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Goree JH, Grant SA, Dickerson DM, Ilfeld BM, Eshraghi Y, Vaid S, Valimahomed AK, Shah JR, Smith GL, Finneran JJ, Shah NN, Guirguis MN, Eckmann MS, Antony AB, Ohlendorf BJ, Gupta M, Gilbert JE, Wongsarnpigoon A, Boggs JW. Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement. Neuromodulation 2024; 27:847-861. [PMID: 38739062 DOI: 10.1016/j.neurom.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVES Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA. MATERIALS AND METHODS Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT). RESULTS A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing. CONCLUSIONS This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.
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Affiliation(s)
- Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Stuart A Grant
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Yashar Eshraghi
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Sandeep Vaid
- Better Health Clinical Research, Newnan, GA, USA
| | | | - Jarna R Shah
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - G Lawson Smith
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Nirav N Shah
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Maged N Guirguis
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Maxim S Eckmann
- Department of Anesthesiology, University of Texas San Antonio, San Antonio, TX, USA
| | | | - Brian J Ohlendorf
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Mayank Gupta
- Neuroscience Research Center, Overland Park, KS, USA
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Chelly JE, Goel SK, Kearns J, Kopac O, Sadhasivam S. Nanotechnology for Pain Management. J Clin Med 2024; 13:2611. [PMID: 38731140 PMCID: PMC11084313 DOI: 10.3390/jcm13092611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.
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Affiliation(s)
- Jacques E. Chelly
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA
| | - Shiv K. Goel
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Jeremy Kearns
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Orkun Kopac
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
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Hofer DM, Harnik M, Lehmann T, Stüber F, Baumbach P, Dreiling J, Meissner W, Stamer UM. Trajectories of pain and opioid use up to one year after surgery: analysis of a European registry. Br J Anaesth 2024; 132:588-598. [PMID: 38212183 DOI: 10.1016/j.bja.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Long-term opioid use after surgery is a crucial healthcare problem in North America. Data from European hospitals are scarce and differentiation of chronic pain has rarely been considered. METHODS In a mixed surgical cohort of the PAIN OUT registry, opioid use and chronic pain were evaluated before surgery, and 6 and 12 months after surgery (M6/M12). Subgroups with or without opioid medication and pre-existing chronic pain were analysed. M12-chronic pain was categorised as chronic postsurgical pain (CPSP) meeting the ICD-11 definition, chronic pain related to surgery not meeting the ICD-11 definition, and chronic pain unrelated to surgery. Primary endpoint was the rate of M12 opioid users. Variables associated with M12 opioid use and patient-reported outcomes were evaluated. RESULTS Of 2326 patients, 5.5% were preoperative opioid users; 4.4% and 3.5% took opioids at M6 and M12 (P<0.001). Chronic pain before operation and at M6/M12 was reported by 41.2%, 41.8%, and 34.7% of patients, respectively (P<0.001). The rate of M12 opioid users was highest in group unrelated (22.3%; related 8.3%, CPSP 1.5%; P<0.001). New opioid users were 1.1% (unrelated 7.1%, related 2.3%, CPSP 0.7%; P<0.001). M12 opioid users reported more pain, pain-related physical and affective interference, and needed more opioids than non-users. The predominant variable associated with M12 opioids was preoperative opioid use (estimated odds ratio [95% confidence interval]: 28.3 [14.1-56.7], P<0.001). CONCLUSIONS Opioid use was low in patients with CPSP, and more problematic in patients with chronic pain unrelated to surgery. A detailed assessment of chronic pain unrelated or related to surgery or CPSP is necessary. CLINICAL TRIAL REGISTRATION NCT02083835.
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Affiliation(s)
- Debora M Hofer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Harnik
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer and Data Sciences, University Hospital Jena, Jena, Germany
| | - Frank Stüber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Philipp Baumbach
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Johannes Dreiling
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Winfried Meissner
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Ulrike M Stamer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of BioMedical Research, University of Bern, Bern, Switzerland; Pain and Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Brussels, Belgium.
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Madsen C, Korona-Bailey J, Janvrin ML, Schoenfeld AJ, Koehlmoos TP. Opioid prescribing and use in the Military Health System: a framework synthesis, FY2016-FY2021. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1133-1137. [PMID: 37280084 PMCID: PMC10546480 DOI: 10.1093/pm/pnad072] [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: 12/04/2022] [Revised: 05/02/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse. METHODS We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use. RESULTS Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients. CONCLUSIONS Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.
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Affiliation(s)
- Cathaleen Madsen
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Jessica Korona-Bailey
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Miranda Lynn Janvrin
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Harvard Medical School, Brigham & Women’s Hospital, Boston, MA 02115, United States
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Hah JM, Vialard JDV, Efron B, Mackey SC, Carroll IR, Amanatullah DF, Narasimhan B, Hernandez-Boussard T. Preoperative Versus Perioperative Risk Factors for Delayed Pain and Opioid Cessation After Total Joint Arthroplasty: A Prospective Cohort Study. Pain Ther 2023; 12:1253-1269. [PMID: 37556071 PMCID: PMC10444739 DOI: 10.1007/s40122-023-00543-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION The evolution of pre- versus postoperative risk factors remains unknown in the development of persistent postoperative pain and opioid use. We identified preoperative versus comprehensive perioperative models of delayed pain and opioid cessation after total joint arthroplasty including time-varying postoperative changes in emotional distress. We hypothesized that time-varying longitudinal measures of postoperative psychological distress, as well as pre- and postoperative use of opioids would be the most significant risk factors for both outcomes. METHODS A prospective cohort of 188 patients undergoing total hip or knee arthroplasty at Stanford Hospital completed baseline pain, opioid use, and emotional distress assessments. After surgery, a modified Brief Pain Inventory was assessed daily for 3 months, weekly thereafter up to 6 months, and monthly thereafter up to 1 year. Emotional distress and pain catastrophizing were assessed weekly to 6 months, then monthly thereafter. Stepwise multivariate time-varying Cox regression modeled preoperative variables alone, followed by all perioperative variables (before and after surgery) with time to postoperative opioid and pain cessation. RESULTS The median time to opioid and pain cessation was 54 and 152 days, respectively. Preoperative total daily oral morphine equivalent use (hazard ratio-HR 0.97; 95% confidence interval-CI 0.96-0.98) was significantly associated with delayed postoperative opioid cessation in the perioperative model. In contrast, time-varying postoperative factors: elevated PROMIS (Patient-Reported Outcomes Measurement Information System) depression scores (HR 0.92; 95% CI 0.87-0.98), and higher Pain Catastrophizing Scale scores (HR 0.85; 95% CI 0.75-0.97) were independently associated with delayed postoperative pain resolution in the perioperative model. CONCLUSIONS These findings highlight preoperative opioid use as a key determinant of delayed postoperative opioid cessation, while postoperative elevations in depressive symptoms and pain catastrophizing are associated with persistent pain after total joint arthroplasty providing the rationale for continued risk stratification before and after surgery to identify patients at highest risk for these distinct outcomes. Interventions targeting these perioperative risk factors may prevent prolonged postoperative pain and opioid use.
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Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA.
- , 1070 Arastradero Rd., Suite 200, Palo Alto, CA, 94304, USA.
| | - Julien D Veron Vialard
- Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA
| | - Bradley Efron
- Departments of Statistics, Stanford University, Stanford, CA, USA
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Ian R Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | | | - Balasubramanian Narasimhan
- Departments of Statistics, Stanford University, Stanford, CA, USA
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Tina Hernandez-Boussard
- Departments of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Department of Medicine, Stanford University, Stanford, CA, USA
- Department of Surgery, Stanford University, Stanford, CA, USA
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Johnson Z, Scribner M, Patzkowski J, Patzkowski M. Continuous Intravenous Ketamine for Pain Control After Tibial or Femoral Osteotomy. Mil Med 2023; 188:3248-3251. [PMID: 36043263 DOI: 10.1093/milmed/usac241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/16/2022] [Accepted: 07/27/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The purpose of this case series is to evaluate the potential of continuous intravenous ketamine administration as part of a multimodal strategy to reduce opioid requirements after high tibial osteotomy (HTO) and distal femoral osteotomy (DFO). METHODS We examined the average postoperative numerical rating scale pain intensity score from admission to the postanesthesia care unit to 8 am of the first postoperative day of four patients who underwent HTO or DFO. Pain scores were analyzed as the time-weighted sum of pain intensity differences using the trapezoidal rule of the curve, resulting in an area under the curve (AUC). RESULTS Patient A had an AUC of 2,828 over 1,180 minutes with an average pain score of 2.4/10. Patient B had an AUC of 1,418 over 1,285 minutes with an average pain score of 1.1/10. Patient C had an AUC of 4,217 over 1,155 minutes with an average pain score of 3.7/10. Patient D had an AUC of 4,498 over 1,030 minutes with an average pain score of 4.4/10. All were able to go home on postoperative day 1. CONCLUSIONS This novel perioperative pain pathway including multiple non-opioid pain adjuncts and a low-dose continuous ketamine infusion is an effective method for pain management in knee periarticular osteotomies. LEVEL OF EVIDENCE Level 4; Case Series.
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Affiliation(s)
- Zackary Johnson
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Maggie Scribner
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Jeanne Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Michael Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
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Shetty PN, Sanghavi KK, Mete M, Giladi AM. Prescription Opioids and Patient-Reported Outcomes and Satisfaction After Carpal Tunnel Release Surgery. Hand (N Y) 2023; 18:772-779. [PMID: 34991385 PMCID: PMC10336819 DOI: 10.1177/15589447211064365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Amount of opioid use correlates poorly with procedure-related pain; however, prescription limits raise concerns about inadequate pain control and impacts on patient-reported quality indicators. There remain no consistent guidelines for postoperative pain management after carpal tunnel release (CTR). We sought to understand how postoperative opioid use impacts patient-reported outcomes after CTR. METHODS This is a pragmatic cohort study using prospectively collected data from all adult patients undergoing uncomplicated primary CTR over 17 months at our center. Patients were categorized as having received or not received a postoperative opioid prescription, and then as remaining on a prescription opioid at 2-week follow-up or not. Questionnaires were completed before surgery and at 2-week follow-up. We collected brief Michigan Hand questionnaire (bMHQ) score, Patient-Reported Outcomes Measurement Information System Global Health score, satisfaction, and pain score. RESULTS Of 505 included patients, 405 received a postoperative prescription and 67 continued use at 2-weeks. These 67 patients reported lower bMHQ, lower satisfaction, and higher postoperative pain compared to those that discontinued. Multivariable regressions showed that receiving postoperative prescriptions did not significantly influence outcomes or satisfaction. However, remaining on the prescription at 2 weeks was associated with significantly lower bMHQ scores, particularly in patients reporting less pain. CONCLUSIONS Patients remaining on a prescription after CTR reported worse outcomes compared to those who discontinued. Unexpectedly, the widest bMHQ score gap was seen across patients reporting lowest pain scores. Further research into this high-risk subgroup is needed to guide policy around using pain and patient-reported outcomes as quality measures.Level of Evidence: Level III.
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Affiliation(s)
- Pragna N. Shetty
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Kavya K. Sanghavi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
- MedStar Health Research Institute, Hyattsville, MD, USA
| | - Mihriye Mete
- MedStar Health Research Institute, Hyattsville, MD, USA
| | - Aviram M. Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Matthews DE, Rella RT. Retrospective Analysis of Surgeon-Placed Nerve Block and Indwelling Catheter in the Adductor Canal in Total Knee Arthroplasty. Cureus 2023; 15:e39833. [PMID: 37397678 PMCID: PMC10314755 DOI: 10.7759/cureus.39833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is now being performed in the outpatient setting, and often the postoperative pain is managed with opioid analgesics. Non-opioid pain management modalities are in crucial demand, and we propose a surgical technique that can potentially result in less pain and the decrease in the use of opioid analgesia following TKA. The purpose of this study was to investigate the safety and efficacy of a novel peripheral nerve block (PNB) that includes a single injection and catheter placement for a continuous regional nerve block in total knee arthroplasty. METHODS Fifty-six patients underwent TKA by a single surgeon utilizing the novel method. Patient-reported outcomes were entered into an outcomes database and compared to an aggregate of over 3,500 comparative TKA patients. A visual analog scale (VAS) evaluated perioperative pain. Patient perioperative opioid usage, expectations of pain control, the incidence of common side effects, and the average hospital length of stay (LOS) were collected. RESULTS Compared to the aggregate of patients in the database, the patients who received the novel surgeon-placed adductor canal block (ACB) and catheter placement reported findings that suggest this technique can possibly lead to a decrease in the severity of pain in addition to a reduction in side effects and the need for opioid analgesia. LOS for these patients was short, and patient satisfaction scores were excellent for the surgeon performing this technique. CONCLUSIONS Using the placement technique described, surgeons can reproducibly perform a single injection of PNB and place an indwelling catheter in the adductor canal through direct visualization of the muscles that make up the borders of the adductor canal. This technique offers potential advantages over pain management modalities that can be elucidated in further studies. The power of this study is limited due to these findings having not been analyzed for statistical significance.
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Affiliation(s)
- Daniel E Matthews
- Orthopedic Surgery, University of South Alabama College of Medicine, Mobile, USA
- Orthopedic Surgery, Alabama Orthopedic Sports Medicine, Daphne, USA
| | - Robert T Rella
- Orthopedic Surgery, University of South Alabama College of Medicine, Mobile, USA
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Heins SE, Seelam R, Schell TL, Wong EC. Predictors of Long-Term Opioid Use After Hospitalization for Traumatic Injury in a Racially and Ethnically Diverse Population: A 12-Month Prospective Observational Study. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:122-129. [PMID: 36165692 PMCID: PMC10167926 DOI: 10.1093/pm/pnac147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Long-term prescription opioid use is a significant risk factor for opioid morbidity and mortality, and severe traumatic injury is an important initiation point for prescription opioid use. This study examines predictors of long-term prescription opioid use among a racially and ethnically diverse population of patients hospitalized for traumatic injury. METHODS Study participants (N= 650) from two urban Level I trauma centers were enrolled. Baseline information on demographics, injury characteristics, self-reported pre-injury substance use and mental health, and personality characteristics and attitudes was collected through interviews during the initial hospitalization. Patients were interviewed again at 3 months and 12 months and asked about prescription opioid use in the prior 7 days. Multivariable logistic regressions assessed participants' baseline characteristics associated with opioid use at one or more follow-up interviews. RESULTS Pre-injury use of prescription painkillers had the strongest association with prescription opioid use at follow-up (adjusted odds ratio: 3.10; 95% confidence interval: 1.86-5.17). Older age, health insurance coverage at baseline, length of hospitalization, higher current pain level, pre-injury post-traumatic stress disorder symptoms, and discharge to a location other than home were also associated with significantly higher odds of prescription opioid use at follow-up. CONCLUSIONS Providers could consider screening for past use of prescription pain relievers and post-traumatic stress disorder before hospital discharge to identify patients who might benefit from additional resources and support. However, providers should ensure that these patients' pain management needs are still being met and avoid abrupt discontinuation of prescription opioid use among those with a history of long-term use.
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Abstract
Orthopaedic trauma patients have high rates of psychiatric disorders, which put them at risk for worse outcomes after injury and surgery, including worse pain. Mental health conditions, such as depression and anxiety, can affect the perception of pain. Pain can also exacerbate or contribute to the development of mental illness after injury. Interventions to address both mental health and pain among orthopaedic trauma patients are critical. Balancing safety and comfort amid a drug overdose epidemic is challenging, and many clinicians do not feel comfortable addressing mental health or have the resources necessary. We reviewed the literature on the complex relationship between pain and mental health and presented examples of scalable and accessible interventions that can be implemented to promote the health and recovery of our patients. Interventions described include screening for depression in the orthopaedic trauma clinic and the emergency department or inpatient setting during injury and using a comprehensive and evidence-based multimodal pain management regimen that blends pharmacologic alternatives to opioids and physical and cognitive strategies to manage pain.
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Sokil LE, Rogero RG, McDonald EL, Corr D, Fuchs D, Winters BS, Pedowitz DI, Daniel JN, Raikin SM, Shakked RJ. Self-Reported Pain Tolerance and Opioid Pain Medication Use After Foot and Ankle Surgery. Foot Ankle Spec 2022; 15:438-447. [PMID: 33158380 DOI: 10.1177/1938640020970371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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 Orthopaedic surgeons must consider their postoperative pain management strategies to minimize harm from prescription opioid use. Patients often reference their pain threshold to predict how they will tolerate surgical pain and the need for postoperative analgesia, but the direct relationship between these factors has not yet been studied. The purpose of this study was to determine the relationship between patients' self-reported pain tolerance and prescription opioid usage after foot and ankle surgery. METHODS This is a retrospective follow-up of a prospective cohort study of adult patients who underwent outpatient foot and ankle surgeries. Patient and procedural demographics, opioid pills dispensed, and opioid pills consumed by the first postoperative visit were obtained. Patients were contacted at a mean of 13.1 ± 4.0 months postoperatively and asked to respond to the qualitative statement "Pain doesn't bother me as much as it does most people." Patients were also asked their quantitative pain threshold (0-100), with 0 being "very pain intolerant" and 100 being a "very high pain tolerance," as well other questions regarding past surgical and narcotic consumption history. RESULTS Of the 700 survey respondents, the average age was 50.9 years and 34.7% were male. Bivariate analysis determined that predictors of lower postoperative opioid consumption included higher quantitative (P = .047) and qualitative (P = .005) pain tolerance scores. Multivariate analysis for the entire cohort demonstrated that higher qualitative pain threshold was associated with lower postoperative opioid consumption (P = .005) but this did not meet statistical significance as an independent predictor of the top quartile of pill consumers. CONCLUSION Assessment of both qualitative and quantitative score of patients' pain threshold prior to surgery may assist the surgeon in tailoring postoperative pain control. Additionally, asking this question can create an opportunity for educating patients regarding responsible utilization of narcotic medication. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Laura E Sokil
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ryan G Rogero
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Elizabeth L McDonald
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Daniel Corr
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Daniel Fuchs
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
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Secrist E, Wally MK, Yu Z, Castro M, Seymour RB, Hsu JR. Depression Screening and Behavioral Health Integration in Musculoskeletal Trauma Care. J Orthop Trauma 2022; 36:e362-e368. [PMID: 35981227 DOI: 10.1097/bot.0000000000002361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To report our experiences in implementing a behavioral health integration pathway, including a validated depression screening and referral to care. DESIGN Retrospective case series. SETTING Single surgeon's musculoskeletal trauma outpatient practice during calendar year 2019. PATIENTS All patients presenting to the practice during 2019 were included (n = 573). INTERVENTION We piloted the usage of Patient Health Questionnaire (PHQ)-2 and PHQ-9 screening. An evidence-based, real-time treatment protocol embedded in the electronic health record was triggered when a patient screened positive for depression including an automated behavioral health integration pathway. MAIN OUTCOME MEASUREMENTS The percentage of patients screened, the results of the PHQ screening, and the number of patients referred and enrolled in behavioral health programs were collected. RESULTS Of the 573 patients, 476 (83%) received the PHQ-2 screening, 80 (14%) had a current screening on file (within 1 year), and 17 (3.0%) were not screened. One hundred seventy-two patients (36%) had a PHQ-2 score of 2 or greater and completed the PHQ-9; of them, 60 (35% of patients screened with full PHQ-9, 13% of patients screened) screened positive for symptoms of moderate depression (PHQ-9 score ≥10), and 19 (4.0%) reported passive suicidal ideation (PHQ-9 item 9). Fifty of these patients were referred to behavioral health through the pathway, and 8 patients enrolled in the program. Ten patients were not referred because of a technical error that was quickly resolved. Patients reporting suicidal ideation were managed with psychiatric crisis resources including immediate virtual consult in the examination room. CONCLUSIONS This case series demonstrates the feasibility of screening patients for depressive symptoms and making necessary referrals to behavioral health in outpatient musculoskeletal trauma care. We identified 50 patients with depression and appropriately triaged them for further care in our community.
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Affiliation(s)
- Eric Secrist
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Manuel Castro
- Department of Psychiatry, Atrium Health, Charlotte, NC
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
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Ghaddaf AA, Alsharef JF, Alhindi AK, Bahathiq DM, Khaldi SE, Alowaydhi HM, Alshehri MS. Influence of perioperative opioid-related patient education: A systematic review and meta-analysis. PATIENT EDUCATION AND COUNSELING 2022; 105:2824-2840. [PMID: 35537899 DOI: 10.1016/j.pec.2022.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 04/01/2022] [Accepted: 04/27/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To determine the role of perioperative protocolized opioid-specific patient education on opioid consumption for individuals undergoing surgical procedures. METHODS We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) that compared protocolized perioperative opioid-specific patient education to the usual care for adult individuals undergoing surgical interventions. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes. RESULTS In total, 15 RCTs that enrolled 2546 participants were deemed eligible. Protocolized opioid-specific patient education showed a significant reduction in postoperative opioid consumption and postoperative pain score compared to usual care (SMD= -0.15, 95% confidence interval [CI]: -0.28 to -0.03 and SMD= -0.17, 95% CI: -0.28 to -0.06, respectively). No significant difference was found between the protocolized opioid-specific patient education and the usual care in terms of the number of refill requests (RR=0.82, 95% CI: 0.50-1.34), patients with opioid leftovers (RR=0.92, 95% CI: 0.78-1.08), and patients taking opioids after hospital discharge. CONCLUSIONS This meta-analysis demonstrated that protocolized opioid-specific patient education significantly reduces postoperative opioid consumption and pain score but has no influence on the number of opioid refill requests, opioid leftovers, and opioid use after hospital discharge. PRACTICE IMPLICATIONS Healthcare professionals may offer opioid-related educational sessions for the surgical patients during the perioperative period through a video-based material that emphasizes the role of alternative analgesics to opioids, patients' expectations about the post-operative pain, and the potential side effects of opioid consumptions.
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Affiliation(s)
- Abdullah A Ghaddaf
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Jawaher F Alsharef
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Abeer K Alhindi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Dena M Bahathiq
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Shahad E Khaldi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Hanin M Alowaydhi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Mohammed S Alshehri
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Surgery/Orthopedic section, King Abdulaziz Medical City, Jeddah, Saudi Arabia.
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Abstract
OBJECTIVE To understand the changes in opioid cessation surrounding the release of CDC guidelines and changes in state Medicaid coverage at the individual patient level. METHODS This study used a 20% national sample of Medicare beneficiaries between 2013 and 2018 with at least 90 days of consecutive opioid use in the first year of either of 2 study periods (2013-2015 or 2016-2018). Cessation of opioid use was assessed in year 3 of each period by generalized linear mixed models. RESULTS Opioid cessation rates were higher in period 2 (11.2%) compared to period 1 (10.1%). Adjusted for beneficiary characteristics, those in period 2 had 1.07 times the odds of cessation (95% CI: 1.05-1.09) compared to those in period 1. Additionally, the increase in opioid cessation over time was larger in states with Medicaid expansion compared to those without. CONCLUSION The increase in opioid cessation after 2016 suggests the potential effects of the CDC guidelines on opioid prescribing and underscores the need for further research on the relationship between opioid cessation and subsequent change in pain control, quality of life, and opioid toxicity.
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Affiliation(s)
- Jordan Westra
- Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
- *Correspondence: Jordan Westra, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA (e-mail: )
| | - Mukaila Raji
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA
| | - Yong-fang Kuo
- Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA
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Psychiatric Comorbidities Associated with Persistent Postoperative Opioid Use. Curr Pain Headache Rep 2022; 26:701-708. [PMID: 35960447 DOI: 10.1007/s11916-022-01073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review outlines the psychiatric comorbidities associated with persistent opioid use in the postoperative period. We finish our analysis with evidence-based, patient-centered interventions that can be rendered in the perioperative setting to decrease postoperative opioid requirements. RECENT FINDINGS Opioids are overprescribed in the USA, especially in the postoperative setting. Excess opioids can result in diversion and contribute to the ongoing opioid epidemic. Mental health and substance use disorders can contribute to persistent postoperative opioid use. Adequately managing these disorders preoperatively promises to reduce persistent postoperative opioid use. Due to the lack of homogenous, evidence-based recommendations on the appropriate quantity and duration of postoperative opioid therapy, there is wide variability in provider prescribing habits. Further research is needed to establish surgery-specific postoperative opioid therapy protocols. Opioids continue to be a mainstay in the treatment of postoperative pain. Unmonitored postoperative opioid use can lead to opioid use disorder. Mental health disorders increase susceptibility to persistent postoperative opioid use. By managing these psychiatric illnesses preoperatively, clinicians have the ability to decrease opioid consumption postoperatively. Lastly, given the healthcare burden of opioid misuse and abuse, it is important to establish concrete protocols to guide provider-prescribing habits.
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Rodnoi P, Dickey RM, Teotia SS, Haddock NT. Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety. J Reconstr Microsurg 2022; 38:742-748. [PMID: 35714625 DOI: 10.1055/s-0042-1749595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS) protocols have decreased postoperative opioid consumption and hospital length of stay in deep inferior epigastric perforator (DIEP) flap breast reconstruction. We aim to evaluate whether there needs to be further adjustments to best improve outcomes specifically in patients with a preexisting psychiatric condition. METHODS A retrospective review was performed of all patients that underwent DIEP flap breast reconstruction between October 2018 and September 2020. This includes all patients with the most recent ERAS protocol implementation of intraoperative transverse abdominal plane blocks with liposomal bupivacaine. We looked at patients with a psychiatric diagnosis at the time of surgery. Specifically, forms of depression and anxiety were the psychiatric diagnoses for these patients. We divided these patients into three groups: those with no diagnoses, those with a single diagnosis, and those with both diagnoses. Primary outcomes observed were postoperative opioid consumption and length of stay. A one-way analysis of variance determined whether there was a difference between the three groups and a Tukey post hoc analysis made pairwise comparisons. A p-value of < 0.05 was significant. RESULTS A total of 176 patients were analyzed in this study: 59 (33.5%) of our study population had a diagnosis of either depression, anxiety, or both. Postoperative opioid consumption was higher in patients with a psychiatric diagnosis compared with those without (123.8 to 91.5; p < 0.0005). A multiple regression model consisting of operating time, hospital length of stay, whether the patient has a psychiatric diagnosis, and history of chemotherapy statistically significantly predicted opioid consumption (p < 0.0005). CONCLUSION With similar hospital length of stay postoperatively, it is notable that patients with a psychiatric diagnosis had significantly higher amounts of postoperative opioid consumption. This study highlights the need to further improve multidisciplinary integrated care for patients with psychiatric comorbidities to improve pain management postoperatively.
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Affiliation(s)
- Pope Rodnoi
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan M Dickey
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Abstract
This review summarizes current evidence related to perioperative opioid prescription fulfillment and use and discusses the role of personalized anesthesia care in mitigating opioid-related harms without compromising analgesia.
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18
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Reif de Paula T, Nemeth SK, Kurlansky PA, Simon HL, Miller LK, Keller DS. A Randomized Controlled Trial Examining the Impact of an Anorectal Surgery Multimodal Enhanced Recovery Program on Opioid Use. Ann Surg 2022; 275:e22-e29. [PMID: 33351458 DOI: 10.1097/sla.0000000000004701] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anorectal cases may be a common gateway to the opioid epidemic. Opioid reduction is inherent in enhanced recovery after surgery (ERAS) protocols, but little work has evaluated ERAS in these cases. OBJECTIVE To determine if ERAS could reduce postoperative opioid utilization in ambulatory anorectal surgery without sacrificing patient pain or satisfaction. METHODS A randomized controlled trial assigned ambulatory anorectal patients to ERAS (experimental) or routine care (surgeon's choice) for pain management (control) over 30-days postoperatively. Primary outcome was overall days of opioid use. Secondary outcomes included pain and satisfaction scores over multiple time points and new persistent opioid use. The Visual Analog Scale, Functional Pain Scale, and EQ-5D-3L measured patient-reported pain and satisfaction. Univariate analysis compared outcomes overall and at individual time points. Two-way mixed ANOVA evaluated pain and satisfaction measures between groups and over time. RESULTS Thirty-two patients were randomized into each arm (64 total). The control group consumed significantly more opioids after discharge (median 121.3MME vs 23.5MME, P < 0.001). Significantly more control patients requested additional narcotics (P = 0.004), made unplanned calls (P = 0.009), and had unplanned clinic visits (P = 0.003). The control group had significantly more days on opioids (mean 14.4 vs 2.2, P < 0.001). Three control patients (9.4%) versus no experimental patients had new persistent opioid use. The mean global health, EQ5D-3L, Visual Analog Scale, and Functional Pain scores were comparable between groups over time. CONCLUSIONS An ERAS protocol in ambulatory anorectal surgery is feasible, and resulted in reduced opioid use, and healthcare utilization, with no difference in pain or patient satisfaction. This challenges the paradigm that extended opioids are needed for effective postoperative pain management.
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Affiliation(s)
- Thais Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Samantha K Nemeth
- Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York
| | - Paul A Kurlansky
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York
| | - Hillary L Simon
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, NY
| | - Lydia K Miller
- Department of Anesthesia, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
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Stone AV, Murphy ML, Jacobs CA, Lattermann C, Hawk GS, Thompson KL, Conley CEW. Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure. Cartilage 2022; 13:19476035221087703. [PMID: 35333656 PMCID: PMC9137305 DOI: 10.1177/19476035221087703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 01/19/2022] [Accepted: 02/16/2022] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs. DESIGN Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders. RESULTS A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, P < 0.001; OCA: 30.4% vs. 24.8%, P = 0.032; ACI: 33.7% vs. 26.2%, P = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, P = 0.012; OAT: $5,221 vs. $3,823*, P < 0.001; OCA: $6,973 vs. $3,992*, P < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% (P < 0.001) and 28.0% for OAT patients (P = 0.034). There was no statistical difference for ACI patients (P = 0.654). CONCLUSION Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses. LEVEL OF EVIDENCE Level III, retrospective therapeutic study.
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Affiliation(s)
- Austin V. Stone
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Meredith L. Murphy
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Cale A. Jacobs
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Christian Lattermann
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory S. Hawk
- Department of Statistics, University of Kentucky, Lexington, KY, USA
| | | | - Caitlin E. W. Conley
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
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Preoperative Opioid Utilization Patterns and Postoperative Opioid Utilization: A Retrospective Cohort Study. Anesthesiology 2021; 135:1015-1026. [PMID: 34731242 DOI: 10.1097/aln.0000000000004026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Among chronic opioid users, the association between decreasing or increasing preoperative opioid utilization and postoperative outcomes is unknown. The authors hypothesized that decreasing utilization would be associated with improved outcomes and increasing utilization with worsened outcomes. METHODS Using commercial insurance claims, the authors identified 57,019 chronic opioid users (10 or more prescriptions or 120 or more days supplied during the preoperative year), age 18 to 89 yr, undergoing one of 10 surgeries between 2004 and 2018. Patients with a 20% or greater decrease or increase in opioid utilization between preoperative days 7 to 90 and 91 to 365 were compared to patients with less than 20% change (stable utilization). The primary outcome was opioid utilization during postoperative days 91 to 365. Secondary outcomes included alternative measures of postoperative opioid utilization (filling a minimum number of prescriptions during this period), postoperative adverse events, and healthcare utilization. RESULTS The average age was 63 ± 13 yr, with 38,045 (66.7%) female patients. Preoperative opioid utilization was decreasing for 12,347 (21.7%) patients, increasing for 21,330 (37.4%) patients, and stable for 23,342 (40.9%) patients. Patients with decreasing utilization were slightly less likely to fill an opioid prescription during postoperative days 91 to 365 compared to stable patients (89.2% vs. 96.4%; odds ratio, 0.323; 95% CI, 0.296 to 0.352; P < 0.001), though the average daily doses were similar among patients who continued to utilize opioids during this timeframe (46.7 vs. 46.5 morphine milligram equivalents; difference, 0.2; 95% CI, -0.8 to 1.2; P = 0.684). Of patients with increasing utilization, 93.6% filled opioid prescriptions during this period (odds ratio, 0.57; 95% CI, 0.52 to 0.62; P < 0.001), with slightly lower average daily doses (44.3 morphine milligram equivalents; difference, -2.2; 95% CI, -3.1 to -1.3; P < 0.001). Except for alternative measures of persistent postoperative opioid utilization, there were no clinically significant differences for the secondary outcomes. CONCLUSIONS Changes in preoperative opioid utilization were not associated with clinically significant differences for several postoperative outcomes including postoperative opioid utilization. EDITOR’S PERSPECTIVE
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21
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Best MJ, Harris AB, Mohler JM, Wilckens JH. Associations between preoperative depression and opioid use after anterior cruciate ligament reconstruction and concomitant procedures. PHYSICIAN SPORTSMED 2021; 49:445-449. [PMID: 33197357 DOI: 10.1080/00913847.2020.1851158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objectives: To determine rates of perioperative opioid use and characterize associations between preoperative depression and chronic and cumulative opioid consumption after ACL reconstruction.Methods: Using insurance claims data, we identified 48,657 adults who underwent ACL reconstruction from 2010 to 2015, had prescription drug insurance, and had ≥1 year of continuous insurance enrollment postoperatively. Chronic opioid use was defined as filling ≥120 days' supply from 3 to 12 months postoperatively. Logistic and linear regression, controlled for age, sex, and Charlson Comorbidity Index value, were used to determine associations of preoperative depression with binary and continuous outcomes, respectively.Results: Preoperatively, 2,237 patients (4.6%) had depression and 2,387 (4.9%) were taking opioids; patients with depression had 6.5 times the odds (95% confidence interval [CI]: 5.8, 7.3) of taking opioids than patients without depression. Postoperatively, 25% of the patients filled ≥1 opioid prescription; mean duration of use was 13 ± 11 days, and 362 patients (0.7%) had chronic use. Patients with preoperative depression were less likely than patients without depression to fill an opioid prescription postoperatively (OR 0.2, 95% CI: 0.2, 0.2). Of patients who filled opioid prescriptions postoperatively, those with preoperative depression were more likely to refill that prescription at least once (OR 2.0, 95% CI: 1.9, 2.2) but did not have greater odds of chronic use (OR 0.9, 95% CI: 0.5, 1.5). Preoperative depression was not associated with greater cumulative opioid consumption from 3 to 12 months postoperatively (β = -40, 95% CI: -226, 146).Conclusion: Although patients with preoperative depression were more likely to take opioids preoperatively and to obtain ≥1 opioid refill postoperatively, they did not have greater odds of chronic postoperative opioid use or greater cumulative opioid consumption after ACL reconstruction.
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Affiliation(s)
- Matthew J Best
- From the Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew B Harris
- From the Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica M Mohler
- United States Naval Academy, Sport Psychology Services, Midshipmen Development Center, Annapolis, MD, USA
| | - John H Wilckens
- From the Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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Hozack BA, Rivlin M, Lutsky KF, Beredjiklian PK. Overall Opioid Consumption Is Not Associated With the Amount of Opioids Administered and Prescribed on the Day of Upper Extremity Surgery. Hand (N Y) 2021; 16:781-784. [PMID: 31965858 PMCID: PMC8647310 DOI: 10.1177/1558944719897419] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Orthopedic surgeons need to better understand the effect their opioid-prescribing habits have on patients. The purpose of our study was to evaluate whether the type of procedure or initial amount of opioids prescribed postoperatively leads to increased consumption of opioids. Methods: Consecutive patients undergoing upper extremity surgery were enrolled. The medical record and Pennsylvania Prescription Drug Monitoring Program Web site were used to record all prescriptions of controlled substances consumed intraoperatively, in the recovery room, and in prescriptions filled 6 months postoperatively. Morphine equivalent units (MEUs) were used to quantify the amount of opioids. Results: Two hundred ninety patients were included in the study. The mean MEU administered intraoperatively was 25.1 (0-50). The MEU provided in the recovery room was 2.9 (0-60). The MEU prescribed on the day of surgery was 155.6 (137-178). We used the Pearson correlation coefficient of r = 0, meaning no/weak correlation, and r = 1, meaning a strong correlation. Neither MEUs provided intraoperatively or in recovery, nor MEUs prescribed postoperatively correlated with prescriptions filled (r = 0.13, 0.02, 0.09, respectively). Although patients undergoing bony procedures were prescribed more opioids (P < .001), opioid consumption intraoperatively, in recovery, and in prescriptions filled was not significantly different. Conclusions: The MEUs administered and prescribed on the day of surgery did not affect the amount of prescriptions filled postoperatively. Finally, patients undergoing bony procedures were prescribed more opioids than those undergoing soft tissue procedures, but they did not consume or fill more opioids postoperatively.
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Affiliation(s)
- Bryan A. Hozack
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA,Bryan A. Hozack, Rothman Institute, Thomas Jefferson University Hospitals, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA.
| | - Michael Rivlin
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kevin F. Lutsky
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Hah JM, Lee E, Shrestha R, Pirrotta L, Huddleston J, Goodman S, Amanatullah DF, Dirbas FM, Carroll IR, Schofield D. Return to work and productivity loss after surgery: A health economic evaluation. Int J Surg 2021; 95:106100. [PMID: 34600123 PMCID: PMC8604782 DOI: 10.1016/j.ijsu.2021.106100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/27/2021] [Accepted: 09/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We aimed to identify preoperative psychosocial factors associated with return-to-work (RTW) and the associated cost of productivity loss due to work absenteeism following surgery. Research demonstrates a high economic burden from productivity loss after surgery, but the comparative cost of productivity loss relative to income across different operations has not been examined. MATERIALS AND METHODS A mixed surgical cohort recruited for a randomized controlled trial were prospectively followed for up to two years following surgery with daily phone assessments to three months, weekly assessments thereafter to six months, then monthly assessments thereafter to determine RTW status, opioid use and pain. RESULTS 183 of 207 (88.3%) patients in paid employment prior to surgery, who provided at least one day of follow-up, were included in this analysis. The average cost of productivity loss due to work absenteeism was $13 761 (median $9064). Patients who underwent total knee replacement incurred the highest income loss. Medical claims filed before surgery were significantly associated with relative income loss (AOR 5.09; 95% CI 1.73-14.96; p < 0.01) and delayed postoperative RTW. Elevated preoperative PTSD symptoms were associated with delayed RTW (HR 0.78; 95%CI 0.63-0.96; p-value = 0.02) while male gender (HR 1.63; 95%CI 1.11-2.38; p-value = 0.01) was associated with faster postoperative RTW. CONCLUSION Surgery places a high economic burden on individuals due to postoperative productivity loss. Multidisciplinary approaches, such as pathways, that facilitate the operation and recovery may mitigate the economic consequences for patients, employers, and the healthcare system.
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Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA Centre for Economic Impacts of Genomic Medicine, Macquarie University, Sydney, NSW, Australia Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA Department of Orthopaedic Surgery and (by courtesy) Bioengineering, Stanford University, Stanford, CA, USA Department of General Surgery, Stanford University, Stanford, CA, USA
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Ishida H, Zhang Y, Gomez R, Shannonhouse J, Son H, Banik R, Kim YS. In Vivo Calcium Imaging Visualizes Incision-Induced Primary Afferent Sensitization and Its Amelioration by Capsaicin Pretreatment. J Neurosci 2021; 41:8494-8507. [PMID: 34452938 PMCID: PMC8513701 DOI: 10.1523/jneurosci.0457-21.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/27/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
Previous studies have shown that infiltration of capsaicin into the surgical site can prevent incision-induced spontaneous pain like behaviors and heat hyperalgesia. In the present study, we aimed to monitor primary sensory neuron Ca2+ activity in the intact dorsal root ganglia (DRG) using Pirt-GCaMP3 male and female mice pretreated with capsaicin or vehicle before the plantar incision. Intraplantar injection of capsaicin (0.05%) significantly attenuated spontaneous pain, mechanical, and heat hypersensitivity after plantar incision. The Ca2+ response in in vivo DRG and in in situ spinal cord was significantly enhanced in the ipsilateral side compared with contralateral side or naive control. Primary sensory nerve fiber length was significantly decreased in the incision skin area in capsaicin-pretreated animals detected by immunohistochemistry and placental alkaline phosphatase (PLAP) staining. Thus, capsaicin pretreatment attenuates incisional pain by suppressing Ca2+ response because of degeneration of primary sensory nerve fibers in the skin.SIGNIFICANCE STATEMENT Postoperative surgery pain is a major health and economic problem worldwide with ∼235 million major surgical procedures annually. Approximately 50% of these patients report uncontrolled or poorly controlled postoperative pain. However, mechanistic studies of postoperative surgery pain in primary sensory neurons have been limited to in vitro models or small numbers of neurons. Using an innovative, distinctive, and interdisciplinary in vivo populational dorsal root ganglia (DRG) imaging (>1800 neurons/DRG) approach, we revealed increased DRG neuronal Ca2+ activity from postoperative pain mouse model. This indicates widespread DRG primary sensory neuron plasticity. Increased neuronal Ca2+ activity occurs among various sizes of neurons but mostly in small-diameter and medium-diameter nociceptors. Capsaicin pretreatment as a therapeutic option significantly attenuates Ca2+ activity and postoperative pain.
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Affiliation(s)
- Hirotake Ishida
- Department of Oral and Maxillofacial Surgery, University of Texas Health and Science Center at San Antonio, Texas, 78229
| | - Yan Zhang
- Department of Oral and Maxillofacial Surgery, University of Texas Health and Science Center at San Antonio, Texas, 78229
| | - Ruben Gomez
- Department of Oral and Maxillofacial Surgery, University of Texas Health and Science Center at San Antonio, Texas, 78229
| | - John Shannonhouse
- Department of Oral and Maxillofacial Surgery, University of Texas Health and Science Center at San Antonio, Texas, 78229
| | - Hyeonwi Son
- Department of Oral and Maxillofacial Surgery, University of Texas Health and Science Center at San Antonio, Texas, 78229
| | - Ratan Banik
- Department of Anesthesiology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, 55455
| | - Yu Shin Kim
- Department of Oral and Maxillofacial Surgery, University of Texas Health and Science Center at San Antonio, Texas, 78229
- Programs in Integrated Biomedical Sciences, Translational Sciences, Biomedical Engineering, Radiological Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229
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25
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Verrier M, Niu S, Kroetch K, Buro K, Douglas C, Green J, Pedersen ME, Dillane D. A prospective observational study of persistent opioid use after complex foot and ankle surgery. Can J Anaesth 2021; 69:945-952. [PMID: 34561837 DOI: 10.1007/s12630-021-02104-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/18/2021] [Accepted: 07/30/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The incidence of persistent postsurgical opioid use (PPOU) after complex foot and ankle surgery is unknown. We aimed to determine the incidence and characteristics of PPOU in opioid-naïve, occasional, and regular opioid users at baseline and at six weeks, three months, and six months postoperatively. METHODS We conducted a prospective observational study in patients undergoing complex foot and ankle surgery over an 18-month period. Daily opioid consumption was recorded at the indicated intervals. Logistic regression models were fit to predict the risk of opioid use at these intervals. The Brief Pain Inventory (BPI) was used to record pain intensity and interference. Correlations were tested between opioid use and BPI interference parameters. RESULTS Eighty-two out of 139 consecutively approached patients were included in the final analysis. Six percent (98.3% confidence interval [CI], 2 to 20) of patients who were not using opioids preoperatively at baseline were using opioids daily at three and six months after surgery. Fifty percent (98.3% CI, 26 to 73) of patients who were regular opioid users preoperatively continued to use opioids daily six months after surgery. All associations between BPI interference parameters and opioid use were estimated to be positive. CONCLUSION The probability of using opioid analgesia six months after complex foot and ankle surgery was significantly higher in patients who used opioids preoperatively. Regular preoperative opioid use was associated with a greater risk of PPOU compared with occasional or "as required" opioid use prior to surgery.
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Affiliation(s)
- Michelle Verrier
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - Shuang Niu
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kimberly Kroetch
- Department of Mathematics and Statistics, MacEwan University, Edmonton, AB, Canada
| | - Karen Buro
- Department of Mathematics and Statistics, MacEwan University, Edmonton, AB, Canada
| | - Chris Douglas
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - James Green
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mary E Pedersen
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada. .,University of Alberta, 2-150 Clinical Sciences Building, Edmonton, AB, Canada.
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Ilyas AM, Chapman T, Zmistowski B, Sandrowski K, Graham J, Hammoud S. The Effect of Preoperative Opioid Education on Opioid Consumption After Outpatient Orthopedic Surgery: A Prospective Randomized Trial. Orthopedics 2021; 44:123-127. [PMID: 33561870 DOI: 10.3928/01477447-20210201-07] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pain management and opioid consumption following outpatient orthopedic surgery may be influenced by several variables, including knowledge of safe opioid use. A prospective randomized study was undertaken to understand the effect of preoperative opioid education on opioid consumption following outpatient orthopedic surgeries. A total of 237 patients undergoing outpatient orthopedic surgeries were prospectively randomized to receive preoperative opioid education or not. Postoperative data collected included the number of pills taken, daily visual analog scale (VAS) pain scores, adverse events, and attitude toward the pain experience. A total of 107 patients were randomized to receive preoperative education and 130 to not receive preoperative education. On average, 27 pills were prescribed to each patient. The preoperative opioid education group consumed significantly fewer opioids (6 pills) when compared with the group not receiving education (12 pills) (P<.05). The findings were the same with upper and lower extremity surgeries. Overall, the 2 groups of patients had similar daily VAS scores and were satisfied with their postoperative pain experience irrespective of opioid education. Of the total opioid pills prescribed during the study, only 46% were ultimately consumed. Preoperative education significantly reduced the number of prescription opioid pills and total morphine equivalents consumed by patients in the period following outpatient orthopedic surgery, with no negative effects on pain experience. This finding was consistent in both upper and lower extremity surgery. Approximately twice the number of opioids were prescribed than ultimately consumed by patients. [Orthopedics. 2021;44(2):123-127.].
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Hartwell MJ, Selley RS, Alvandi BA, Dayton SR, Terry MA, Tjong VK. Reduced Opioid Prescription After Anterior Cruciate Ligament Reconstruction Does Not Affect Postoperative Pain or Prescription Refills: A Prospective, Surgeon-Blinded, Randomized, Controlled Trial. Arthrosc Sports Med Rehabil 2021; 3:e651-e658. [PMID: 34195628 PMCID: PMC8220566 DOI: 10.1016/j.asmr.2020.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 12/29/2020] [Indexed: 11/12/2022] Open
Abstract
Purpose To investigate opioid utilization after anterior cruciate ligament (ACL) reconstruction in the setting of a multimodal pain regimen and assess the feasibility of prescribing fewer opioids to achieve adequate postoperative pain control. Methods Patients undergoing ACL reconstruction in conjunction with a multimodal approach to pain control were randomized to receive either 30 or 60 tablets of hydrocodone (10 mg)–acetaminophen (325 mg). Patients were contacted at multiple time points up to 21 days after surgery to assess opioid utilization and medication side effects. We compared the mean number of tablets used between groups as the primary outcome. Preoperative variables associated with an increased risk of higher opioid pain medication requirements were also assessed. Results The final analysis included 43 patients in the 30-tablet group and 42 in the 60-tablet group. There was no significant difference between groups in the number of tablets consumed (9.5 vs 12.2, P = .22), number of days opioids were required (4.5 vs 6.2, P = .14), 3-month opioid refill rates (12% vs 7%, P = .48), or postoperative pain control at any point up to 21 days after surgery. The 30-tablet group had a significantly smaller proportion of unused tablets compared with the 60-tablet group (69% of prescribed tablets [910 tablets] vs 80% of prescribed tablets [2,027 tablets], P < .001). Opioids were required after surgery by 91% of patients (n = 77), and 81% could have had their pain medication requirements met with a prescription for 15 tablets. Risk factors for increased postoperative opioid use included a family history of substance abuse (β = 14.1; 95% confidence interval, 5.7-22.4; P = .0014) and increased pain score at 2 hours after surgery (β = 1.07; 95% confidence interval, 0.064-2.07; P = .037). Conclusions Orthopaedic surgeons may significantly reduce the number opioid tablets prescribed after ACL reconstruction without affecting postoperative pain control or refill rates. Level of Evidence Level I, randomized controlled trial.
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Affiliation(s)
- Matthew J Hartwell
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Ryan S Selley
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Bejan A Alvandi
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Steven R Dayton
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Michael A Terry
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Vehniah K Tjong
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
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Keller DS, Kenney BC, Harbaugh CM, Waljee JF, Brummett CM. A national evaluation of opioid prescribing and persistent use after ambulatory anorectal surgery. Surgery 2021; 169:759-766. [PMID: 33288211 PMCID: PMC8194057 DOI: 10.1016/j.surg.2020.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgery is a common gateway to opioid-related morbidity. Ambulatory anorectal cases are common, with opioids widely prescribed, but there is limited data on their role in this crisis. We sought to determine prescribing trends, new persistent opioid use rates, and factors associated with new persistent opioid use after ambulatory anorectal procedures. METHODS The Optum Clinformatics claims database was analyzed for opioid-naïve adults undergoing outpatient hemorrhoid, fissure, or fistula procedures from January 1, 2010, to June 30, 2017. The main outcome measure was the rate of new persistent opioid use after anorectal cases. Secondary outcomes were annual rates of perioperative opioid fills and the prescription size over time (oral morphine equivalents). RESULTS A total of 23,426 cases were evaluated: 69.09% (n = 16,185) hemorrhoids, 24.29% (n = 5,690) fissures, and 6.45% (n = 1,512) fistulas. The annual rate of perioperative opioid fills decreased on average 1.2%/year, from 72% in 2010 to 66% in 2017 (P < .001). Prescribing rates were consistently highest for fistulas, followed by hemorrhoids, then fissures (P < .001). There was a significant reduction in prescription size (oral morphine equivalents) over the study period, with median oral morphine equivalents (interquartile range) of 280 (250-400) in 2010 and 225 (150-375) in 2017 (P < .0001). Overall, 2.1% (n = 499) developed new persistent opioid use. Logistic regression found new persistent opioid use was associated with additional perioperative opioid fills (odds ratio 3.92; 95% confidence interval: 2.92-5.27; P < .0001), increased comorbidity (odds ratio 1.15; confidence interval: 1.09-1.20; P < .00001), tobacco use (odds ratio 1.79; confidence interval: 1.37-2.36; P < .0001), and pain disorders (odds ratio, 1.49; confidence interval, 1.23-1.82); there was no significant association with procedure performed. CONCLUSION Over 2% of ambulatory anorectal procedures develop new persistent opioid use. Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed. This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY.
| | - Brooke C Kenney
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Calista M Harbaugh
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer F Waljee
- Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Chad M Brummett
- Institute of Healthcare Policy and Innovation, Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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Bernardini GL, Brust JCM. Pain Control in Aneurysmal Subarachnoid Hemorrhage Patients in the ICU: Can We Avoid Contributing to the Opioid Crisis? Neurology 2021; 96:873-874. [PMID: 33766989 DOI: 10.1212/wnl.0000000000011907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Gary L Bernardini
- From the Neurology Department (G.L.B.), New York-Presbyterian/Queens, Flushing; and Neurology Department (J.C.M.B.), New York Neurological Institute/Columbia Affiliation, NY.
| | - John C M Brust
- From the Neurology Department (G.L.B.), New York-Presbyterian/Queens, Flushing; and Neurology Department (J.C.M.B.), New York Neurological Institute/Columbia Affiliation, NY
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Hah JM, Hilmoe H, Schmidt P, McCue R, Trafton J, Clay D, Sharifzadeh Y, Ruchelli G, Hernandez Boussard T, Goodman S, Huddleston J, Maloney WJ, Dirbas FM, Shrager J, Costouros JG, Curtin C, Mackey SC, Carroll I. Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial. J Pain Res 2020; 13:2959-2970. [PMID: 33239904 PMCID: PMC7680674 DOI: 10.2147/jpr.s269370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use. Methods In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18–75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively. Results Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87–1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68–0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40–0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39–0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80–0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89–1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06–1.77; P=0.016). Conclusion Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.
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Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Heather Hilmoe
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Peter Schmidt
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Rebecca McCue
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA.,VA Program Evaluation and Resource Center, VHA Office of Mental Health Operations, Palo Alto, CA, USA
| | - Debra Clay
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Gabriela Ruchelli
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Tina Hernandez Boussard
- Department of Medicine, Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Stuart Goodman
- Department of Orthopaedic Surgery and (by Courtesy) Bioengineering, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - James Huddleston
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | | | - Joseph Shrager
- Division of Thoracic Surgery, Stanford University, Stanford, CA, USA
| | - John G Costouros
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Catherine Curtin
- Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Ian Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
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Sheehan JR, Wilson S, Quinlan J, Beer S, Darwent M, Dainty JR, Ezra M, Keating L. Prescription Of analgesia in Emergency Medicine (POEM): a multicentre observational survey of pain relief in patients presenting with an isolated limb fracture and/or dislocation. Br J Pain 2020; 14:211-220. [PMID: 33194185 DOI: 10.1177/2049463719858513] [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: 11/15/2022] Open
Abstract
Background Acute pain is one of the most commonly cited reasons for attendance to the emergency department (ED), and the Royal College of Emergency Medicine (RCEM) Best Practice Guideline (2014) acknowledged that the current management of acute pain in UK EDs is inadequate and has a poor evidence base. Methods The Prescription Of analgesia in Emergency Medicine (POEM) survey is a cross-sectional observational survey of consecutive patients presenting to 12 National Health Service (NHS) EDs with limb fracture and/or dislocation in England and Scotland and was carried out between 2015 and 2017. The primary outcome was to assess the adequacy of pain management in the ED against the recommendations in the RCEM Best Practice Guidelines. Results In all, 8346 patients were identified as attending the ED with a limb fracture and/or dislocation but adherence to RCEM guidelines could only be evaluated for the 4160 (49.8%) patients with a recorded pain score. Of these, 2409/4160 (57.9%) patients received appropriate pain relief, but only 1347 patients were also assessed within 20 minutes of their arrival in the ED. Therefore, according to the RCEM guidelines, only 16.1% (1347/8346) of all patients were assessed and had satisfactory pain management in the ED. Conclusions The POEM survey has identified that pain relief for patients with an isolated limb fracture remains inadequate when strictly compared to the RCEM Best Practice Guidelines. However, we have found that some patients receive analgesia despite having no pain score recorded, while other analgesic modalities are provided that are not currently encompassed by the Best Practice Guidelines. Future iterations of these guidelines may wish to encompass the breadth of available modalities of pain relief and the whole patient journey. In addition, more work is needed to improve timely and repeated assessment of pain and its recording, which has been better achieved in some EDs than others.
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Affiliation(s)
- James Robert Sheehan
- Department of Anaesthesia, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sarah Wilson
- Emergency Department, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Jane Quinlan
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Beer
- Emergency Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Melanie Darwent
- Emergency Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jack R Dainty
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Martyn Ezra
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Liza Keating
- Emergency Department, Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
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Agnew A, Carroll S, Fornelli R, Schell S, Steehler K. Objective Quantification of Opioid Usage After Thyroid Surgery. Int Arch Otorhinolaryngol 2020; 24:e482-e486. [PMID: 33101515 PMCID: PMC7575393 DOI: 10.1055/s-0039-3402496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/15/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction
It is well established that America is in the midst of an opioid crisis with 46 people dying every day from overdoses involving prescription opioids. In the last 2 years, multiple articles have been published indicating that the amount of opioid pain medication needed after discharge from thyroid and parathyroid surgery is low.
Objective
To objectively examine the amount of opioid pain medication required by patients in our practice after thyroid surgery.
Methods
Patients were given a standardized discharge prescription of 30 pills with a combination of 7.5 mg of hydrocodone and 325 mg of acetaminophen after thyroid surgery. They were asked to log the number of pills consumed per day and the level of pain per day using the Wong-Baker faces pain scale. We used in-office pill counts to ensure accuracy of the logs.
Results
While reaching a similar conclusion, the present study is the first to objectively examine the quantity of opioid pain medication consumed between postoperative discharge and office follow-up. Our study objectively demonstrates that 85% of patients consumed less than 75.0 morphine milligram equivalent (MME) after thyroid surgery using in-office pill counts.
Conclusion
Recent multimodality anesthesia research appears promising to dramatically reduce or even eliminate the need for opioid prescriptions upon postoperative discharge.
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Affiliation(s)
- Andrew Agnew
- Department of Medical Education, University of Pittsburgh Medical Center (UPMC), Erie, PA, United States
| | - Sean Carroll
- Department of Otolaryngology Head and Neck Surgery, UPMC Hamot, Erie, PA, United States
| | - Rick Fornelli
- Department of Otolaryngology Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, United States.,Department of Otolaryngology, UPMC Hamot, Erie, PA, United States
| | - Stephen Schell
- Department of Otolaryngology Head and Neck Surgery, UPMC Hamot, Erie, PA, United States
| | - Kirk Steehler
- Department of Otolaryngology Head and Neck Surgery, UPMC Hamot, Erie, PA, United States
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Shen SA, Jafari A, Qualliotine JR, DeConde AS. Incidence and Predictive Factors for Additional Opioid Prescription after Endoscopic Skull Base Surgery. J Neurol Surg B Skull Base 2020; 81:301-307. [PMID: 32500006 DOI: 10.1055/s-0039-1692473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/11/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction Postoperative pain management and opioid use following endoscopic skull base surgery (ESBS) is not well understood. A subset of patients requires additional opioid prescription (AOP) in the postoperative period. The objective of this study is to describe the incidence of AOP, as well as evaluate patient and surgical characteristics that may predict additional pain management requirements following ESBS. Methods A retrospective review of cases undergoing ESBS between November 2016 and August 2018 was performed. We reviewed patients' sociodemographic and clinical data, and Controlled Substance Utilization Review and Evaluation System (CURES) records. Stepwise multivariable logistic regressions were performed to evaluate the factors associated with AOP within 60 days following surgery. Results A total of 42 patients were identified. Indications for ESBS included intracranial mass (64.2%), sinonasal malignancy (23.8%), and skull base reconstruction (9.5%). AOP were recorded in nine patients (21.4%). There were no significant differences in operative factors, including approach, lesion location, or perioperative analgesia between the two cohorts. On multivariable logistic regression, we found that younger age (odds ratio [OR]: 0.891, 95% confidence interval [CI]: 0.79-1.00, p = 0.050), comorbid depression (OR: 86.48, 95% CI: 1.40-5,379.07, p = 0.034), and preoperative opioid use (OR: 104.45, 95% CI: 1.41-7,751.10, p = 0.034) were associated with additional prescriptions postoperatively. Conclusion The requirement for extended postoperative opioid pain control is common after ESBS. Patient demographics including age and psychosocial factors, such as depression may predict the need for AOP after ESBS. These results suggest that patient-driven factors, rather than surgical characteristics, may determine the need for prolonged pain control requirements after ESBS.
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Affiliation(s)
- Sarek A Shen
- School of Medicine, University of California San Diego, La Jolla, California, United States
| | - Aria Jafari
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, United States
| | - Jesse R Qualliotine
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, United States
| | - Adam S DeConde
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, United States
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Lawal OD, Gold J, Murthy A, Ruchi R, Bavry E, Hume AL, Lewkowitz AK, Brothers T, Wen X. Rate and Risk Factors Associated With Prolonged Opioid Use After Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e207367. [PMID: 32584407 PMCID: PMC7317603 DOI: 10.1001/jamanetworkopen.2020.7367] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Prolonged opioid use after surgery may be associated with opioid dependency and increased health care use. However, published studies have reported varying estimates of the magnitude of prolonged opioid use and risk factors associated with the transition of patients to long-term opioid use. OBJECTIVES To evaluate the rate and characteristics of patient-level risk factors associated with increased risk of prolonged use of opioids after surgery. DATA SOURCES For this systematic review and meta-analysis, a search of MEDLINE, Embase, and Google Scholar from inception to August 30, 2017, was performed, with an updated search performed on June 30, 2019. Key words may include opioid analgesics, general surgery, surgical procedures, persistent opioid use, and postoperative pain. STUDY SELECTION Of 7534 articles reviewed, 33 studies were included. Studies were included if they involved participants 18 years or older, evaluated opioid use 3 or more months after surgery, and reported the rate and adjusted risk factors associated with prolonged opioid use after surgery. DATA EXTRACTION AND SYNTHESIS The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed. Two reviewers independently assessed and extracted the relevant data. MAIN OUTCOMES AND MEASURES The weighted pooled rate and odds ratios (ORs) of risk factors were calculated using the random-effects model. RESULTS The 33 studies included 1 922 743 individuals, with 1 854 006 (96.4%) from the US. In studies with available sex and age information, participants were mostly female (1 031 399; 82.7%) and had a mean (SD) age of 59.3 (12.8) years. The pooled rate of prolonged opioid use after surgery was 6.7% (95% CI, 4.5%-9.8%) but decreased to 1.2% (95% CI, 0.4%-3.9%) in restricted analyses involving only opioid-naive participants at baseline. The risk factors with the strongest associations with prolonged opioid use included preoperative use of opioids (OR, 5.32; 95% CI, 2.94-9.64) or illicit cocaine (OR, 4.34; 95% CI, 1.50-12.58) and a preoperative diagnosis of back pain (OR, 2.05; 95% CI, 1.63-2.58). No significant differences were observed with various study-level factors, including a comparison of major vs minor surgical procedures (pooled rate: 7.0%; 95% CI, 4.9%-9.9% vs 11.1%; 95% CI, 6.0%-19.4%; P = .20). Across all of our analyses, there was substantial variability because of heterogeneity instead of sampling error. CONCLUSIONS AND RELEVANCE The findings suggest that prolonged opioid use after surgery may be a substantial burden to public health. It appears that strategies, such as proactively screening for at-risk individuals, should be prioritized.
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Affiliation(s)
- Oluwadolapo D. Lawal
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
| | - Justin Gold
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
| | - Amala Murthy
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
| | - Rupam Ruchi
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville
| | - Egle Bavry
- Pain Medicine Section, Anesthesiology Service, Malcom Randall VA Medical Center, Gainesville, Florida
| | - Anne L. Hume
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
- Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Adam K. Lewkowitz
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, Providence
| | - Todd Brothers
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
- Roger Williams Medical Center, Providence, Rhode Island
| | - Xuerong Wen
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
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35
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Jivraj NK, Raghavji F, Bethell J, Wijeysundera DN, Ladha KS, Bateman BT, Neuman MD, Wunsch H. Persistent Postoperative Opioid Use: A Systematic Literature Search of Definitions and Population-based Cohort Study. Anesthesiology 2020; 132:1528-1539. [PMID: 32243330 PMCID: PMC8202398 DOI: 10.1097/aln.0000000000003265] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events. METHODS The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery. RESULTS Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00. CONCLUSIONS The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures.
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Affiliation(s)
- Naheed K Jivraj
- From the Department of Anesthesiology and Pain Medicine (N.K.J., D.N.W., K.S.L., H.W.) Interdepartmental Division of Critical Care Medicine (H.W.), University of Toronto, Toronto, Canada the Institute of Health Policy Management and Evaluation, Toronto, Canada (N.K.J., D.N.W., K.S.L., H.W.) the University of Limerick, Limerick, Ireland (F.R.) the Sunnybrook Research Institute, Toronto, Canada (J.B., H.W.) the Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada (D.N.W., K.S.L.) the Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B.) the Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (M.D.N.) the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada (H.W.)
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36
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Veal F, Thompson A, Halliday S, Boyles P, Orlikowski C, Bereznicki L. The Persistence of Opioid Use Following Surgical Admission: An Australian Single-Site Retrospective Cohort Study. J Pain Res 2020; 13:703-708. [PMID: 32308469 PMCID: PMC7148161 DOI: 10.2147/jpr.s235764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/07/2020] [Indexed: 11/23/2022] Open
Abstract
Background Acute pain is common following surgery, with opioids frequently employed in its management. Studies indicate that commencing an opioid during a hospital admission increases the likelihood of long-term use. This study aimed to identify the prevalence of opioid persistence amongst opioid-naïve patients following surgery as well as the indication for use. Methods A retrospective review of patients who underwent a surgical procedure at the Royal Hobart Hospital, Tasmania, Australia, between August and September 2016 was undertaken. Patients were linked to the Tasmanian real-time prescription monitoring database to ascertain if they were subsequently dispensed a Schedule 8 opioid (morphine, codeine oxycodone, buprenorphine, hydromorphone, fentanyl, methadone, or tapentadol) and the indication for use. Results Of the 3275 hospital admissions, 1015 opioid-naïve patients were eligible for inclusion. Schedule 8 opioids were dispensed at or within 2 days of discharge in 41.7% of admissions. Thirty-nine (3.9%) patients received prescribed opioids 2-months post-discharge; 1.8% of the patients were approved by State Health to be prescribed Schedule 8 opioids regularly for a chronic condition at 6 months, and 1.3% received infrequent or one-off prescriptions for Schedule 8 opioids at 6 months. Thirteen (1.3%) patients continued Schedule 8 opioids for at least 6 months following their surgery, with the indication for treatment either related to the surgery or the condition which surgery was sought for. Conclusion This study found that there was a low rate of Schedule 8 opioid persistence following surgery, indicating post-surgical pain is not a significant driver for persistent opioid use.
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Affiliation(s)
- Felicity Veal
- Unit for Medication Outcomes Research & Education (UMORE), School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | - Angus Thompson
- Unit for Medication Outcomes Research & Education (UMORE), School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Peter Boyles
- Department of Health, Hobart, Tasmania, Australia
| | | | - Luke Bereznicki
- Unit for Medication Outcomes Research & Education (UMORE), School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
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37
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Nwaneshiudu CA, Shi XY, Clark JD. Incisional Injury Modulates Morphine Reward and Morphine-Primed Reinstatement: A Role of Kappa Opioid Receptor Activation. Anesth Analg 2020; 130:248-257. [PMID: 31166231 DOI: 10.1213/ane.0000000000004142] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Persistent use of prescription opioids beyond the period of surgical recovery is a large part of a public health problem linked to the current opioid crisis in the United States. However, few studies have been conducted to examine whether morphine reward is influenced by acute pain and injury. METHODS In a mouse model of incisional injury and minor trauma, animals underwent conditioning, extinction, and drug-primed reinstatement with morphine to examine the rewarding properties of morphine in the presence of acute incisional injury and drug-induced relapse, respectively. In addition, we sought to determine whether these behaviors were influenced by kappa opioid receptor signaling and measured expression of prodynorphin messenger RNA in the nucleus accumbens and medial prefrontal cortex after conditioning and before reinstatement with morphine and incisional injury. RESULTS In the presence of incisional injury, we observed enhancement of morphine reward with morphine-conditioned place preference but attenuated morphine-primed reinstatement to reward. This adaptation was not present in animals conditioned 12 days after incisional injury when nociceptive sensitization had resolved; however, they showed enhancement of morphine-primed reinstatement. Prodynorphin expression was greatly enhanced in the nucleus accumbens and medial prefrontal cortex of mice with incisional injury and morphine conditioning and remained elevated up to drug-primed reinstatement. These changes were not observed in mice conditioned 12 days after incisional injury. Further, kappa opioid receptor blockade with norbinaltorphimine before reinstatement reversed the attenuation induced by injury. CONCLUSIONS These findings suggest enhancement of morphine reward as a result of incisional injury but paradoxically a protective adaptation with incisional injury from drug-induced relapse resulting from kappa opioid receptor activation in the reward circuitry. Remote injury conferred no such protection and appeared to enhance reinstatement.
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Affiliation(s)
- Chinwe A Nwaneshiudu
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Xiao-You Shi
- Department of Anesthesiology, Perioperative and Pain Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - J David Clark
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,Department of Anesthesiology, Perioperative and Pain Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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38
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Potential for Harm Associated with Discharge Opioids After Hospital Stay: A Systematic Review. Drugs 2020; 80:573-585. [DOI: 10.1007/s40265-020-01294-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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39
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Jacobs CA, Hawk GS, Jochimsen KN, Conley CEW, Vranceanu AM, Thompson KL, Duncan ST. Depression and Anxiety Are Associated With Increased Health Care Costs and Opioid Use for Patients With Femoroacetabular Impingement Undergoing Hip Arthroscopy: Analysis of a Claims Database. Arthroscopy 2020; 36:745-750. [PMID: 31924382 PMCID: PMC7060818 DOI: 10.1016/j.arthro.2019.09.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 09/18/2019] [Accepted: 09/25/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine if opioid use and health care costs in the year before and following hip arthroscopy for femoroacetabular impingement (FAI) differ between those with or without depression or anxiety. METHODS Using the Truven Health Marketscan database, FAI patients who underwent hip arthroscopy between October 2010 and December 2015 were identified (Current Procedural Terminology codes 29914 [femoroplasty], 29915 [acetabuloplasty], and/or 29916 [labral repair]). Patients were excluded if they had incomplete coverage for 1 year either before or following surgery. The number of patients with 1 or more claims related to depression or anxiety during the year before surgery was quantified (International Statistical Classification Diseases and Related Health-9 codes 296, 298, 300, 309, 311). Health care costs in the year before and following hip arthroscopy were compared between those with or without depression or anxiety. We also compared the number of patients in each group who filled a narcotic pain prescription within 180 days before surgery as well as >60 or >90 days after hip arthroscopy. RESULTS Depression or anxiety claims were seen in 5,208/14,830 patients (35.1%) before surgery. A significantly greater proportion of those with preoperative depression or anxiety filled opioid-related prescriptions in the 6 months before surgery (36.2% vs 25.6%, P < .0001) and both >60 days (31.3% vs 24.7%, P < .0001) and >90 days after surgery (29.5% vs 23.4%, P < .0001). The group with preoperative depression or anxiety had significantly greater health care costs both before ($8,775 vs $5,674, P < .0001) and following surgery ($5,287 vs $3,908, P < .0001). CONCLUSIONS Both before and following hip arthroscopy, opioid use and health care costs were significantly greater for FAI patients with comorbid depression or anxiety. LEVEL OF EVIDENCE Level III, retrospective comparative therapeutic study.
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40
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Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, Mythen M, Miller TE, Shaw AD, Gan TJ, Thacker JKM, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives. Anesth Analg 2020; 129:543-552. [PMID: 30897590 DOI: 10.1213/ane.0000000000003941] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.
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Affiliation(s)
- Michael L Kent
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Robert W Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Gary M Oderda
- College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - Debra B Gordon
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Eric Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Monty Mythen
- University College London National Institute of Health Research (NIHR) Biomedical Research Centre, London, United Kingdom
| | - Timothy E Miller
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Julie K M Thacker
- Division of Advanced Oncologic and Gastrointestinal Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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41
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Sanchez Traun KB, Schauberger CW, Ramirez LD, Jones CW, Lindberg AF, Molero Bravo RA, Wright TE, Traun BD, Peterson SE, Rudolf VP. Opioid prescribing trends in postpartum women: a multicenter study. Am J Obstet Gynecol MFM 2019; 1:100055. [PMID: 33345845 DOI: 10.1016/j.ajogmf.2019.100055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The postpartum period can be a particularly vulnerable time for exposure to opioid medications, and there are currently no consensus guidelines for physicians to follow regarding opioid prescribing during this period. OBJECTIVE The purpose of this study was to evaluate inter- and intrahospital variability in opioid prescribing patterns in postpartum women and better understand the role of clinical variables in prescribing. STUDY DESIGN Data were extracted from electronic medical records on 4248 patients who delivered at 6 hospitals across the United States from January 2016 through March 2016. The primary outcome of the study was postpartum opioid prescription at the time of hospital discharge. Age, parity, route of delivery, and hospital were analyzed individually and with multivariate analyses to minimize confounding factors. Statistical methods included χ2 to analyze frequency of opioid prescription by hospital, parity, tobacco use, delivery method, and laceration type. An analysis of variance was used to analyze morphine equivalent dose by hospital. RESULTS The percentage of women prescribed postpartum opioids varied significantly by hospital, ranging from 27.6% to 70.9% (P <0.001). Oxycodone-acetaminophen was the most commonly prescribed medication (50.3%) with each hospital having its preferred opioid type. Median number of tablets prescribed ranged from 20 to 40 (P < .0001). Primiparous women were more likely to receive opioids than multiparous women when broken down by a parity of 1, 2, 3, 4, and ≥5 (52.8%, 48.0%, 47.6%, 40.1%, and 45.8%, respectively, P = .0005). Among women who had vaginal deliveries, opioid prescription rates were higher in women who experienced either a second-degree laceration (35.5%, P = .0002) or a third-/fourth-degree laceration (59.3%, P < .001). CONCLUSION Postpartum opioid prescription rates vary widely among hospitals, but providers within the same hospital tend to follow similar prescribing trends. The variation in prescribing found in our study illustrates the need for clear consensus guidelines for postpartum pain management.
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Affiliation(s)
| | | | - Luis D Ramirez
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI
| | - Cresta W Jones
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN
| | - Alisha F Lindberg
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN
| | | | - Tricia E Wright
- Department of Obstetrics and Gynecology, University of Hawaii, Honolulu, HI
| | - Benjamin D Traun
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI
| | - Suzanne E Peterson
- Department of Obstetrics and Gynecology, Swedish Medical Center, Seattle, WA
| | - Vania P Rudolf
- Addiction Recovery Services, Swedish Medical Center, Seattle, WA
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Hah J, Mackey SC, Schmidt P, McCue R, Humphreys K, Trafton J, Efron B, Clay D, Sharifzadeh Y, Ruchelli G, Goodman S, Huddleston J, Maloney WJ, Dirbas FM, Shrager J, Costouros JG, Curtin C, Carroll I. Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA Surg 2019; 153:303-311. [PMID: 29238824 DOI: 10.1001/jamasurg.2017.4915] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice. Objective To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation. Design, Setting, and Participants A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings. Interventions Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours. Main Outcomes and Measures Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year. Results Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]). Conclusions and Relevance Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research. Trial Registration clinicaltrials.gov Identifier: NCT01067144.
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Affiliation(s)
- Jennifer Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
| | - Peter Schmidt
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Rebecca McCue
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Keith Humphreys
- Center for Healthcare Evaluation, Veterans Health Administration, Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
| | - Jodie Trafton
- Center for Healthcare Evaluation, Veterans Health Administration, Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California.,Veterans Administration Program Evaluation and Resource Center, Veterans Health Administration Office of Mental Health Operations, Menlo Park, California
| | - Bradley Efron
- Department of Biomedical Data Science, Stanford University, Palo Alto, California
| | - Debra Clay
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Gabriela Ruchelli
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California
| | - Stuart Goodman
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California.,Department of Bioengineering, Stanford University, Palo Alto, California
| | - James Huddleston
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Frederick M Dirbas
- Department of General Surgery, Stanford University, Palo Alto, California
| | - Joseph Shrager
- Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University, Palo Alto, California
| | - John G Costouros
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Catherine Curtin
- Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Ian Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California
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43
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Weingarten TN, Taenzer AH, Elkassabany NM, Le Wendling L, Nin O, Kent ML. Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps. PAIN MEDICINE 2019; 19:2296-2315. [PMID: 29727003 DOI: 10.1093/pm/pny079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andreas H Taenzer
- Departments of Anesthesiology.,Pediatrics, The Dartmouth Institute, Dartmouth Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda Le Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Olga Nin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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44
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Badash I, Lui CG, Hur K, Acevedo JR, Ference EH, Wrobel BB. Quantifying the use of opioids in the immediate postoperative period after endoscopic sinus surgery. Laryngoscope 2019; 130:1122-1127. [DOI: 10.1002/lary.28178] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/02/2019] [Accepted: 06/19/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Ido Badash
- Keck School of MedicineUniversity of Southern California Los Angeles California U.S.A
| | - Christopher G. Lui
- Keck School of MedicineUniversity of Southern California Los Angeles California U.S.A
| | - Kevin Hur
- Caruso Department of Otolaryngology–Head and Neck SurgeryUniversity of Southern California Los Angeles California U.S.A
| | - Joseph R. Acevedo
- Caruso Department of Otolaryngology–Head and Neck SurgeryUniversity of Southern California Los Angeles California U.S.A
| | - Elisabeth H. Ference
- Caruso Department of Otolaryngology–Head and Neck SurgeryUniversity of Southern California Los Angeles California U.S.A
| | - Bozena B. Wrobel
- Caruso Department of Otolaryngology–Head and Neck SurgeryUniversity of Southern California Los Angeles California U.S.A
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45
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Oliver JE, Carlson C. Misperceptions about the 'Opioid Epidemic:' Exploring the Facts. Pain Manag Nurs 2019; 21:100-109. [PMID: 31327624 DOI: 10.1016/j.pmn.2019.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/01/2019] [Accepted: 05/22/2019] [Indexed: 11/16/2022]
Abstract
A plethora of statistics and claims exist concerning the rise in prescription opioid use and the increase in opioid-related deaths. Eleven misperceptions were identified that underlie some of the growing national concern and backlash against opioid use. Misperceptions include the number of opioid overdose deaths, the quality of government-sponsored data and guidelines, the impact of opioid dose escalation on overdose risk, postoperative opioid use associated with long-term use, and the link between prescription opioid use and heroin initiation. Implications for research, practice and education include (a) a call for improvement in data recording, (b) unbiased and clear reporting of information, (c) a call for health care providers to ask critical questions when presented with data, and (d) a call for policymakers to avoid unnecessarily restrictive practices that are founded in fear and may cause unintended harm to patients in pain.
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Affiliation(s)
- June E Oliver
- Pain Service, Swedish Covenant Hospital, Chicago, Illinois, USA
| | - Cathy Carlson
- School of Nursing, Northern Illinois University, DeKalb, Illinois, USA.
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46
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Ilfeld BM, Ball ST, Cohen SP, Hanling SR, Fowler IM, Wongsarnpigoon A, Boggs JW. Percutaneous Peripheral Nerve Stimulation to Control Postoperative Pain, Decrease Opioid Use, and Accelerate Functional Recovery Following Orthopedic Trauma. Mil Med 2019; 184:557-564. [PMID: 30901395 DOI: 10.1093/milmed/usy378] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/14/2018] [Indexed: 11/13/2022] Open
Abstract
Orthopedic trauma is a significant military problem, causing several of the most disabling conditions with high rates of separation from duty and erosion of military readiness. The objective of this report is to summarize the findings of case series of a non-opioid therapy-percutaneous peripheral nerve stimulation (PNS) - and describe its potential for postoperative analgesia, early opioid cessation, and improved function following orthopedic trauma. Percutaneous PNS has been evaluated for the treatment of multiple types of pain, including two case series on postoperative pain following total knee replacement (n = 10 and 8, respectively) and a case series on postamputation pain (n = 9). The orthopedic trauma induced during TKR is highly representative of multiple types of orthopedic trauma sustained by Service members and frequently produces intense, prolonged postoperative pain and extended opioid use following surgery. Collectively, the results of these three clinical studies demonstrated that percutaneous PNS can provide substantial pain relief, reduce opioid use, and improve function. These outcomes suggest that there is substantial potential for the use of percutaneous PNS following orthopedic trauma.
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Affiliation(s)
- Brian M Ilfeld
- University of California San Diego, 200 W Arbor Drive, San Diego, CA
| | - Scott T Ball
- University of California San Diego, 200 W Arbor Drive, San Diego, CA
| | - Steven P Cohen
- Johns Hopkins School of Medicine, Department of Anesthesiology and Critical Care Medicine, 1800 Orleans Street, Baltimore, MD
| | - Steven R Hanling
- Medical College of Georgia, Department of Anesthesiology & Perioperative Medicine, BIW-2144 1120 15th Street, Augusta, GA
| | - Ian M Fowler
- Naval Medical Center San Diego, Department of Anesthesiology, 34800 Bob Wilson Dr, San Diego, CA
| | | | - Joseph W Boggs
- SPR Therapeutics, 22901 Millcreek Boulevard, Suite 110, Cleveland, OH
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47
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Gabriel RA, Ilfeld BM. Peripheral nerve blocks for postoperative analgesia: From traditional unencapsulated local anesthetic to liposomes, cryoneurolysis and peripheral nerve stimulation. Best Pract Res Clin Anaesthesiol 2019; 33:293-302. [PMID: 31785715 DOI: 10.1016/j.bpa.2019.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 02/01/2023]
Abstract
Peripheral nerve blocks (PNBs) using local anesthetics either via single injection or continuous perineural catheter have been the mainstay for regional anesthesia and are a vital component of postoperative multimodal opioid-sparing pain management. There are some limitations to PNBs, however, mainly its limited duration of action, but also risk of catheter-associated infection and dislodgements. Furthermore, local anesthetic-based blocks can induce sensory deficits and motor weakness, possibly increasing the risk of falling and/or decreasing the ability to participate in postoperative rehabilitation. In this review, we first discuss various local anesthetic-based PNB techniques for major surgery and then review newer modalities, including liposome bupivacaine, cryoanalgesia, and peripheral nerve stimulation; all of which may offer advantages over single and continuous local anesthetic-based PNBs.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA.
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA.
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48
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Lillemoe HA, Marcus RK, Day RW, Kim BJ, Narula N, Davis CH, Gottumukkala V, Aloia TA. Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids. Surgery 2019; 166:22-27. [PMID: 31103198 PMCID: PMC6579699 DOI: 10.1016/j.surg.2019.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/30/2019] [Accepted: 02/06/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pathways of enhanced recovery in liver surgery decrease inpatient opioid use; however, little data exist regarding their effect on discharge prescriptions and post-discharge opioid intake. METHODS For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to enhanced recovery vs. traditional care pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The enhanced recovery in liver surgery protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation. RESULTS Of 244 cases, 147 enhanced recovery patients were compared with 97 traditional pathway patients. Enhanced recovery patients were older (median 57 years vs 52 years, P = .031) and more frequently had minimally invasive operations (37% vs 16%, P < .001), with fewer major complications (2% vs 9%, P = .011). Enhanced recovery patients were less likely to be discharged with a prescription for traditional opioids (26% vs 79%, P < .001) and less likely to require opioids at their first postoperative visit (19% vs 61%, P < .001) despite similarly low patient-reported pain scores (median 2/10 both groups, P = .500). On multivariable analysis, the traditional recovery pathway was independently associated with traditional opioid use at the first follow-up (odds ratio 6.4, 95% confidence interval 3.5-12.1; P < .001). CONCLUSION The implementation of an enhanced recovery in liver surgery pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other populations at risk of persistent opioid use, enhanced recovery strategies can eliminate excess availability of opioids.
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Affiliation(s)
- Heather A Lillemoe
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Rebecca K Marcus
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Ryan W Day
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Bradford J Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Nisha Narula
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Catherine H Davis
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston.
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49
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Evaluation of Opioid Use With Split Doses of Oral Opioids in a Postcesarean Delivery Analgesia Order Set. Obstet Gynecol 2019; 134:120-127. [DOI: 10.1097/aog.0000000000003305] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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Stulberg JJ, Schäfer WLA, Shallcross ML, Lambert BL, Huang R, Holl JL, Bilimoria KY, Johnson JK. Evaluating the implementation and effectiveness of a multi-component intervention to reduce post-surgical opioid prescribing: study protocol of a mixed-methods design. BMJ Open 2019; 9:e030404. [PMID: 31164370 PMCID: PMC6561445 DOI: 10.1136/bmjopen-2019-030404] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Opioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers' role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies. METHODS AND ANALYSIS The Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network's enterprise data warehouse will be used to evaluate the intervention's effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site. ETHICS AND DISSEMINATION The study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).
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Affiliation(s)
- Jonah J Stulberg
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Willemijn L A Schäfer
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Meagan L Shallcross
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bruce L Lambert
- Centre for Communication and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Reiping Huang
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jane L Holl
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Karl Y Bilimoria
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Julie K Johnson
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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