Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders

Chronic Use of Prescription Pain Medication and Outcomes in Patients With Burn Injury: A Burn Model System National Database Study

OBJECTIVE

This study attempts to examine long-term pain medication usage after burn injury and its association with functional and psychosocial outcomes.

DESIGN

This is a multicenter retrospective cohort study utilizing the Burn Model System National Longitudinal Database. Participants injured from 2015 to 2021 were divided into two groups, those taking and not taking prescription pain medication at 12 mos after injury. Regression analyses examined associations between pain medication use and outcomes at 12 mos, adjusting for demographics, burn size, length of hospital stay, and preinjury pain medication use and employment status. Outcomes included VR-12 Physical and Mental Component Summary scores Patient-Reported Outcomes Measurement Information System Anxiety and Depression scores, Satisfaction with Life Scale, and employment status.

RESULTS

Of 358 participants analyzed, prescription pain medication use was associated with worse outcomes at 12 mos: Physical Component Summary (β = -7.11, P < 0.001), Mental Component Summary (β = -6.01, P < 0.001), and Patient-Reported Outcomes Measurement Information System Depression (β = 4.88, P < 0.001) and Anxiety (β = 6.16, P < 0.001). Satisfaction with Life Scale was not significantly associated with pain medication use ( P = 0.069) and those taking pain medication were 52% less likely to be employed at 12 mos ( P = 0.035).

CONCLUSIONS

There is a significant association between prescription pain medication use and worse physical, mental, and employment outcomes at 12 mos after burn injury.

Impact of Prescription Medicines on Work-Related Outcomes in Workers with Musculoskeletal Disorders or Injuries: A Systematic Scoping Review

PURPOSE

Medicines are often prescribed to workers with musculoskeletal disorders (MSDs) and injuries to relieve pain and facilitate their recovery and return to work. However, there is a growing concern that prescription medicines may have adverse effects on work function. This scoping review aimed to summarize the existing empirical evidence on prescription medicine use by workers with MSD or injury and its relationship with work-related outcomes.

METHODS

We identified studies through structured searching of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Scopus, Web of Science and Cochrane library databases, and via searching of dissertations, theses, and grey literature databases. Studies that examined the association between prescription medicine and work-related outcomes in working age people with injury or MSDs, and were published in English after the year 2000 were eligible.

RESULTS

From the 4884 records identified, 65 studies were included for review. Back disorders and opioids were the most commonly studied musculoskeletal conditions and prescription medicines, respectively. Most studies showed a negative relationship between prescription medicines and work outcomes. Opioids, psychotropics and their combination were the most common medicines associated with adverse work outcomes. Opioid prescriptions with early initiation, long-term use, strong and/or high dose and extended pre- and post-operative use in workers' compensation setting were consistently associated with adverse work function. We found emerging but inconsistent evidence that skeletal muscle relaxants and non-steroidal anti-inflammatory drugs were associated with unfavorable work outcomes.

CONCLUSION

Opioids and other prescription medicines might be associated with adverse work outcomes. However, the evidence is conflicting and there were relatively fewer studies on non-opioid medicines. Further studies with more robust design are required to enable more definitive exploration of causal relationships and settle inconsistent evidence.

Increased Use and Large Variation in Strong Opioids and Metamizole (Dipyrone) for Minor and Major Musculoskeletal Injuries Between 2008 and 2018: An Analysis of a Representative Sample of Swiss Workers

PURPOSE

Musculoskeletal (MSK) injuries are a major contributing factor for chronic pain. To date, little is known how pain medication use in MSK injuries has changed over time. We assessed pain medication prescription for MSK injuries in a representative sample of Swiss workers between 2008 and 2018.

METHODS

Retrospective analysis of the Swiss Accident Insurance Fund (Suva) data. We calculated annual pain medication use, treatment days, and costs associated with pain medication use in minor and major MSK injuries.

RESULTS

In total, 1,921,382 cases with MSK injuries with ≥ 1 pain medication were analyzed. Whereas MSK injuries with ≥ 1 pain medication increased by 9.4%, we observed a larger increase in metamizole (+ 254%), strong opioids (+ 88.4%), coxibs (+ 85.8%), and paracetamol (+ 28.1%). Strong opioids were increasingly used in minor (+ 91.4%) and major (+ 88.3%) injuries. The increase in metamizole (+ 390.6%) and coxibs (+ 115.5%) was larger in minor injuries compared to major injuries (+ 238.7% and + 80.6%, respectively). Medical expenses decreased in all medications except for strong opioids where a substantial increase was observed (+ 192.4% in minor; + 34% in major injuries).

CONCLUSIONS

We observed a disproportionate increase in metamizole, strong opioids, coxibs, and paracetamol prescriptions even in minor MSK injuries between 2008 and 2018. Whereas treatment costs decreased for all pain medications, there was a substantial increase in strong opioids. A more liberal prescription practice of opioids conflict with current evidence-based practice recommendations and need to be addressed by physicians and policy makers.

Productivity Loss Among Opioid and Benzodiazepine Users in the United States: A Medical Expenditure Panel Survey From 2010 to 2019

OBJECTIVE

The aim of the study is to estimate the association between productivity losses and the use of prescription opioids and benzodiazepines among employed US adults with painful conditions.

METHODS

Using Medical Expenditures Panel Survey (2010-2019), we used two-part (logistic regression and generalized linear model with zero-truncated negative binomial link) model to compare missed workdays due to illness or injury among employed adults with a painful condition.

RESULTS

Of the eligible sample of 57,413 working US individuals, 14.65% were prescription opioid users, 2.95% were benzodiazepine users, and 1.59% were both opioid and benzodiazepine users. The predicted missed workdays were 5.75 (95% Confidence Limit [CL]: 5.58-5.92) days for benzodiazepine users, 13.06 (95% CL: 12.88-13.23) days among opioid users, and 15.18 (95% CL: 14.46-15.90) days for opioid and benzodiazepine concomitant users.

CONCLUSIONS

Concomitant use of prescription opioids and benzodiazepines was significantly associated with having more missed workdays among employed adults with documented painful conditions.

Medical Cannabis Use and Inflammatory Cytokines and Chemokines Among Adult Chronic Pain Patients

Background: Utilizing cannabis as a therapeutic option for chronic pain (CP) has increased significantly. However, data regarding the potential immunomodulatory effects of cannabis in CP patients remain scarce. We aimed at exploring the relationship between cannabis use and inflammatory cytokines and chemokines among a cohort of CP patients. Methods: Adult patients with a CP diagnosis and medical authorization of cannabis were enrolled. Patients completed validated clinical questionnaires and self-reported the effectiveness of cannabis for symptom management. Patients' blood and cannabis samples were analyzed for the presence of four major cannabinoids, two major cannabinoid metabolites, 29 different cytokines/chemokines, and cortisol. The multivariable linear regression model was used to identify cannabis and patient factors associated with immune markers. Results: Fifty-six patients (48±15 years; 64% females) were included, with dried cannabis (53%) being the most common type of cannabis consumed. Seventy percent of products were considered delta-9-tetrahydrocannabinol (Δ9-THC)-dominant. The majority of patients (96%) self-reported effective pain management, and 76% reported a significant decrease in analgesic medication usage (p≤0.001). Compared with males, female patients had higher plasma levels of cannabidiol (CBD), cannabidiolic acid, Δ9-THC, and 11-hydroxy-Δ9-tetrahydrocannabinol but lower concentrations of delta-9-tetrahydrocannabinolic acid and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH). Females had significantly lower eotaxin levels (p=0.04) in comparison to male patients. The regression analysis indicated that high cannabis doses were related to increased levels of interleukin (IL)-12p40 (p=0.02) and IL-6 (p=0.01), whereas female sex was associated with decreased eotaxin (p≤0.01) concentrations. Blood CBD levels were associated with lower vascular endothelial growth factor (p=0.04) concentrations, and THC-COOH was a factor related to decreased tumor necrosis factor alpha (p=0.02) and IL-12p70 (p=0.03). Conclusion: This study provides further support for the patient-perceived effectiveness of cannabis in managing CP symptoms and reducing analgesic medication consumption. The results suggest a potential sex difference in metabolizing cannabinoids, and the varying immune marker concentrations may support a possible immunomodulatory effect associated with patient sex and cannabis product type. These preliminary findings provide grounds for further validation using larger, well-designed studies with longer follow-up periods.

Analgesic consumption in a large sample of people in musculoskeletal rehabilitation: A descriptive study

BACKGROUND

Consumption of opioids is increasing worldwide in people with chronic non-cancer pain, although their effectiveness is debated.

OBJECTIVES

The aim of the current study was to evaluate analgesic consumption and its association with different variables (demographic variables, pain, anxiety/depression, catastrophism, and kinesiophobia), in the field of musculoskeletal rehabilitation, where no data are available.

METHODS

This was a retrospective study over a period of 8 years on people hospitalised for rehabilitation after injury. Participants were classified into 3 categories: no analgesics (NA), non-opioid analgesics (NOA), and opioid analgesics (OPA). ANOVA or chi-squared tests were used to compare the 3 groups.

RESULTS

A total of 4,350 people (84% men; mean [SD] age, 44 [11] years) were included. In total, 20% were taking OPA, 40% NOA and 40% NA. In the OPA group, tramadol was mainly used, and the morphine equivalent median dose was 8.3 mg/day. In the NOA group, paracetamol and ibuprofen were mostly used. Symptoms increased progressively across the 3 groups (NA/NOA/OPA), with increased levels of pain severity/interference, anxiety/depression and catastrophizing, and a higher prevalence of neuropathic pain in the OPA group versus the others.

CONCLUSIONS

These results are consistent with those found in groups of people with chronic pain taking larger doses of opioids and following opioid reduction or cessation programs. Opioid prescription did not increase over the 8 years, which was reassuring. These factors are important to emphasise because they can be modified in the rehabilitation setting with interdisciplinary management.

REGISTRATION

Our database was registered on Mendeley Data.

Factors influencing pain medication and opioid use in patients with musculoskeletal injuries: a retrospective insurance claims database study

Opioid use is only recommended in selected cases of musculoskeletal (MSK) injuries. We assessed factors associated with increased opioid use in MSK injuries. In a retrospective analysis of over four million workers with MSK injuries using the Swiss National Accident Insurance Fund (Suva) database, we analyzed risk factors by multivariate logistic regression. Injury severity was associated with pain medication, opioid, and strong opioid use. Whereas fractures, contusions, and ruptures had higher odds for any pain medication use, increased odds for strong opioids were observed in fractures, superficial injuries, and other injuries. Injuries of the shoulders, elbow, chest, back/spine, thorax, and pelvis/hips showed high odds for opioid use (odds ratio (OR) > 2.0). Injuries of the shoulders had higher odds for strong opioid use (OR 1.136; 95% CI 1.040-1.241). The odds for using strong opioids increased from 2008 OR 0.843 (95% confidence interval (CI) 0.798-0.891) to 2018 OR 1.503 (95% CI 1.431-1.578), compared to 2013. Injury severity, type of injury, and injured body parts influenced the use of pain medication and overall opioid use in musculoskeletal injuries. Strong opioids were more often used in fractures but also in superficial and other minor injuries, which indicates that other factors play a role when prescribing strong opioids.

Adverse Events of the Long-Term Use of Opioids for Chronic Non-cancer Pain: A Narrative Review

BACKGROUND

The long-term use of opioids for chronic non-cancer pain (CNCP) has drawn more attention and debate. Although opioids are frequently used to treat chronic pain, their effectiveness and safety over extended periods are still unknown.

OBJECTIVES

The purpose of this review is to provide an overview of what is currently known about the adverse events of long-term use of opioids in CNCP. It also delivers patient-centered strategies designed to mitigate these risks.

METHODS

We conducted a literature search in PubMed, MEDLINE, EMBASE, and Web of Science databases. Search terms included CNCP, pain pathophysiology, opioid pharmacodynamics, opioid prescribing trends, guidelines for opioid use, and opioid side effects.  Results: Our review highlights that while opioids may provide short-term relief from CNCP, their effectiveness diminishes over time due to the development of opioid tolerance. This tolerance often leads to increased dosages, which can subsequently result in opioid dependence. Additionally, long-term opioid therapy is associated with a spectrum of adverse effects, including constipation, drowsiness, respiratory depression, and potential for drug interactions. Furthermore, our review indicates that alternative pain management strategies play a crucial role in controlling CNCP. They offer significant benefits with fewer adverse events. These strategies include non-opioid medications, physical therapy, cognitive-behavioral therapy (CBT), various interventional procedures, injection therapy, and acupuncture.

CONCLUSION

Using opioids to manage CNCP presents several challenges. Given these challenges, alternative treatments are being considered as viable options. Moreover, it is crucial to customize treatment plans to align with the patients' specific health requirements, existing conditions, and potential risks to ensure the best possible outcomes.

A Review of Federal and Statewide Guidelines and Their Effects on Orthopedics

In the past three decades, the use of opioids has risen tremendously. Pain was named the "fifth patient vital sign" in the 1990s, and from that point, opioid usage has continued to grow throughout the 2010s leading to its recognition as a crisis. The United States is responsible for 80% of the global opioid usage while only accounting for less than 5% of the global population. Previously opioids were mostly used to treat acute pain, however, opioids have been most recently used to manage chronic pain as well. The opioid crisis has presented new challenges in treating pain while preventing the abuse of these medications in a system that lacks standardization of treatment guidelines across the United States. Therefore, the authors of this review examine the current national recommendations to help manage the ongoing opioid crisis and explore how they may impact orthopedic patient care.

Dose Escalations Among Workers' Compensation Claimants Using Opioid Medications-An 8 Year Postinjury Follow up Study

OBJECTIVE

The aim of the study is to determine the morphine equivalent dose in milligrams (MED)/day escalation trend after initial utilization.

METHODS

A total of 25,108 lost time claims filed between 1998 and 2007 were followed for 8 years from injury date. Claims were stratified by initial MED/day at 3 months after injury into four groups (0, 1 to < 15, 15 to < 30, and ≥30 MED/day). The slopes in MED/year of opioid dose escalation were determined for each initial MED/day group.

RESULTS

The slopes of MED/day escalation by initial MED categories were similar ( P ≥ 0.05) ranging from 5.38 to 7.76 MED annually. On average, MED/day increased in a liner pattern with a slope at 6.28 MED/year ( P < 0.01).

CONCLUSIONS

Opioid MED/day increased in a linear pattern, regardless of initial MED/day dose.

Increase in Deltoid Compartment Pressures Immediately After Arthroscopic Rotator Cuff Repair Does Not Significantly Affect Postoperative Opioid Consumption

Purpose

To investigate the association between changes in individual (anterior, lateral, and posterior) and overall deltoid compartment pressures and postoperative opioid consumption up to 14 days after primary double-row arthroscopic rotator cuff repair (ARCR).

Methods

In 113 consecutive patients undergoing primary double-row ARCR, anterior, lateral, and posterior deltoid compartment pressures were measured prior to incision and immediately after closure with a manometer. Postoperatively, all patients were provided with an identical rehabilitation protocol, quantity and dose of opioid tablets, and pain journal in which to record daily opioid consumption and visual analog scale pain scores for 14 days after surgery. The pain journals were collected at the first postoperative visit, and opioid consumption was calculated based on morphine equivalents. Statistical analysis was performed to determine the association between deltoid compartment pressures and opioid consumption postoperatively.

Results

Sixty-nine percent of patients who met the inclusion criteria (74 of 107) returned the pain journals. The mean age at the time of surgery was 57.4 ± 8.8 years (range, 30-75 years), with female patients being significantly older (P = .03). The mean length of surgery was 71.7 ± 16.3 minutes. No significant association between increase in individual (anterior, lateral, or posterior) or mean overall compartment pressures and morphine equivalents of opioid consumption was appreciated on any postoperative day.

Conclusions

No significant correlation between increase in individual or overall deltoid compartment pressures after ARCR and postoperative opioid consumption in the immediate postoperative period was found in this study.

Level of Evidence

Level II, prospective cohort study.

Chronic Opioid Use Independently Increases Complications and Resource Utilization After Primary Total Joint Arthroplasty

BACKGROUND

Current literature suggests a link between the chronic use of opioids and musculoskeletal surgical complications. Given the current opioid epidemic, the need to elucidate the effects of chronic opioid use (OD) on patient outcomes and cost has become important. The purpose of this study was to determine if OD is an independent risk factor for inpatient postoperative complications and resource utilization after primary total joint arthroplasty.

METHODS

A total of 3,545,565 patients undergoing elective, unilateral, primary total hip (THA) and knee (TKA) arthroplasty for osteoarthritis from January 2016 to December 2019 were identified using a large national database. In-hospital postoperative complications, length of stay, and total costs adjusted for inflation in opioid + patients were compared with patients without chronic opioid use (OD). Logistic regression analyses were used to control for cofounding factors.

RESULTS

OD patients undergoing either THA or TKA had a higher risk of postoperative complications including respiratory (odds ratio (OR): 1.4 and OR: 1.3), gastrointestinal (OR: 1.8 and OR: 1.8), urinary tract infection (OR: 1.1 and OR: 1.2), blood transfusion (OR: 1.5 and OR: 1.4), and deep vein thrombosis (OR: 1.7 and OR: 1.6), respectively. Total cost ($16,619 ± $9,251 versus $15,603 ± $9,181, P < .001), lengths of stay (2.15 ± 1.37 versus 2.03 ± 1.23, P < .001), and the likelihood for discharge to a rehabilitation facility (17.8 versus 15.7%, P < .001) were higher in patients with OD.

CONCLUSION

OD was associated with higher risk for in-hospital postoperative complications and cost after primary THA and TKA. Further studies to find strategies to mitigate the impact of opioid use on complications are required.

High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews

BACKGROUND

This overview was originally published in 2017, and is being updated in 2022.  Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue, for which opioids are prescribed by some physicians for pain management. There are concerns that the use of high doses of opioids for CNCP lacks evidence of effectiveness, and may increase the risk of adverse events.

OBJECTIVES

To describe the evidence from Cochrane Reviews and overviews regarding the efficacy and safety of high-dose opioids (defined as 200 mg morphine equivalent or more per day) for CNCP.

METHODS

We identified Cochrane Reviews and overviews by searching the Cochrane Database of Systematic Reviews in The Cochrane Library. The date of the last search was 21 July 2022. Two overview authors independently assessed the search results. We planned to analyse data on any opioid agent used at a high dose for two weeks or more for the treatment of CNCP in adults.

MAIN RESULTS

We did not identify any reviews or overviews that met the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses, where all doses were analysed as a single group; we were unable to extract any data for high-dose use only.

AUTHORS' CONCLUSIONS

There is a critical lack of high-quality evidence, in the form of Cochrane Reviews, about how well high-dose opioids work for the management of CNCP in adults, and regarding the presence and severity of adverse events.  No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Considering that high-dose opioids have been, and are still being used in clinical practice to treat CNCP, knowing about the efficacy and safety of these higher doses is imperative.

Opioid Consumption Patterns and Prolonged Opioid Use Among Opioid-Naïve Ankle Fracture Patients

INTRODUCTION

Previous literature has demonstrated an association between acute opioid exposure and the risk of long-term opioid use. Here, the investigators assess immediate postoperative opioid consumption patterns as well as the incidence of prolonged opioid use among opioid-naïve patients following ankle fracture surgery.

METHODS

Included patients underwent outpatient open reduction and internal fixation of an ankle or tibial plafond fracture over a 1-year period. At patients' first postoperative visit, opioid pills were counted and standardized to the equivalent number of 5-mg oxycodone pills. Prolonged use was defined as filling a prescription for a controlled substance more than 90 days after the index procedure, tracked by the New Jersey Prescription Drug Monitoring Program up to 1 year postoperatively.

RESULTS

At the first postoperative visit, 173 patients consumed a median of 24 out of 40 pills prescribed. The initial utilization rate was 60%, and 2736 pills were left unused. In all, 32 (18.7%) patients required a narcotic prescription 90 days after the index procedure. Patients with a self-reported history of depression (P = .11) or diabetes (P = .07) demonstrated marginal correlation with prolonged narcotic use.

CONCLUSION

Our study demonstrated that, on average, patients utilize significantly fewer opioid pills than prescribed and that many patient demographics are not significant predictors of continued long-term use following outpatient ankle fracture surgery. Large variations in consumption rates make it difficult for physicians to accurately prescribe and predict prolonged narcotic use.

LEVEL OF EVIDENCE

Level III.

Total knee arthroplasty is associated with greater immediate post-surgical pain and opioid use than total hip arthroplasty

BACKGROUND

As greater emphasis is being placed on opioid reduction strategies and implementation of multimodal analgesia, we sought to determine whether immediate post-surgical opioid consumption was different between THA and TKA.

METHODS

A single-institution total joint arthroplasty database was used to identify patients who underwent elective THA and TKA from 2016 to July 2019. Baseline demographic data, operative time (defined by incision time), and American Society of Anesthesiologist (ASA) class were collected. Morphine milligram equivalents (MME) were calculated and derived from prospectively documented nursing opioid administration events, while visual analog scale (VAS) scores represented pain levels, both of which were collected as part of our institution's standard protocols. Activity Measure for Post-Acute Care (AMPAC) was used to determine physical therapy progress.

RESULTS

A total of 11,693 cases were identified: 5,909 THA (50.53%) and 5784 (49.47%) TKA. THA patients tended to be slightly younger (63.38 years, SD 11.61 years, vs 65.72 years, SD 9.56 years; p < 0.01) and have lower BMIs (28.92 kg/m² vs 32.52 kg/m²; p < 0.01). THA patients had lower ASA scores in comparison to TKA patients (p < 0.01). Aggregate opioid consumption (93.76 MME vs 147.55 MME; p < 0.01) along with first 24-h and 48-h usage was significantly less for THA as compared to TKA. Similarly, mean pain scores (4.15 vs 5.08; p < 0.01) were lower for THA, while AMPAC mobilization scores were higher (20.88 vs 19.29; p < 0.01) when compared to TKA.

CONCLUSION

THA patients reported lower pain scores and were found to require less opioid medication in the immediate post-surgical period than TKA patients.

Peri-OPerative Pain Management, Education & De-escalation (POPPMED), a novel anaesthesiologist-led program, significantly reduces acute and long-term postoperative opioid requirements: a retrospective cohort study

Supplemental Digital Content is Available in the Text.

Perioperative pain management, education, and de-escalation, a single anaesthesiologist-led perioperative service, managed older, high-risk opioid-tolerant patients to achieve sustained oral morphine equivalent daily dosage reductions safely after major orthopaedic, abdominal, and neurosurgery.

Introduction:

The opioid tolerant patient requiring surgery is highly likely to be discharged on high Oral Morphine Equivalent Daily Dosages (OMEDDs), with concomitant risk of increased morbidity and mortality.

Objectives:

We proposed that a single anaesthesiologist-led POPPMED (Peri-Operative Pain Management, Education & De-escalation) service could reduce both short and long-term postoperative patient OMEDDs.

Methods:

From April 2017, our anaesthesiologist-led POPPMED service, engaged 102 perioperative patients treated with >50mg preoperative OMEDDs. We utilized behavioural interventions; acute opioid reduction and/ or rotation; and regional, multimodal and ketamine analgesia to achieve lowest possible hospital discharge and long term OMEDDs.

Results:

Patients' preoperative OMEDDs were [median (IQR): 115mg (114mg)], and were representative of an older [age 62 (15) years], high-risk [89% ASA status 3 or 4] patient population. 46% of patients received an acute opioid rotation; 70% received ketamine infusions; and 44% regional analgesia. OMEDDs on discharge [-25mg (82mg), p=0.003] and at 6-12 months [-55mg (105mg ), p<0.0001] were significantly reduced; 84% and 87% of patients achieved OMEDD reduction on discharge and at 6-12 months. Patients with >90mg preoperative OMEDDs achieved greater reductions [discharge: 71% of patients, -52 mg (118 mg) p<0.0001; 6-12 months: 90% of patients, -90mg (115mg), p<0.0001]. On comparison with a pre-POPPMED surgical cohort, Postoperative Day 1-3 11-point Numerical Rating Scale (NRS-11) area under the curve (AUC) measurements at rest and on movement were not significantly different (largest NRS-11:hours AUC difference [median(IQR)] 22 [13], p= 0.24). Hospital length of stay was variably increased.

Conclusions:

POPPMED achieved sustained OMEDD reductions safely in an older, high-risk opioid tolerant population, with analgesia comparable to a non-POPPMED cohort, and surgery specific effects on length of stay.

Artesunate Therapy Alleviates Fracture-Associated Chronic Pain After Orthopedic Surgery by Suppressing CCL21-Dependent TREM2/DAP12 Inflammatory Signaling in Mice

Chronic pain after bone fracture and orthopedic surgery is often refractory to most analgesics currently in use, thus emphasizing the urgent need for improved therapeutic medications. Chemokine-dependent neuroinflammation is critical for excitatory synaptic plasticity and central nociception sensitization. Recent studies have focused on the inhibition of inflammatory responses by artesunate, the first anti-malaria drug extracted from artemisinin. The present study investigated the analgesic effects and potential targets of artesunate in a mouse model of chronic pain induced by tibial fracture and orthopedic surgery. Three injections of artesunate were intrathecally administered on a daily basis from days 4 to 6 after fracture. We reported that repetitive exposure to artesunate (10 and 100 μg but not 1 μg) dose-dependently prevented fracture-induced mechanical and cold allodynia. Moreover, single intrathecal injection of artesunate (100 μg) alleviated the established chronic pain on day 14 after fracture surgery. Intraperitoneal artesunate (10 and 50 mg kg^-1) therapy was effective against chronic fracture pain. Intriguingly, artesunate inhibited the upregulation of spinal chemokine CCL21, triggering receptor expressed on myeloid cells 2 (TREM2) and DNAX-activating protein of 12 kDa (DAP12) expressions and microglia activation in fracture mice. Furthermore, spinal CCL21 neutralization attenuated the severity of fracture-associated post-surgical pain. Exogenous CCL21-induced acute inflammatory pain was impaired by artesunate therapy. Additionally, the pharmacological blockage of TREM2 reduced recombinant CCL21-elicited behavioral hypernociception. The present findings demonstrate that artesunate therapy reduces the initiation and maintenance of fracture-associated chronic postoperative pain by inhibiting CCL21-dependent TREM2/DAP12 inflammatory signaling and microglia activation, thus suggesting that artesunate could emerge as a therapeutic strategy for fracture pain management.

A review of trial and real-world data applying elements of a realist approach to identify behavioural mechanisms supporting practitioners to taper opioids

This evidence synthesis applying realist concepts and behavioural science aimed to identify behavioural mechanisms and contexts that facilitate prescribers tapering opioids. We identified relevant opioid‐tapering interventions and services from a 2018 international systematic review and a 2019 England‐wide survey, respectively. Interventions and services were eligible if they provided information about contexts and/or behavioural mechanisms influencing opioid‐tapering success. A stakeholder group (n = 23) generated draft programme theories based around the 14 domains of the Theoretical Domains Framework. We refined these using the trial and service data. From 71 articles and 21 survey responses, 56 and 16 respectively were included, representing primary care, hospital, specialist pain facilities and prison services. We identified 6 programme theories comprising 5 behavioural mechanisms: prescribers' knowledge about how to taper; build prescribers' beliefs about capabilities to initiate tapering discussions and manage psychological consequences of tapering; perceived professional role in tapering; the environmental context enabling referral to specialists; and facilitating positive social influence by aligning patient: prescriber expectations of tapering. No interventions are addressing all 6 mechanisms supportive of tapering. Work is required to operationalise programme theories according to organisational structures and resources. An example operationalisation is combining tapering guidelines with information about local excess opioid problems and endorsing these with organisational branding. Prescribers being given the skills and confidence to initiate tapering discussions by training them in cognitive‐based interventions and incorporating access to psychological and physical support in the patient pathway. Patients being provided with leaflets about the tapering process and informed about the patient pathway.

Rapid Discontinuation of Chronic, High-Dose Opioid Treatment for Pain: Prevalence and Associated Factors

PURPOSE

To examine the prevalence of rapid discontinuation of chronic, high-dose opioid analgesic treatment, and identify associated patient, clinician, and community factors.

METHODS

Using 2017-2018 retail pharmacy claims data from IQVIA, we identified chronic, high-dose opioid analgesic treatment episodes discontinued during these years and determined the percent of episodes meeting criteria for rapid discontinuation. We used multivariable logistic regression to estimate the probability of rapid discontinuation, conditional on having a discontinued chronic, high-dose opioid treatment episode, as a function of patient, provider, and county characteristics.

RESULTS

We identified 810,120 new, chronic, high-dose opioid treatment episodes discontinued in 2017 or 2018, of which 72.0% (n=583,415) were rapidly discontinued. Rapid discontinuation was significantly more likely among Medicare (aOR 1.14, 95% CI 1.12 to 1.15) and Medicaid enrollees (aOR 1.03, 95% CI 1.02 to 1.05) compared to the commercially insured; in counties with higher fatal overdose rates (aOR 1.03, 95% CI 1.01 to 1.04) compared to counties with the lowest fatal overdose rates; and in counties with a higher percentage of non-white residents (aOR 1.21 for counties in the highest quartile relative to the lowest, 95% CI 1.19 to 1.24). Likelihood of rapid discontinuation also varied by prescriber specialty.

CONCLUSIONS

Most chronic, high-dose opioid treatment episodes that ended in 2017 or 2018 were discontinued more rapidly than recommended by clinical guidelines, raising concerns about adverse patient outcomes. Our findings highlight the need to understand what drives discontinuation and to inform safer opioid tapering and discontinuation practices.

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

OBJECTIVE

To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.

DESIGN

Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Original research in English. Case reports and cross sectional studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).

RESULTS

Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05).

CONCLUSIONS

Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.

REVIEW REGISTRATION

PROSPERO CRD42020140943.

Opioid use prior to surgery is associated with worse preoperative and postoperative patient reported quality of life and decreased surgical cost effectiveness for symptomatic adult spine deformity; A matched cohort analysis

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Multi-center, matched analysis of surgically treated SASD patients demonstrated preoperative opioid users reported greater pain, worse physical function, worse self-image preoperatively and at minimum 2-years postoperative and reported lower treatment satisfaction compared to opioid nonusers (p<0.05).

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Preoperative opioid users had longer ICU (40.8 vs 21.4 hours) and hospital stay (10.5 vs 8.0 days) than nonusers following SASD surgery, respectively (p<0.05).

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Preoperative opioid users demonstrated worse one and two-year postoperative cost/QALY following SASD surgery than nonusers (p<0.05).

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Preoperative opioid users reported greater opioid use at two-years following SASD surgery than preoperative nonusers (41.2% vs. 12.9%; odds ratio=4.5; 95% confidence interval=2.7-8.3; p<0.05).

Background

Preoperative opioid is associated with poor postoperative outcomes for several surgical specialties, including neurosurgical, orthopedic, and general surgery. Patients with symptomatic adult spinal deformity (SASD) are among the highest patient populations reporting opioid use prior to surgery. Surgery for SASD has been demonstrated to improve patient reported quality of life, however, little medical economic data exists evaluating impact of preoperative opioid use upon surgical cost-effectiveness for SASD. The purpose of this study was to evaluate the impact that preoperative opioid use has upon SASD surgery including duration of intensive care unit (ICU) and hospital stay, postoperative complications, patient reported outcome measures (PROMs), and surgical cost-effectiveness using a propensity score matched analysis model.

Methods

Surgically treated SASD patients enrolled into a prospective multi-center SASD study were assessed for preoperative opioid use, and divided into two cohorts; preoperative opioid users (OPIOID) and preoperative opioid non-users (NON). Propensity score matching (PSM) was used to control for patient age, medical comorbidities, spine deformity type and magnitude, and surgical procedures for OPIOID vs NON. Preoperative and minimum 2-year postoperative PROMs, duration of ICU and hospital stay, postoperative complications, and opioid use at one and two years postoperative were compared for OPIOID vs NON. Preoperative, one year, and minimum two-year postoperative SF6D values were calculated, and one- and two-year postoperative QALYs were calculated using SF6D change from baseline. Hospital costs at the time of index surgery were calculated and cost/QALY compared at one and two years postop for OPIOID vs NON.

Results

261/357 patients (mean follow-up 3.3 years) eligible for study were evaluated. Following the PSM control, OPIOID (n=97) had similar preoperative demographics, smoking and depression history, spine deformity magnitude, and surgery performed as NON (n=164; p>0.05). Preoperatively, OPIOID reported greater NRS back pain (7.7 vs 6.7) and leg pain (5.2 vs 3.9), worse ODI (50.8 vs 36.9), worse SF-36 PCS (28.8 vs 35.6), and worse SRS-22r self-image (2.3 vs 2.5) than NON, respectively (p<0.05). OPIOID had longer ICU (41.2 vs 21.4 hours) and hospital stay (10.6 vs 8.0 days) than NON, respectively (p<0.05). At last postoperative follow up, OPIOID reported greater NRS back pain (4.1 vs 2.3) and leg pain (2.9 vs 1.7), worse ODI (32.4 vs 19.4), worse SF-36 PCS (37.4 vs 47.0), worse SRS-22r self-image (3.5 vs 4.0), and lower SRS-22r treatment satisfaction score (2.5 vs 4.5) than NON, respectively (p<0.05). At last follow-up postoperative Cost/QALY was higher for OPIOID ($44,558.31) vs NON ($34,304.36; p<0.05). At last follow up OPIOID reported greater postoperative opioid usage than NON [41.2% vs. 12.9%, respectively; odds ratio =4.7 (95% CI=2.6-8.7; p<0.05)].

Conclusions

Prospective, multi-center, matched analysis demonstrated SASD patients using opioids prior to SASD surgery reported worse preoperative and postoperative quality of life, had longer ICU and hospital stay, had less cost effectiveness of SASD surgery. Preoperative opioid users also reported lower treatment satisfaction, and reported greater postoperative opioid use than non-users. These data should be used to council patients on the negative impact preoperative opioid use can have on SASD surgery.

The Effect of Mobile Care Delivery on Clinically Meaningful Outcomes, Satisfaction, and Engagement Among Physical Therapy Patients: Observational Retrospective Study

Background

Musculoskeletal care is now delivered via mobile apps as a health care benefit. Although preliminary evidence shows that the clinical outcomes of mobile musculoskeletal care are comparable with those of in-person care, no research has examined the features of app-based care that secure these outcomes.

Objective

Drawing on the literature around in-person physical therapy, this study examines how patient-provider relationships and program engagement in app-based physical therapy affect clinically meaningful improvements in pain, function, and patient satisfaction. It then evaluates the effects of patient-provider relationships forged through in-app messages or video visits and timely, direct access to care on patients’ engagement in their recovery.

Methods

We conducted an observational, retrospective study of 814 pre- and postsurveyed participants enrolled in a mobile app physical therapy program where physical therapists prescribed workouts, education, and therapeutic activities after a video evaluation from February 2019 to December 2020. We estimated generalized linear models with logit functions to evaluate the effect of program engagement on clinical outcomes, minimal clinically important differences (MCIDs) in pain (ΔVisual Analogue Scale ≤−1.5) and function (ΔPatient Specific Functional Scale ≥1.3), and the effects of patient-provider relationships and clinical outcomes on patient satisfaction—participant reported likelihood to recommend the program (Net Promoter Scores of 9-10). We estimated Poisson generalized linear models to evaluate the effects of stronger patient-provider relationships and timely access to physical therapy within 24 hours on engagement including the number of weekly workouts and weeks in the program.

Results

The odds that participants (N=814) had a pain MCID increased by 13% (odds ratio [OR] 1.13, 95% CI 1.04-1.23; P=.003) with each weekly workout and the odds of a function MCID by 4% (OR 1.04, 95% CI 1.00-1.08; P=.03) with each week in the program. Participants with MCIDs in function and large changes in pain (Δ Visual Analogue Scale ≤−3.5) were 1.85 (95% CI 1.17-2.93; P=.01) and 2.84 times (95% CI 1.68-4.78; P<.001) more satisfied, respectively. Those with video follow-up visits were 2 to 3 times (P=.01) more satisfied. Each physical therapist’s message increased weekly workouts by 11% (OR 1.11, 95% CI 1.07-1.16; P<.001). Video follow-up visits increased weekly workouts by at least 16% (OR 1.16, 95% CI 1.04-1.29; P=.01) and weeks in the program at least 8% (OR 1.08, 95% CI 1.01-1.14; P=.02). Access was associated with a 14% increase (OR 1.14, 95% CI 1.05-1.24; P=.003) in weekly workouts.

Conclusions

Similar to in-person care, program engagement positively affects clinical outcomes, and strong patient-provider relationships positively affect satisfaction. In app-based physical therapy, clinical outcomes positively affect patient satisfaction. Timely access to care and strong patient-provider relationships, particularly those forged through video visits, affect engagement.

Can Physical Therapy Deliver Clinically Meaningful Improvements in Pain and Function through a Mobile App?: An Observational Retrospective Study

Objective

To examine the effect of digital physical therapy (PT) delivered by mobile application (app) on reducing pain and improving function for people with a variety of musculoskeletal conditions.

Design

An observational, longitudinal, retrospective study using survey data collected pre- and postdigital PT to estimate multilevel models with random intercepts for patient episodes.

Setting

Privately insured employees participating in app-based PT as an employer health care benefit.

Participants

The study sample included 814 participants (N=814) 18 years or older who completed their digital PT program with reported final clinical outcomes between February 2019 (program launch) through December 2020. Mean age of the sample at baseline was 40.9±11.89 years, 47.5% were female, 21% sought care for lower back pain, 16% for shoulders, 15% for knees, and 13% for neck.

Interventions

Digital PT consisted of a synchronous video evaluation with a physical therapist followed by a course of PT delivered through a mobile app.

Main Outcome Measures

Pain was measured by the visual analog scale from 0 “no pain” to 10 “worst pain imaginable” and physical function by the Patient-Specific Functional Scale on a scale from 0 “completely unable to perform” to 10 “able to perform normally.”

Results

After controlling for significant demographics, comorbid conditions, adverse symptoms, chronicity, and severity, the results from multilevel random intercept models showed decreased pain (−2.69 points; 95% CI, −2.86 to −2.53; P<.001) and increased physical function (+2.67 points; 95% CI, 2.45-2.89; P<.001) after treatment.

Conclusions

Digital PT was associated with clinically meaningful improvements in pain and function among a diverse set of participants. These early data are an encouraging indicator of the clinical benefit of digital PT.

Preoperative Opioid Use Predicts Postoperative Opioid Use and Inferior Clinically Notable Outcomes After Total Shoulder Arthroplasty

INTRODUCTION

Preoperative opioid use (OU) may negatively affect outcomes after total shoulder arthroplasty (TSA). This study aims to evaluate the influence of preoperative OU on achievement of midterm clinically notable outcomes (CSOs) after TSA and identify factors associated with prolonged postoperative OU and persistent pain after TSA.

METHODS

Using a single-institution, prospectively collected TSA registry, we retrospectively identified patients who underwent surgery between 2014 and 2019. Subjects were stratified into two cohorts: preoperative OU within 12 months of surgery and opioid naive (N-OU) patients. Minimum 1-year postoperative scores and achievement of CSOs patient-reported outcome measures (PROMs), as well as predictors of postoperative OU and persistent pain, were analyzed.

RESULTS

A total of 817 patients were included with 706 patients in the N-OU cohort and 111 patients in the OU cohort. Although both patients in the N-OU and OU cohorts showed statistically significant improvements at the 1-year follow-up, absolute PROM scores were less favorable in the OU cohort (all P < 0.05). Preoperative opioid users were significantly less likely to achieve minimal clinically important difference (odds ratios [ORs]: 0.47 to 2.4, all P < 0.05) and patient acceptable symptomatic state (ORs: 0.41 to 2.12, all P < 0.05) on the American Shoulder and Elbow Surgeon, Single Assessment Numeric Evaluation, Constant-Murley Shoulder Score, Visual Analogue Scale (VAS) pain, Veterans Rand 12-Item Health Survey, Short-Form 12-Item Health Survey, and Veterans Rand 6D and substantial clinical benefit (OR: 0.50 to 0.56, P < 0.05) on the American Shoulder and Elbow Surgeon and Single Assessment Numeric Evaluation. Preoperative OU significantly predicted increased OU at 6 months (OR: 7.11, P = 0.009) and 1-year follow-up (OR: 40.23, P < 0.001) and persistent pain at 1 year (OR: 2.37, P = 0.001).

CONCLUSION

Preoperative OU markedly correlated with worse PROMs at 1 year postoperatively. Although preoperative opioid users demonstrate improvement in functional-related and health-related quality-of-life PROMs after TSA, they are markedly less likely to achieve CSOs and were more likely to report persistent pain and continued OU at 6-month and 1-year follow-ups. Opioid users undergoing TSA should be counseled regarding their expected outcomes, and preventive measures should aim to limit prolonged OU/abuse after surgery.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Long-Term Medicare Costs Associated With Opioid Analgesic Therapy vs Spinal Manipulative Therapy for Chronic Low Back Pain in a Cohort of Older Adults

OBJECTIVES

The purpose of this study was to compare Medicare healthcare expenditures for patients who received long-term treatment of chronic low back pain (cLBP) with either opioid analgesic therapy (OAT) or spinal manipulative therapy (SMT).

METHODS

We conducted a retrospective observational study using a cohort design for analysis of Medicare claims data. The study population included Medicare beneficiaries enrolled under Medicare Parts A, B, and D from 2012 through 2016. We assembled cohorts of patients who received long-term management of cLBP with OAT or SMT (such as delivered by chiropractic or osteopathic practitioners) and evaluated the comparative effect of OAT vs SMT upon expenditures, using multivariable regression to control for beneficiary characteristics and measures of health status, and propensity score weighting and binning to account for selection bias.

RESULTS

The study sample totaled 28,160 participants, of whom 77% initiated long-term care of cLBP with OAT, and 23% initiated care with SMT. For care of low back pain specifically, average long-term costs for patients who initiated care with OAT were 58% lower than those who initiated care with SMT. However, overall long-term healthcare expenditures under Medicare were 1.87 times higher for patients who initiated care via OAT compared with those initiated care with SMT (95% CI 1.65-2.11; P < .0001).

CONCLUSIONS

Adults aged 65 to 84 who initiated long-term treatment for cLBP via OAT incurred lower long-term costs for low back pain but higher long-term total healthcare costs under Medicare compared with patients who initiated long-term treatment with SMT.

Trends in the Utilization and Dose of Gabapentinoids in Combination With Opioids in an Injured Worker Population Between 2008 and 2018

OBJECTIVE

To determine long term (11 year) trends in gabapentin and pregabalin prescribing among workers' compensation claimants at various opioid dose combinations (low, medium, high, and very high) in Louisiana.

METHOD

A longitudinal study of 18,737 claimants who filled any prescriptions between 2008 and 2018.

RESULTS

The proportion of claimants prescribed opioids alone at all dose levels decreased dramatically. The proportion claimants prescribed the combination of low dose opioids and low dose gabapentinoids increased (7.7% to 10.9%). Prescribing higher daily doses of gabapentinoids was associated with higher daily doses of opioids. Gabapentinoid prescribing was associated with continued prescribing of medium and high dose opioids as claims matured.

CONCLUSIONS

Overall opioid prescribing decreased over time, while prescribing low dose opioids with gabapentinoids, increased.

Reassessing the minimum two-year follow-up standard after total shoulder arthroplasty-Is one year sufficient?

BACKGROUND

US Food and Drug Administration Investigation Device Exemption studies and academic journals emphasize the importance of two-year follow-up data in reporting outcomes of total shoulder arthroplasty, but there is limited data evaluating appropriate follow-up length. We aim to evaluate change in postoperative outcomes and complications between one and two years following anatomic and reverse total shoulder arthroplasties.

METHODS

We retrospectively identified 250 patients who underwent anatomic and reverse total shoulder arthroplasties between 2013 and 2016 from a single surgeon arthroplasty registry. Patients without both one- and two-year follow-up data were excluded. We compared American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale for pain, and goniometer-measured range of motion.

RESULTS

Patient-reported outcome measurements (p > 0.05) did not change between one and two years postoperatively following both reverse (n = 146) and anatomic (n = 104) total shoulder arthroplasties. Range of motion increased slightly (p < 0.05), but this change was not clinically relevant. There were no additional complications.

DISCUSSION

Minimum two-year clinical follow-up may not be necessary for future shoulder arthroplasty Investigation Device Exemption and other peer-reviewed investigations. Patient-reported outcomes (ASES and pain score) and range of motion plateau at one year postoperatively without additional complications. One-year follow-up is an acceptable minimum follow-up length.

LEVEL OF EVIDENCE

Level III-retrospective analysis.

Anxiety and Fear Avoidance Beliefs and Behavior May Be Significant Risk Factors for Chronic Opioid Analgesic Therapy Reliance for Patients with Chronic Pain-Results from a Preliminary Study

OBJECTIVE

To describe differences between patients with chronic, non-cancer pain (CNCP) who were successfully able to cease full mu agonist chronic opioid analgesic therapy (COAT), and those who exhibited refractory COAT reliance, among those who participated in a multidisciplinary program designed for COAT cessation.

DESIGN

A retrospective review of electronic medical records (EMR) data was organized for preliminary analysis.

SETTING

A multicenter private practice specializing in CNCP, which received patient referrals from the surrounding geographical area of primary and specialty care offices in Northern California.

SUBJECTS

Data from 109 patients with CNCP who participated in a multidisciplinary program to cease COAT between the dates of October 2017 to December 2019 were examined.

METHODS

EMR data, pre-COAT cessation, of oral morphine milligram equivalence (MME) and validated questionnaire responses assessing anxiety and fear-based beliefs and behavior, as well as opioid misuse, were extracted and compared between those who successfully ceased COAT and those who did not.

RESULTS

Patients who were unsuccessful at COAT cessation reported significantly higher Fear Avoidance Beliefs Questionnaire (FAB) scores. No significant differences were found based on incoming MME amounts, Current Opioid Misuse Measure (COMM) or Tampa Scale of Kinesiophobia (TSK) scores. Pain Catastrophizing Scale (PCS) scores showed a split pattern with unclear significance.

CONCLUSIONS

Results suggest that fear avoidance beliefs and behavior, as measured by the FAB, play a significant role in refractory COAT reliance for patients with CNCP.

Pain Appraisals in Patients with Physical Injury: Assessing the Role of Distress Tolerance in the Relationship between Depression and Pain Catastrophizing

Pain is a complex construct contributing to significant impairment, particularly among physically injured patients seeking treatment in trauma and orthopedic surgery settings in which social workers are an integral component of care. The biopsychosocial theory, fear-avoidance, and cognitive mediation models of pain suggest that psychological factors (for example, depression) affect one's ability to tolerate distress, leading to negative pain appraisals, such as catastrophizing. This study examined whether distress tolerance serves as a mechanism by which depression is associated with pain catastrophizing. We administered a health survey to outpatient trauma and orthopedic surgery clinic patients who were using opioid medications; 84 patients were included in the final analysis; 39.3 percent screened positive for depression. A multilevel mediation model using structural equation modeling revealed a significant direct effect from depression to pain catastrophizing (ß = .31, z = 3.96, p < .001) and a significant indirect effect by distress tolerance (Δß = .27, z = 3.84, p < .001). These results, which suggest that distress tolerance partially mediated the path from depression to pain catastrophizing, can inform social workers and other members of the multidisciplinary team about both the critical role of psychosocial factors after injury and interventions to improve postinjury recovery.

The Cost of Lost Productivity in an Opioid Utilizing Pain Sample

Background and Aims

Chronic pain affects more adults in the United States than any other condition. Opioid medications are widely used in the treatment of chronic pain, but there remains considerable risk and cost associated with their use. This study aims to characterize the effects of opioid prescribing for chronic pain and similar pain conditions on lost productivity in the United States.

Methods

This was a retrospective, longitudinal, observational study of chronic pain patients in 2011–2014. We identified patients with a diagnosis of musculoskeletal pain receiving index prescription for opioids in administrative claims and studied disability absence in a linked health and productivity management database. Patients were grouped as de novo and continued use opioid users before index, and by opioid dose in the year after index. Days of disability were compared before and after index with bootstrapping. Effect of opioid dose group on disability was evaluated with negative binomial regression. Lost productivity cost was compared before and after index.

Results

The cohort contained 16,273 de novo and 6604 continued use patients. On average, de novo patients used 24.8 days of disability after index, an increase of 18.3 more days compared to before (p < 0.001). Continued use patients used 30.7 days after index, 9 more days than before (p < 0.001). There was a dose–response relationship between dose group and days of disability in de novo patients (p < 0.001). The weighted-average cost per person of lost productivity was $4344 higher in the year after index compared to the year before.

Conclusion

Opioid prescriptions for pain patients were associated with significant disability use and lost productivity costs. With the evolution of opioid-prescribing practices, CDC recommendations, and the HHS Pain Management Best Practices, there is opportunity to use alternative pain therapies without the risks of opioid-induced side effects to improve work productivity.

Risk Factors for Increased Consumption of Narcotics After Hip Arthroscopy: A Prospective, Randomized Control Trial

INTRODUCTION

No accepted standard exists regarding the number of opioids to prescribe after many surgical procedures, and previous literature has indicated that the number of opioids prescribed influences the total number of pills consumed. The goal of this study was to investigate whether prescribing less opioids after hip arthroscopy results in less total postoperative utilization without compromising analgesia and identify risk factors for increased use.

METHODS

This study randomized 111 patients to receive either 30 or 60 tablets of hydrocodone/acetaminophen 10 to 325 mg after hip arthroscopy. Demographic information, pain instruments, and scores including International Hip Outcome Tool (iHOT-12) were collected preoperatively. Postoperatively, patients were contacted over the course of 3 weeks to determine their Numeric Pain Rating Scale scores, total number of tablets taken/leftover, and the last day that they required narcotic pain medications, which were calculated and compared for each group. Preoperative variables that increased the risk of higher narcotic pain medication requirements were assessed.

RESULTS

Patients in the 60-tablet group had significantly more tablets leftover than the 30-tablet group (49.5 versus 22.0, P < 0.001) and had no significant difference in Numeric Pain Rating Scale scores at 24 hours, 48 hours, or final follow-up. The 30- and 60-tablet groups demonstrated no significant difference in average tablets consumed (9.2 and 10.5, P = 0.60), respectively. Risk factors for increased postoperative opioid use included preoperative opioid use (B = 12.62, 95% confidence interval [CI], 6.28-18.96, P < 0.001) or muscle relaxant use (B = 22.45, 95% CI, 7.59-37.31, P < 0.0036) within 1 year preoperatively. Preoperative iHOT-12 scoring also significantly predicted postoperative opioid consumption in this cohort (B = -0.25, 95% CI, -0.45 to -0.036, P < 0.022).

CONCLUSION

The number of leftover tablets after hip arthroscopy can be significantly reduced by prescribing 30 tablets compared with 60 tablets without affecting postoperative pain control. Total tablets prescribed in this cohort did not affect total opioid utilization. Preoperative factors including opioid or muscle relaxant use and iHOT-12 scores can be used to predict postoperative opioid requirements.

Establishing Clinically Significant Outcomes for Patient-Reported Outcomes Measurement Information System After Biceps Tenodesis

PURPOSE

To establish thresholds for improvement in patient-reported outcome scores that correspond with clinically significant outcomes (CSOs) including the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive testing (CAT) and pain interference (PIF) CAT after biceps tenodesis (BT) and to assess patient variables that are associated with achieving these outcomes.

METHODS

After institutional review board approval was obtained, a prospectively maintained institutional database was queried for patients undergoing BT between December 2017 and August 2019. Patients undergoing BT in isolation or BT in conjunction with rotator cuff debridement, SLAP repair, subacromial decompression, or distal clavicle excision were included in the analysis. Anchor- and distribution-based methods were used to calculate the MCID whereas an anchor-based method was used to calculate SCB and the PASS for PROMIS UE CAT and PIF CAT.

RESULTS

A total of 112 patients (86.8% follow-up) who underwent BT were included for analysis. The MCID, net SCB, absolute SCB, and PASS for PROMIS UE CAT were 4.02, 9.25, 43.4, and 41.1, respectively. The MCID, net SCB, absolute SCB, and PASS for PROMIS PIF CAT were -4.12, -10.7, 52.4, and 52.4, respectively. Higher preoperative UE CAT and PIF CAT scores, preoperative opioid use, depression, and living alone were negative predictors of CSO achievement. Male sex and regular participation in exercise were positive predictors of CSO achievement.

CONCLUSIONS

Patients with higher preoperative UE scores were less likely to achieve the MCID (odds ratio [OR], 0.84), whereas patients with higher preoperative PIF scores were less likely to achieve absolute SCB and the PASS (OR, 0.83-0.89). Most patients achieved the MCID for PIF CAT (70.5%) and UE CAT (62.5%) at final follow-up. Male sex (OR, 4.38-9.15) and regular exercise participation (OR, 6.45-18.94) positively predicted CSO achievement, whereas preoperative opioid use (OR, 0.06), depression (OR, 0.23), and living alone (OR, 0.90) were negative predictors of CSO achievement.

LEVEL OF EVIDENCE

Level IV, case series.

Spinal caspase-6 regulates AMPA receptor trafficking and dendritic spine plasticity through netrin-1 in postoperative pain after orthopedic surgery for tibial fracture in mice

Chronic postoperative pain hinders functional recovery after bone fracture and orthopedic surgery. Recently reported evidence indicates that caspase-6 is important in excitatory synaptic plasticity and pathological pain. Meanwhile, netrin-1 controls postsynaptic recruitment of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) and synaptogenesis. The present work aimed to examine whether caspase-6 and netrin-1 contribute to fracture-induced postoperative allodynia. A mouse model of tibial fracture by intramedullary pinning was generated for inducing postoperative pain. Then, paw withdrawal threshold, spinal caspase-6 activity, netrin-1 secretion, AMPAR trafficking, and spine morphology were examined. Caspase-6 inhibition and netrin-1 knockdown by shRNA were performed to elucidate the pathogenetic mechanism of allodynia and its prevention. Whole-cell patch-clamp recording was performed to assess caspase-6's function in spinal AMPAR-induced current. Tibial fractures after orthopedic operation initiated persistent postsurgical mechanical and cold allodynia, accompanied by increased spinal active caspase-6, netrin-1 release, GluA1-containing AMPAR trafficking, spine density, and AMPAR-induced current in dorsal horn neurons. Caspase-6 inhibition reduced fracture-associated allodynia, netrin-1 secretion, and GluA1 trafficking. Netrin-1 deficiency impaired fracture-caused allodynia, postsynaptic GluA1 recruitment, and spine plasticity. The specific GluA2-lacking AMPAR antagonist NASPM also dose dependently prevented postoperative pain. The reduction of fracture-mediated postoperative excitatory synaptic AMPAR current in the dorsal horn by caspase-6 inhibition was compromised by recombinant netrin-1. Exogenous caspase-6 induced pain hypersensitivity, reversing by netrin-1 knockdown or coapplication of NASPM. Thus, spinal caspase-6 modulation of GluA1-containing AMPAR activation and spine morphology through netrin-1 secretion is important in the development of fracture-related postsurgical pain in the mouse.

Preoperative Opioid Use Is Associated With Persistent Use, Readmission and Postoperative Complications After Arthroscopic Knee Surgery

PURPOSE

To evaluate factors associated with prolonged opioid use after arthroscopic knee surgery and to identify associations between preoperative usage and postoperative complications.

METHODS

The MarketScan commercial database was searched to identify patients who underwent arthroscopic knee surgery from 2005 to 2014 (based on Current Procedure Terminology code). Preoperative comorbidities including Diagnostic and Statistical Manual of Mental Disorders mental health disorders, chronic pain, chronic regional pain syndrome, obesity, tobacco use, non-narcotic medications and diabetes were queried and documented. Patients who filled opioid prescriptions 1 to 3 months before surgery were identified. Patients who filled opioid prescriptions after surgery were identified. Adjusted odds ratios and 95% confidence intervals were calculated using multivariable logistic regression analysis to determine factors associated with prolonged postoperative opioid use.

RESULTS

In total, 1,012,486 patients who underwent arthroscopic knee surgery were identified, and we determined which of these patients were on preoperative opioids. Preoperative opioid usage was associated with a statistically significant increased risk of usage out to 1 year. There was a statistically significant association between postoperative usage and preoperative variables (mental health diagnosis, smokers, chronic pain, chronic regional pain syndrome, and use of non-narcotic medications). There was a statistically significant association between preoperative opioid use and 90-day readmission and postoperative complications.

CONCLUSION

In this study, we found that patients taking opioids 1 to 3 months before arthroscopic knee surgery have increased risk of postoperative use. Additionally, chronic opioid use, chronic pain, or use of non-narcotic medications has the highest risk of postoperative opioid use. Finally, preoperative use was associated with an increased risk of 90-day readmission.

EVIDENCE

Prognostic Level IV Evidence.

Association of opioid misuse with anxiety and depression: A systematic review of the literature

The opioid epidemic is a public health problem associated with a host of negative outcomes. Although clinicians recognize covariation between opioid misuse with anxiety and depressive symptoms and disorders, research on this topic has only recently accumulated. Progress in this domain is impeded by the lack of systematic and integrative research to better understand and treat these co-occurring problems. This paper represents the first attempt to systematically review the empirical literature examining relations between opioid use and misuse, and anxiety and depression. In the first section, we define key terms and describe the article selection strategy. In the second section, we review the prevalence of anxiety and depressive symptoms among individuals who use and misuse prescription and illicit opioids. In the third section, we review the magnitude of associations between anxiety and depressive symptoms and disorders with opioid misuse, as well as highlight studies examining the longitudinal and temporal sequence of the relations between these variables. In the fourth section, we focus on experimental therapeutics, reviewing what is known about individual difference and transdiagnostic vulnerability factors for anxiety and depression that might contribute to opioid misuse and its symptoms. Finally, we discuss current knowledge gaps and present a heuristic model to guide future research.

Reducing the use of opioids by patients with chronic pain: an effectiveness study with long-term follow-up

This study addresses the problem of long-term opioid use by chronic pain patients. The study involved a secondary analysis of unanalyzed data from a published study of 2 versions of cognitive-behavioural therapy-based interdisciplinary treatment for chronic pain. In this study, we examined whether the use of opioids by 140 chronic pain patients could be ceased sustainably over 12 months after participation in the comprehensive interdisciplinary pain management program aimed at enhancing pain self-management. On admission to the treatment, there were no significant differences between those patients taking or not taking opioids on usual pain, pain interference in daily activities, pain-related disability, depression severity, as well as in pain cognitions. After the treatment, the use of opioids was significantly reduced, both in numbers taking any and in mean doses, and these gains were maintained over the 12-month follow-up. Finally, cessation of opioids during treatment was associated with more substantial and consistent improvements in usual pain, depression severity, pain interference, pain-related disability, and pain cognitions, relative to those who reduced their opioids but did not cease them. These findings support the idea of using training in pain self-management strategies as a viable alternative to long-term opioid use by patients with chronic pain.

Benefits and Harms of Long-term Opioid Dose Reduction or Discontinuation in Patients with Chronic Pain: a Rapid Review

BACKGROUND

Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the Centers for Disease Control & Prevention to limit prescribing of high-dose opioids. However, this practice change is occurring largely in the absence of data regarding patient outcomes. A 2017 systematic review found inconclusive evidence on the impact of LTOT dose reduction and discontinuation on pain severity and function, quality of life, withdrawal symptoms, substance abuse, and adverse effects. This rapid systematic review provides an updated evidence synthesis of patient outcomes following LTOT dose reduction including serious harms such as overdose and suicide.

METHODS

We systematically searched numerous bibliographic databases from January 2017 (the end search date of the 2017 systematic review) through May 2020. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, abstract data, and grade strength of evidence, with a second reviewer checking.

RESULTS

We included 49 studies-1 systematic review, 34 studies included in that systematic review, and 14 new studies. We prioritized evidence synthesis of 19 studies with the most applicability to the Veteran population and outpatient settings. Among these studies, improvements in mean pain scores were common among patients tapering opioids while participating in intensive multimodal pain interventions and mostly unchanged with less intensive or nonspecific co-interventions. Our confidence in these findings is low due to methodological limitations of the studies. Observational data suggests that serious harms such as opioid overdose and suicidal ideation can occur following opioid dose reduction or discontinuation, but the incidence of these harms at the population level is unknown.

DISCUSSION

The net balance of benefits and harms of LTOT dose reduction for patients with chronic pain is unclear. Clinicians should closely monitor patients during the tapering process given the potential for harm.

Risk Factors for Preoperative Opioid Use in Patients Undergoing Primary Anatomic Total Shoulder Arthroplasty

The effect of preoperative opioid use in orthopedic patients has been highlighted. Numerous studies have identified worse patient outcomes with pre-operative opioid use; however, there is currently no information identifying risk factors for preoperative opioid use in the total shoulder arthroplasty (TSA) population. The purpose of this study was to determine risk factors for preoperative opioid use in patients undergoing primary anatomic TSA for primary osteoarthritis (OA) and to determine baseline preoperative patient-reported outcomes (PROs) in preoperative opioid users compared with nonopioid users. The authors studied 982 TSAs performed for primary glenohumeral joint OA in a prospective TSA registry. Patient demographic and clinical characteristics were prospectively assessed and included age; sex; socioeconomic status (SES); smoking status; body mass index (BMI); and history of chronic back pain, depression, diabetes mellitus, and heart disease. Preoperative PROs, range of motion measurements, and preoperative opioid use for shoulder pain were assessed. Overall, 254 (25.9%) of 982 total patients were taking preoperative opioids for shoulder pain in the setting of primary OA. Female sex (P=.023), younger age (P=.019), obesity (BMI >30 kg/m²) (P=.043), chronic back pain (P<.001), and lower SES (P=.002) were associated with increased preoperative opioid use following multivariate logistic regression. Patients with opioid use had significantly worse preoperative pain scores (P<.001), American Shoulder and Elbow Surgeons scores (P<.001), and total Constant scores (P<.002) compared with the non-opioid group. [Orthopedics. 2020;43(6):356-360.].

Unintended consequences of COVID-19 safety measures on patients with chronic knee pain forced to defer joint replacement surgery

COVID-19 crisis deferred elective arthroplasty leading to potential surgical backlog. Prolonged surgical waiting times may worsen physical and mental health of patients in chronic pain.

In recent months, with the emergence of the COVID-19 pandemic, the American College of Surgeons and the U.S. Centers for Disease Control and Prevention officially recommended the delay of nonemergency procedures until the public health crisis is resolved. Deferring elective joint replacement surgeries for an unknown period is likely to decrease the incidence of infection with SARS-CoV-2 but is likely to have detrimental effects in individuals suffering from chronic knee pain. These detrimental effects extend beyond the discomfort of osteoarthritis (OA) and the inconvenience of rescheduling surgery. Disabling pain is a driving factor for individuals to seek medical intervention, including pharmacological palliative treatment and surgical procedures. The need for surgical intervention due to chronic pain as for knee and hip replacement is now put on hold indefinitely because access to surgical care has been limited. Although a moderate delay in surgical intervention may not produce a significant progression of OA within the knee, it could lead to muscle wasting due to immobility and exacerbate comorbidities, making rehabilitation more challenging. Importantly, it will have an impact on comorbidities driven by OA severity, notably decreased quality of life and depression. These patients with unremitting pain become increasingly susceptible to substance use disorders including opioids, alcohol, as well as prescription and illegal drugs. Appreciation of this downstream crisis created by delayed surgical correction requires aggressive consideration of nonsurgical, nonopiate supported interventions to reduce the morbidity associated with these delays brought upon by the currently restricted access to joint repair.

Preoperative Opioid Use Predicts Prolonged Postoperative Opioid Use and Inferior Patient Outcomes Following Anterior Cruciate Ligament Reconstruction

PURPOSE

(1) To determine patient factors associated with prolonged opioid use following anterior cruciate ligament reconstruction (ACLR) and (2) to evaluate the influence of preoperative opioid use on patient-reported outcomes.

METHODS

Patients who underwent ACLR and used opioids before the perioperative period, which was defined as the window 30 days before 15 days following the index surgery, were designated as preoperative opioid users. Patients who used opioids only in the perioperative period or post-operative period were designated as opioid-naïve. Predictors of opioid use at 6 and 12 months postoperatively and associations between preoperative opioid use and patient outcomes were assessed.

RESULTS

After institutional review board approval, we identified 253 patients (225 opioid-naïve and 28 opioid users ) who underwent ACLR from 2014 to 2018 at a single institution and had one year follow up (median: 11.6 months; interquartile range [8.9-14.3]). Patients with a history of preoperative opioid use (odds ratio [OR] 3.63, P = .034), greater preoperative visual analog scale pain scores (OR 1.32, 95% CI 1.04-1.67; P = .003), and greater body mass index (OR 1.09, P = .018) were significantly more likely to be taking opioids at 6 months postoperatively. Patients with a perioperative opioid intake of greater than 513 oral morphine equivalents were significantly more likely to continue taking opioids at the 6 month (OR 3.17, P = .024) and the 1 year (OR 3.34, P = .048) postoperative time points. Patients with preoperative opioid use were significantly less likely to achieve the patient acceptable symptomatic state (PASS) on the International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score (KOOS) Sport, KOOS Joint Replacement, KOOS Pain, KOOS Symptoms, KOOS Quality of Life, and KOOS Activities of Daily Living.

CONCLUSIONS

Preoperative opioid use, body mass index >30, and greater visual analog scale pain scores were predictors of continued opioid use at 6 months postoperatively. Preoperative opioid users were more likely to continue taking opioids, demonstrate significantly worse patient reported outcomes at baseline and 1-year postoperatively, and were less likely to achieve patient acceptable symptomatic state.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Relationships Between Opioid Dosing, Pain Severity, and Disability in a Community-Based Chronic Pain Population: An Exploratory Retrospective Analysis

OBJECTIVE

To determine the relationship between opioid dose change, pain severity, and function in patients with chronic pain.

DESIGN

Retrospective cohort study.

SETTING

Community interdisciplinary pain management practice.

SUBJECTS

A total of 778 patients with chronic pain prescribed opioids for three or more consecutive months between April 1, 2013, and March 1, 2015.

METHODS

Changes in opioid dose, pain severity rating, modified Roland Morris Disability Questionnaire score, and opioid risk data were extracted from medical records and analyzed for associations.

RESULTS

Two hundred forty-three subjects (31.2%) had an overall dose decrease, 223 (28.7%) had a dose increase, and 312 (40.1%) had no significant change in dose (<20% change). There was a weak negative correlation between change in opioid dose and change in pain severity (r = -0.08, P = 0.04) but no association between change in disability scores and dose change (N = 526, P = 0.13). There was a weak positive correlation between change in pain severity rating and change in disability scores (r = 0.16, P < 0.001).

CONCLUSIONS

The results suggest that escalating opioid doses may not necessarily result in clinically significant improvement of pain or disability. Similarly, significant opioid dose reductions may not necessarily result in worsened pain or disability. This exploratory investigation raised questions of possible subgroups of patients who might demonstrate improvement of pain and disability with opioid dose adjustments, and further research should prospectively explore this potential, given the limitations inherent in retrospective analyses. Prescribers should still consider reduction of opioid doses as recommended by current guidelines, in an effort to mitigate the potential risks associated with high-dose treatment.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

CONTEXT

Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined.

OBJECTIVE

Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit.

STUDY DESIGN

Systematic rapid realist review.

DATASET

Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation.

RESULTS

95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion.

CONCLUSIONS

Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.

Risk Factors for Prolonged Opioid Use and Effects of Opioid Tolerance on Clinical Outcomes After Anterior Cervical Discectomy and Fusion Surgery

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim of this study was to determine risk factors for prolonged opioid use and to investigate whether opioid-tolerance affects patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) surgery.

SUMMARY OF BACKGROUND DATA

There is a lack of consensus on risk factors that can affect continued opioid use after cervical spine surgery and the influence of opioid use on patient-reported outcomes.

METHODS

Ninety-two patients who underwent ACDF for degenerative cervical pathologies were retrospectively identified and their opioid usage before surgery was investigated using a state-sponsored prescription drug monitoring registry. Opioid-naïve and opioid tolerant groups were defined using criteria most consistent with the Federal Drug Administration (FDA) definition. Patient-reported outcomes were then collected, including the Short Form-12 (SF-12) Physical Component (PCS-12) and Mental Component (MCS-12), the Neck Disability Index (NDI), the Visual Analogue Scale Neck (VAS neck) and the Visual Analogue Scale Arm (VAS Arm) pain scores. Logistic regression was used to determine predictors for prolonged opioid use following ACDF. Univariate and multivariate analyses were conducted to compare change in outcomes over time between the two groups.

RESULTS

Logistic regression analysis demonstrated that opioid tolerance was a significant predictor for prolonged opioid use after ACDF (odds ratio [OR]: 18.2 [1.46, 226.4], P = 0.02). Duration of usage was also found to be a significant predictor for continued opioid use after surgery (OR: 1.10 [1.0, 1.03], P = 0.03). No other risk factors were found to be significant predictors. Both groups overall experienced improvements in patient-reported outcomes after surgery. Multiple linear regression analysis, controlling for patient demographics, demonstrated that opioid-tolerant user status positively affected change in outcomes over time for NDI (β = -13.7 [-21.8,-5.55], P = 0.002) and PCS-12 (β = 6.99 [2.59, 11.4], P = 0.003) but no other outcomes measured.

CONCLUSION

Opioid tolerance was found to be a significant predictor for prolonged opioid use after ACDF. Additionally, opioid-naïve and opioid-tolerant users experienced overall improvements across PROMs following ACDF. Opioid-tolerance was associated with NDI and PCS-12 improvements over time compared to opioid-naïve users.

LEVEL OF EVIDENCE

4.

Does early physical therapy intervention reduce opioid burden and improve functionality in the management of chronic lower back pain?

Introduction

Chronic lower back pain is a leading cause of disability in US adults. Opioid use continues to be controversial despite the Centers for Disease Control and Prevention guidance on chronic pain management to use nonpharmacologic and nonopioid pharmacologic interventions. The objectives of the study were to assess the impact of early physical therapy (PT) intervention on improving functionality and reducing opioid burden in patients with chronic lower back pain.

Methods

A single-center, retrospective chart review of patients receiving ≥6 PT visits and treated with either opioids first (OF) or PT first (PTF) therapy for chronic lower back pain were evaluated. Concomitant use of nonopioid and nonpharmacologic therapy was permitted. The Oswestry Disability Index (ODI), a survey measuring functionality, was recorded for PTF group. Pain scores and medication use including opioids were collected at treatment initiation and completion.

Results

One hundred and eighty patients were included in three groups: OF group (n = 60), PTF group (n = 60), and PTF + ODI group (n = 60). The PTF + ODI group had mean ODI reduction of 11.9% (P < .001). More OF patients were lost to follow up (68.3%) or failed PT (60%) compared to the PTF group, 38.3% and 3.3% (P < .001). Reduction in both opioid and nonopioid medications as well as pain scores were observed but not statistically significant.

Discussion

Early PT resulted in improved functionality, decreased pain, and reduced medication use upon PT completion. These findings suggest PT, along with nonopioid modalities, are a viable first-line option for the management of chronic lower back pain.

Surgical Treatment of Patients With Dual Hip and Spinal Degenerative Disease: Effect of Surgical Sequence of Spinal Fusion and Total Hip Arthroplasty on Postoperative Complications

STUDY DESIGN

Retrospective study.

OBJECTIVE

To determine how lumbar spinal fusion-total hip arthroplasty (LSF-THA) operative sequence would affect THA outcomes.

SUMMARY OF BACKGROUND DATA

Outcomes following THA in patients with a history of lumbar spinal degenerative disease and fusion are incompletely understood.

METHODS

The PearlDiver Research Program (http://www.pearldiverinc.com) was used to identify patients undergoing primary THA. Patients were divided into four cohorts: 1) Primary THA without spine pathology, 2) remote LSF prior to hip pathology and THA, and patients with concurrent hip and spinal pathology that had 3) THA following LSF, and 4) THA prior to LSF. Postoperative complications and opioid use were assessed with multivariable logistic regression to determine the effect of spinal degenerative disease and operative sequence.

RESULTS

Between 2007 and 2017, 85,595 patients underwent primary THA, of whom 93.6% had THA without lumbar spine degenerative disease, 0.7% had a history of remote LSF, and those with concurrent hip and spine pathology, 1.6% had THA prior to LSF, and 2.4% had THA following LSF. Patients with hip and lumbar spine pathology who underwent THA prior to LSF had significantly higher rates of dislocation (aOR = 2.46, P < 0.0001), infection (aOR = 2.65, P < 0.0001), revision surgery (aOR = 1.91, P < 0.0001), and postoperative opioid use at 1 month (aOR: 1.63, P < 0.001), 3 months (aOR = 1.80, P < 0.001), 6 months (aOR: 2.69, P < 0.001), and 12 months (aOR = 3.28, P < 0.001) compared with those treated with THA following LSF.

CONCLUSION

Patients with degenerative hip and lumbar spine pathology who undergo THA prior to LSF have a significantly increased risk of postoperative dislocation, infection, revision surgery, and prolonged opioid use compared with THA after LSF. Surgeons should consider the surgical sequence of THA and LSF on outcomes for patients with this dual pathology. Shared decision making between patients, spine surgeons, and arthroplasty surgeons is necessary to optimize outcomes in patients with concomitant hip and spine pathology.

LEVEL OF EVIDENCE

3.

Comparison of opioid use and prescribing patterns in orthopedic surgery in Japan and the United States: A JOA-AOA Traveling Fellowship Investigation

BACKGROUND

The US continues to be in the midst of an opioid epidemic. The prescription of narcotics for acute injury or post-operative pain is a common inciting event leading to opioid abuse and addiction. It is eminently important for orthopedic surgeons to lead the charge in changing practice patterns to decrease the prescribing and subsequent use and abuse of opioids. Anecdotally, many surgeons are aware that use of opioids for post-operative pain is substantially less in other countries compared to the US. However, this has not been well quantified and may be useful information to guide practice.

METHODS

The 2018 American Orthopedic Association (AOA)- Japanese Orthopedic Association (JOA) traveling fellows developed a survey to compare orthopedic surgeon-reported opioid prescribing patterns after various common orthopedic surgeries in Japan and the US.

RESULTS

We present here survey data demonstrating significantly less post-operative prescription of opioids in Japan in terms of number of pills provided and duration of prescriptions compared to orthopedic surgeons in the US.

CONCLUSION

We hope this provides meaningful data to motivate orthopedic surgeons in the US to evaluate and potentially alter their own prescription habits to help mitigate the opioid crisis.

Patient and clinician incentives and barriers for opioid use for musculoskeletal disorders a qualitative study on opioid use in musculoskeletal setting

Introduction

Strategies for pain alleviation have relied heavily on opioids in the recent decades. One consequence is a crisis of opioid misuse, overdose, and overdose related death. This study sought patient and clinician incentives and barriers to the use of opioids in musculoskeletal illness.

Methods

In this qualitative study, twenty-eight patients and eight clinicians participated in a semi-structured interview seeking incentives and barriers for opioid use and prescription in musculoskeletal illness. Interviews were conducted by a trained qualitative interviewer. The interview data were transcribed and analyzed using a thematic analysis framework.

Results

Patient incentives for opioid use included doctor's orders, opioids being the only effective way to alleviate pain, alleviating symptoms of depression and anxiety, being able to keep a job, and lower cost of opioids relative to alternative treatment options. Patient barriers included associated risks (side effects, addiction) and wanting to control pain intensity. Clinician incentives for prescribing opioids included adequate pain alleviation, patient satisfaction, relatively inexpensive costs of opioids, convenience and doing what was taught by the clinician's superior. Lacking time and resources to adequately inform patients on appropriate opioid use and alternative treatments, likely results in more opioid prescribing than arguably necessary. Barriers for opioid prescribing included specific patient characteristics (psychiatric background, history of opioid misuse) and illness characteristics (nature of the injury, medical contra-indications).

Conclusion

Patients feel that opioids should be used with caution. Clinicians in this study reported a tendency to default to opioids out of habit and convenience. Both patients and clinicians were aware that opioids are often misused to treat emotional pain.

Preinjury Narcotic Use Does Not Affect Treatment for Compartment Syndrome

OBJECTIVES

To determine the association of preinjury opioid use on incidence of fasciotomy after lower extremity trauma.

DESIGN

Retrospective case-control study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

We identified 245 consecutive patients treated with fasciotomy for compartment syndrome of the lower extremity from 2011 to 2016. Of these, 115 were excluded for isolated vascular injury without fracture, age younger than 18 years, out-of-state residence, nontraumatic etiology, and/or incomplete opioid records. Three hundred ninety age- and sex-matched patients with tibial fractures not requiring fasciotomy were selected for comparison.

INTERVENTION

Review of demographics, injury characteristics, and opioid prescriptions.

MAIN OUTCOME MEASUREMENTS

Rate of preinjury narcotic use.

RESULTS

There was no significant difference in chronic opioid use between patients requiring fasciotomy and those who did not (odds ratio = 0.80, 95% confidence interval: 0.43-1.50, P = 0.49). There was no significant difference in average morphine milligram equivalents (MME)/day (66.6 vs. 77.4, P = 0.68). There was no significant difference in active opioid use (odds ratio = 0.76, 95% confidence interval: 0.45-1.29, P = 0.30). There was no significant difference in average MME/day (69.3 vs. 75.6, P = 0.80) for active narcotic users.

CONCLUSION

There were no differences in the rate or average MME/day of preinjury opioid use between patients with a tibia fracture treated with or without fasciotomy for compartment syndrome. These results indicate that pre-existing opioid use does not interfere with the accurate diagnosis of compartment syndrome in trauma patients. The diagnosis and treatment of compartment syndrome is not affected by preinjury narcotic use and potential associations with opiate-induced hyperalgesia.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Trajectories of sickness absence and disability pension before and after opioid initiation for noncancer pain: a 10-year population-based study

Chronic noncancer pain is a leading cause of sickness absence (SA) and disability pension (DP). The objectives of this study were to identify trajectories of SA/DP before and after strong and weak opioid initiation for noncancer pain and the factors associated with these trajectories. A longitudinal population-based study of 201,641 people (24-59 years) without cancer who initiated opioid analgesics in 2009 in Sweden was conducted. Trajectories of net annual SA/DP days in the 5 years before/after opioid initiation were estimated with group-based trajectory modelling. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with trajectory groups. Among the 6.9% of people initiating strong opioids, 12.5% had persistent high SA/DP (estimated 320 days/year) before and after opioid initiation and 72.9% had persistent low/minimum SA/DP (estimated 30 days/year). Approximately 8.6% of people had increasing SA/DP, and 6.1% had decreasing SA/DP after opioid initiation, although this seemed to reflect continuation of preinitiation patterns. Trajectories were similar at lower SA/DP days/year among those initiating weak opioids. Persistent high SA/DP among strong opioid initiators were associated with ≥5 comorbidities (OR = 8.72, 95% CI 5.61-13.56), ≤9 years of education (OR = 5.83, 95% CI 4.84-7.03), and previous use of antidepressants (OR = 4.57, 95% CI 3.89-5.37) and antipsychotics (OR = 4.49, 95% CI 2.93-6.88). Three-quarters of people initiating opioids for noncancer pain had persistent low/minimum levels of SA/DP 5 years before and after initiation. Increasing and decreasing SA/DP after opioid initiation seemed to reflect a continuation of preinitiation patterns. Our findings highlight the complex range of sociodemographic and medication-related factors associated with persistent SA/DP.