to 44.50 (44.06 to 44.93) (P = 0.002). This decrease was observed for each subspecialty (all P values < 0.05). Similar significant reductions were appreciated across cohorts in the number of claims per beneficiary (all P values < 0.05). The opioid prescription rate among all orthopaedic surgeons and each subspecialty decreased significantly over the study period after controlling for various patient and surgeon characteristics (all P values < 0.05). CONCLUSION Orthopaedic surgeons across subspecialties have reduced their rates of opioid prescriptions over recent years. Although increased prescription-limiting legislation, alternative methods of pain control, and prescriber reeducation regarding the correct quantity of opioids needed for postoperative pain relief, ongoing research, and efforts are needed to translate these reductions into clinically meaningful changes.
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Affiliation(s)
- Alexander J. Acuña
- From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH (Acuña, Jella, Dr. Samuel, Cwalina, Dr. Kamath), and the Department of Orthopaedic Surgery, Sutter Health–Burlingame Center, Burlingame, CA (Dr. Kim)
| | - Tarun K. Jella
- From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH (Acuña, Jella, Dr. Samuel, Cwalina, Dr. Kamath), and the Department of Orthopaedic Surgery, Sutter Health–Burlingame Center, Burlingame, CA (Dr. Kim)
| | - Linsen T. Samuel
- From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH (Acuña, Jella, Dr. Samuel, Cwalina, Dr. Kamath), and the Department of Orthopaedic Surgery, Sutter Health–Burlingame Center, Burlingame, CA (Dr. Kim)
| | - Thomas B. Cwalina
- From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH (Acuña, Jella, Dr. Samuel, Cwalina, Dr. Kamath), and the Department of Orthopaedic Surgery, Sutter Health–Burlingame Center, Burlingame, CA (Dr. Kim)
| | - Todd S. Kim
- From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH (Acuña, Jella, Dr. Samuel, Cwalina, Dr. Kamath), and the Department of Orthopaedic Surgery, Sutter Health–Burlingame Center, Burlingame, CA (Dr. Kim)
| | - Atul F. Kamath
- From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH (Acuña, Jella, Dr. Samuel, Cwalina, Dr. Kamath), and the Department of Orthopaedic Surgery, Sutter Health–Burlingame Center, Burlingame, CA (Dr. Kim)
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Reisener MJ, Hughes AP, Okano I, Zhu J, Lu S, Salzmann SN, Shue J, Sama AA, Cammisa FP, Girardi FP, Soffin EM. The association of transversus abdominis plane block with length of stay, pain and opioid consumption after anterior or lateral lumbar fusion: a retrospective study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3738-3745. [PMID: 33934219 DOI: 10.1007/s00586-021-06855-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Anterior (ALIF) and lateral (LLIF) lumbar interbody fusion is associated with significant postoperative pain, opioid consumption and length of stay. Transversus abdominis plane (TAP) blocks improve these outcomes in other surgical subtypes but have not been applied to spine surgery. A retrospective study of 250 patients was performed to describe associations between TAP block and outcomes after ALIF/LLIF. METHODS The electronic medical records of 129 patients who underwent ALIF or LLIF with TAP block were compared to 121 patients who did not. All patients were cared for under a standardized perioperative care pathway with comprehensive multimodal analgesia. Differences in patent demographics, surgical factors, length of stay (LOS), opioid consumption, opioid-related side effects and pain scores were compared in bivariable and multivariable regression analyses. RESULTS In bivariable analyses, TAP block was associated with a significantly shorter LOS, less postoperative nausea/vomiting and lower opioid consumption in the post-anesthesia care unit (PACU). In multivariable analyses, TAP block was associated with significantly shorter LOS (β - 12 h, 95% CI (- 22, - 2 h); p = 0.021). Preoperative opioid use was a strong predictive factor for higher opioid consumption in the PACU, opioid use in the first 24 h after surgery and longer LOS. We did not find significant differences in pain scores at any times between the groups. CONCLUSION TAP block may represent an effective addition to pain management and opioid-reducing strategies and improve outcomes after ALIF/LLIF. Prospective trials are warranted to further explore these associations.
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Affiliation(s)
- Marie-Jacqueline Reisener
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ichiro Okano
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jiaqi Zhu
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Shuting Lu
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Stephan N Salzmann
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew A Sama
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Tucker DW, Homere AJ, Wier JR, Bougioukli S, Carney JJ, Wong M, Inaba K, Marecek GS. Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use. Injury 2021; 52:1234-1238. [PMID: 32948328 DOI: 10.1016/j.injury.2020.09.005] [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: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries. DESIGN Retrospective Cohort Study. SETTING Academic Level-1 Trauma Center. PATIENTS 96 Patients with blunt or ballistic fractures. INTERVENTION Inpatient narcotic pain management after orthopaedic fracture management. MAIN OUTCOME MEASUREMENTS Morphine equivalent units (MEU). RESULTS Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU), 48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption. CONCLUSION Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Douglass W Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Andrew J Homere
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Julien R Wier
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Sofia Bougioukli
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - John J Carney
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Monica Wong
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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Kim HJ, Steinhaus M, Punyala A, Shah S, Elysee JC, Lafage R, Riviera T, Mendez G, Ojadi A, Tuohy S, Qureshi S, Urban M, Craig C, Lafage V, Lovecchio F. Enhanced recovery pathway in adult patients undergoing thoracolumbar deformity surgery. Spine J 2021; 21:753-764. [PMID: 33434650 DOI: 10.1016/j.spinee.2021.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Enhanced recovery (ERAS) pathways can help hospitals maximize the incentives of bundled payment models while maintaining high-quality patient care. A key component of an enhanced recovery pathway is the ability to predictably reduce inpatient length of stay, as this is a critical component of the cost equation. PURPOSE To determine the efficacy of an enhanced recovery pathway on reducing length of stay after thoracolumbar adult deformity surgery. STUDY DESIGN Single surgeon retrospective review of prospectively-collected data. PATIENT SAMPLE Forty adult deformity patients who underwent ≥5 levels of fusion to the pelvis (two to L5) with a single surgeon before and after implementation of an ERAS pathway. METHODS The pathway involved participation by anesthesiology, hospital medicine, and physical therapy, and was designed to achieve goals previously associated with decreased LOS (eg, EBL<1200 mL, procedure time <4.5 hours, avoidance of ICU postoperatively, and mobilization POD0-1). Patients were propensity-score matched 1:1 to a historical cohort (enhanced recovery [ER] and historical [H] cohorts), based on demographics, medical comorbidities, radiographic alignment parameters, and surgical factors. Outcomes were compared to determine the effect of the enhanced recovery pathway. Primary outcomes included LOS and 90-day complications and readmissions. RESULTS After matching, gender, BMI, ASA class, preoperative opioid dependence, day of surgery, sagittal alignment parameters, rate of revision surgery, three-column osteotomies, and interbody fusions were comparable between the cohorts (p>.05). In the ER cohort, there was reduced EBL (920±640 vs. 1437±555, p=.004) and no ER patient went to the ICU immediately following surgery, compared with 30% of H patients (p=.022). The ER cohort also had a greater number of patients ambulating by POD1 compared to the H cohort (100% vs. 55%, p=.010). ER patients had a shorter LOS (4.5±1.3 vs. 7.3±4.4 days, p=.010). A 90-day readmission and complications were comparable between the cohorts (p>.05). CONCLUSIONS The creation of an ERAS pathway for patients undergoing thoracolumbar adult deformity surgery reduced length of stay without negatively affecting short-term morbidity and complications. Given the specificity of this pathway to a single surgeon and hospital, the resources and staffing changes that were instrumental in creating the pathway may not be generalizable to other centers.
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Affiliation(s)
- Han Jo Kim
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA.
| | - Michael Steinhaus
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA
| | - Ananth Punyala
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA
| | - Sachin Shah
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA
| | | | - Renaud Lafage
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA
| | - Tom Riviera
- Hospital for Special Surgery, Department of Nursing, 535 East 70th St., New York, NY 10021, USA
| | - Guillermo Mendez
- Hospital for Special Surgery, Department of Nursing, 535 East 70th St., New York, NY 10021, USA
| | - Ajiri Ojadi
- Hospital for Special Surgery, Department of Nursing, 535 East 70th St., New York, NY 10021, USA
| | - Sharlynn Tuohy
- Hospital for Special Surgery, Department of Physical Therapy, 535 East 70th St., New York, NY 10021, USA
| | - Sheeraz Qureshi
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA
| | - Michael Urban
- Hospital for Special Surgery, Department of Anesthesiology, 535 East 70th St., New York, NY 10021, USA
| | - Chad Craig
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA
| | - Virginie Lafage
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA
| | - Francis Lovecchio
- Hospital for Special Surgery, Spine Service, 535 East 70th St., New York, NY 10021, USA
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50
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Levy N, Quinlan J, El-Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, Cox FJ, de Boer HD, Dowdy SC, Hattingh K, Knaggs RD, Mariano ER, Pelosi P, Scott MJ, Lobo DN, Macintyre PE. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021; 76:520-536. [PMID: 33027841 DOI: 10.1111/anae.15262] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 01/01/2023]
Abstract
This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.
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Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk Hospital, Bury St. Edmunds, UK
| | - J Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - W J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - V Agarwal
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - F J Cox
- Pain Management Service, Critical Care and Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - H D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA
| | - K Hattingh
- Bendigo Health, Bendigo, Victoria, Australia
| | - R D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - P Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - M J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - P E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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