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Nunn KP, Velazquez AA, Bebawy JF, Ma K, Sinedino BE, Goel A, Pereira SM. Perioperative Methadone for Spine Surgery: A Scoping Review. J Neurosurg Anesthesiol 2024:00008506-990000000-00106. [PMID: 38624227 DOI: 10.1097/ana.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/08/2024] [Indexed: 04/17/2024]
Abstract
Complex spine surgery is associated with significant acute postoperative pain. Methadone possesses pharmacological properties that make it an attractive analgesic modality for major surgeries. This scoping review aimed to summarize the evidence for the perioperative use of methadone in adults undergoing complex spine surgery. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was performed using MEDLINE, CINAHL, Cochrane Library, Scopus, Embase, and Joanna Briggs between January 1946 and April 2023. The initial search identified 317 citations, of which 12 met the criteria for inclusion in the review. There was significant heterogeneity in the doses, routes of administration, and timing of perioperative methadone administration in the included studies. On the basis of the available literature, methadone has been associated with reduced postoperative pain scores and reduced postoperative opioid consumption. Though safety concerns have been raised by observational studies, these have not been confirmed by prospective randomized studies. Further research is required to explore optimal methadone dosing regimens, the potential synergistic relationships between methadone and other pharmacological adjuncts, as well as the potential long-term antinociceptive benefits of perioperative methadone administration.
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Affiliation(s)
- Kieran P Nunn
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Ahida A Velazquez
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - John F Bebawy
- Anesthesiology & Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kan Ma
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Bruno Erick Sinedino
- Discipline of Anesthesiology, Department of Surgery, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Akash Goel
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sergio M Pereira
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Ahmad AH, Carreon LY, Glassman SD, Harpe-Bates J, Sampedro BC, Brown ME, Daniels CL, Schmidt GO, Hines B, Gum JL. Opioid-sparing Anesthesia Decreases In-hospital and 1-year Postoperative Opioid Consumption Compared With Traditional Anesthesia: A Propensity-matched Cohort Study. Spine (Phila Pa 1976) 2024; 49:58-63. [PMID: 37612894 DOI: 10.1097/brs.0000000000004806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
STUDY DESIGN Propensity-matched cohort. OBJECTIVE The aim of this study was to determine if opioid-sparing anesthesia (OSA) reduces in-hospital and 1-year postoperative opioid consumption. SUMMARY OF BACKGROUND DATA The recent opioid crisis highlights the need to reduce opioid exposure. We developed an OSA protocol for lumbar spinal fusion surgery to mitigate opioid exposure. MATERIALS AND METHODS Patients undergoing lumbar fusion for degenerative conditions over one to four levels were identified. Patients taking opioids preoperatively were excluded. OSA patients were propensity-matched to non-OSA patients based on age, sex, smoking status, body mass index, American Society of Anesthesiologists grade, and revision versus primary procedure. Standard demographic and surgical data, daily in-hospital opioid consumption, and opioid prescriptions 1 year after surgery were compared. RESULTS Of 296 OSA patients meeting inclusion criteria, 172 were propensity-matched to non-OSA patients. Demographics were similar between cohorts (OSA: 77 males, mean age=57.69 yr; non-OSA: 67 males, mean age=58.94 yr). OSA patients had lower blood loss (326 mL vs. 399 mL, P =0.014), surgical time (201 vs. 233 min, P <0.001) emergence to extubation time (9.1 vs. 14.2 min, P< 0.001), and recovery room time (119 vs. 140 min, P =0.0.012) compared with non-OSA patients. Fewer OSA patients required nonhome discharge (18 vs. 41, P =0.001) compared with the non-OSA cohort, but no difference in length of stay (90.3 vs. 98.5 h, P =0.204). Daily opioid consumption was lower in the OSA versus the non-OSA cohort from postoperative day 2 (223 vs. 185 morphine milligram equivalents, P =0.017) and maintained each day with lower total consumption (293 vs. 225 morphine milligram equivalents, P =0.003) throughout postoperative day 4. The number of patients with active opioid prescriptions at 1, 3, 6, and 12 months postoperative was statistically fewer in the OSA compared with the non-OSA patients. CONCLUSIONS OSA for lumbar spinal fusion surgery decreases in-hospital and 1-year postoperative opioid consumption. The minimal use of opioids may also lead to shorter emergence to extubation times, shorter recovery room stays, and fewer discharges to nonhome facilities.
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Affiliation(s)
- Amer H Ahmad
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY
- Norton Leatherman Spine Center, Louisville, KY
| | | | - Steven D Glassman
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY
- Norton Leatherman Spine Center, Louisville, KY
| | | | | | | | | | | | - Bren Hines
- Norton Leatherman Spine Center, Louisville, KY
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY
- Norton Leatherman Spine Center, Louisville, KY
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Perez EA, Ray E, Gold CJ, Park BJ, Piscopo A, Carnahan RM, Banks M, Sanders RD, Olinger CR, Mueller RN, Woodroffe RW. Postoperative Use of the Muscle Relaxants Baclofen and/or Cyclobenzaprine Associated With an Increased Risk of Delirium Following Lumbar Fusion. Spine (Phila Pa 1976) 2023; 48:1733-1740. [PMID: 36799727 DOI: 10.1097/brs.0000000000004606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 07/28/2022] [Indexed: 02/18/2023]
Abstract
STUDY DESIGN Retrospective, single-center, cohort study. OBJECTIVE Investigate whether the incidence of postoperative delirium in older adults undergoing spinal fusion surgery is associated with postoperative muscle relaxant administration. SUMMARY OF BACKGROUND DATA Baclofen and cyclobenzaprine are muscle relaxants frequently used for pain management following spine surgery. Muscle relaxants are known to cause central nervous system side effects in the outpatient setting and are relatively contraindicated in individuals at high risk for delirium. However, there are no known studies investigating their side effects in the postoperative setting. METHODS Patients over 65 years of age who underwent elective posterior lumbar fusion for degenerative spine disease were stratified into two treatment groups based on whether postoperative muscle relaxants were administered on postoperative day one as part of a multimodal analgesia regimen. Doubly robust inverse probability weighting with cox regression for time-dependent covariates was used to examine the association between postoperative muscle relaxant use and the risk of delirium while controlling for variation in baseline characteristics. RESULTS The incidence of delirium was 17.6% in the 250 patients who received postoperative muscle relaxants compared with 7.9% in the 280 patients who did not receive muscle relaxants ( P=0.001 ). Multivariate analysis to control for variation in baseline characteristics between treatment groups found that patients who received muscle relaxants had a 2.00 (95% CI: 1.14-3.49) times higher risk of delirium compared with controls ( P=0.015 ). CONCLUSION Postoperative use of muscle relaxants as part of a multimodal analgesia regimen was associated with an increased risk of delirium in older adults after lumber fusion surgery. Although muscle relaxants may be beneficial in select patients, they should be used with caution in individuals at high risk for postoperative delirium.
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Affiliation(s)
- Eli A Perez
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Emanuel Ray
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Colin J Gold
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brian J Park
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Anthony Piscopo
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Ryan M Carnahan
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA
| | - Matthew Banks
- Department of Anesthesiology, University of Wisconsin, Madison, WI
| | - Robert D Sanders
- Specialty of Anaesthetics, University of Sydney, Sydney, Australia
- Department of Anaesthetics & Institute of Academic Surgery, Royal Prince Alfred Hospital, Australia
| | - Catherine R Olinger
- Department of Orthopedic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Rashmi N Mueller
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA
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Esfahani K, Tennant W, Tsang S, Naik BI, Dunn LK. Comparison of oral versus intravenous methadone on postoperative pain and opioid use after adult spinal deformity surgery: A retrospective, non-inferiority analysis. PLoS One 2023; 18:e0288988. [PMID: 37478144 PMCID: PMC10361497 DOI: 10.1371/journal.pone.0288988] [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: 01/17/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVE To compare efficacy of oral versus intravenous (IV) methadone on postoperative pain and opioid requirements after spine surgery. METHODS This was a retrospective, single-academic center cohort study evaluating 1010 patients who underwent >3 level spine surgery from January 2017 to May 2020 and received a one-time dose of oral or intravenous methadone prior to surgery. The primary outcome measured was postoperative opioid use in oral morphine equivalents (ME) and verbal response scale (VRS) pain scores up to postoperative day (POD) three. Secondary outcomes were time to first bowel movement and adverse effects (reintubation, myocardial infarction, and QTc prolongation) up to POD 3. RESULTS A total of 687 patients received oral and 317 received IV methadone, six patients were excluded. The IV group received a significantly greater methadone morphine equivalent (ME) dose preoperatively (112.4 ± 83.0 mg ME versus 59.3 ± 60.9 mg ME, p < 0.001) and greater total (methadone and non-methadone) opioid dose (119.1 ± 81.4 mg ME versus 63.9 ± 62.5 mg ME, p < 0.001), intraoperatively. Although pain scores for the oral group were non-inferior to the IV group for all postoperative days (POD), non-inferiority for postoperative opioid requirements was demonstrated only on POD 3. Based on the joint hypothesis for the co-primary outcomes, oral methadone was non-inferior to IV methadone on POD 3 only. No differences in secondary outcomes, including QTc prolongation and arrhythmias, were noted between the groups. CONCLUSIONS Oral methadone is a feasible alternative to IV methadone for patients undergoing spine surgery regarding both pain scores and postoperative opioid consumption.
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Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - William Tennant
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Siny Tsang
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Lauren K. Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States of America
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Geller JS, Milner JE, Pandya S, Mohile NV, Massel DH, Eismont FJ, Maaieh MA. The Impact of the Florida Law HB21 on Opioid Prescribing Patterns After Spine Surgery. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2023; 14:100202. [PMID: 36970062 PMCID: PMC10034149 DOI: 10.1016/j.xnsj.2023.100202] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/18/2023]
Abstract
Background The opioid epidemic represents a major public health issue in the United States and has led to significant morbidity and mortality. On July 1 2018, Florida implemented state-law House Bill 21 (HB21), limiting opioid prescriptions to a 3-day supply for acute pain or 7 days if an exception is documented. The purpose of this study is to evaluate the effects of HB21 on opioid prescribing patterns after spine surgery. Methods Patients 18 years and older who underwent spine surgery between January 2017 and January 2021 were eligible for inclusion. Information including demographics, pills, days, and morphine milligram equivalents (MMEs) was obtained via retrospective chart review using the Florida Prescription Drug Monitoring Program and Epic Chart Review. Student's t tests and Fisher's exact tests were used for comparison of continuous variables. Multiple logistic regression was utilized to determine which variables were associated with postoperative opioid prescriptions. p<.05 was considered significant. Results We reviewed 114 patients who underwent spine surgery from January 2017 to July 2018 and 264 patients from July 2018 to January 21. There were no significant differences between the groups in age, sex, ethnicity, body mass index, number of levels fused, or preoperative opioid use. The average number of MMEs, pills prescribed and days in the first postoperative prescription decreased significantly after HB21. Multiple logistic regression revealed that the variable most predictive of MMEs and number of pills in the first postoperative prescription was postlaw status (p=.002, p=.50). Conclusions Florida law HB21 was successful in decreasing postoperative opioid prescriptions after spine surgery, however, the need for additional progress remains. Legislation should be combined with multimodal pain regimens, as well as patient and provider education in order to further decrease postoperative opioid requirements. Future studies should include a larger number of patients treated by multiple spine surgeons across multiple institutions in order to further evaluate the effects of HB21 on postoperative opioid prescriptions.
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Affiliation(s)
| | - Jacob E. Milner
- Corresponding author. 801 South Miami Ave, Unit 1901, Miami, FL 33130, USA. Tel.: (203) 927-7339.
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Hozack BA, Kistler JM, Vaccaro AR, Beredjiklian PK. Benzodiazepines and Related Drugs in Orthopaedics. J Bone Joint Surg Am 2022; 104:2204-2210. [PMID: 36223476 DOI: 10.2106/jbjs.22.00516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Benzodiazepines are among the most commonly prescribed drugs worldwide and are often used as anxiolytics, hypnotics, anticonvulsants, and muscle relaxants. ➤ The risk of dependence on and abuse of these medications has recently gained more attention in light of the current opioid epidemic. ➤ Benzodiazepines can increase the risk of prolonged opioid use and abuse. ➤ Given the prevalence of the use of benzodiazepines and related drugs, orthopaedic patients are often prescribed these medications. ➤ Orthopaedic surgeons need to be aware of the prevalence of benzodiazepine and related drug prescriptions in the general population, their current uses in orthopaedic surgery, and the risks and adverse effects of their use.
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Affiliation(s)
- Bryan A Hozack
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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