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Deiling B, Mullen K, Shilling AM. Continuous Catheter Techniques. Anesthesiol Clin 2024; 42:317-328. [PMID: 38705679 DOI: 10.1016/j.anclin.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.
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Affiliation(s)
- Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA.
| | - Kenneth Mullen
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
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2
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Liu O, Leon D, Gough E, Hanna M, Jaremko K. A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service. Br J Clin Pharmacol 2024. [PMID: 38817150 DOI: 10.1111/bcp.16118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
AIMS To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). METHODS This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. RESULTS Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). CONCLUSIONS Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.
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Affiliation(s)
- Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Leon
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Gough
- Department of Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Komann M, Rabe Y, Lehmann T, Dreiling J, Weinmann C, Kranke P, Meißner W. Operation-specific risk of postoperative nausea: a cross-sectional study comparing 72 procedures. BMJ Open 2024; 14:e077508. [PMID: 38382957 PMCID: PMC10882331 DOI: 10.1136/bmjopen-2023-077508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 02/06/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Determination of the procedure-specific, risk-adjusted probability of nausea. DESIGN Cross-sectional analysis of clinical and patient-reported outcome data. We used a logistic regression model with type of operation, age, sex, preoperative opioids, antiemetic prophylaxis, regional anaesthesia, and perioperative opioids as predictors of postoperative nausea. SETTING Data from 152 German and Austrian hospitals collected in the Quality Improvement in Postoperative Pain Treatment (QUIPS) registry from 2013 to 2022. Participants completed a validated outcome questionnaire on the first postoperative day. Operations were categorised into groups of at least 100 cases. PARTICIPANTS We included 78 231 of the 293 947 participants from the QUIPS registry. They were 18 years or older, willing and able to participate and could be assigned to exactly one operation group. MAIN OUTCOME MEASURES Adjusted absolute risk of nausea on the first postoperative day for 72 types of operation. RESULTS The adjusted absolute risk of nausea ranged from 6.2% to 36.2% depending on the type of operation. The highest risks were found for laparoscopic bariatric operations (36.2%), open hysterectomy (30.4%), enterostoma relocation (29.8%), open radical prostatectomy (28.8%), laparoscopic colon resection (28.6%) and open sigmoidectomy (28%). In a logistic regression model, male sex (OR: 0.39, 95% CI 0.37 to 0.41, p<0.0001), perioperative nausea and vomiting prophylaxis (0.73, 0.7 to 0.76, p<0.0001), intraoperative regional anaesthesia (0.88, 0.83 to 0.93, p<0.0001) and preoperative opioids for chronic pain (0.74, 0.68 to 0.81, p<0.0001) reduced the risk of nausea. Perioperative opioid use increased the OR up to 2.38 (2.17 to 2.61, p<0.0001). CONCLUSIONS The risk of postoperative nausea varies considerably between surgical procedures. Patients undergoing certain types of operation should receive special attention and targeted prevention strategies. Adding these findings to known predictive tools may raise awareness of the still unacceptably high incidence of nausea in certain patient groups. This may help to further reduce the prevalence of nausea. TRIAL REGISTRATION NUMBER DRKS00006153; German Clinical Trials Register; https://drks.de/search/de/trial/DRKS00006153.
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Affiliation(s)
- Marcus Komann
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Yvonne Rabe
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Thomas Lehmann
- Center for Clinical Studies, Jena University Hospital, Jena, Germany
| | - Johannes Dreiling
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Claudia Weinmann
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, Würzburg, Germany
| | - Winfried Meißner
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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Haddad D, Yu V, Chow R, Yanez D, Rajput K. A Survey Study of Surgeons and Anesthesiologists Regarding Perioperative Multimodal Analgesia for Opioid-Tolerant Patients. J Perianesth Nurs 2024; 39:87-92. [PMID: 37855765 DOI: 10.1016/j.jopan.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE Perioperative pain management of opioid-tolerant patients can be challenging. Although regional anesthesia and multimodal analgesics may be beneficial, these modalities are often underused. It is unclear whether practice patterns for perioperative pain management are determined by the knowledge, attitudes, and beliefs of surgeons and anesthesiologists. DESIGN Descriptive survey. METHODS Using a Qualtrics survey, we polled a randomly selected group of 25 surgeons and 25 anesthesiologists regarding their knowledge, attitudes, beliefs, and practices for pain management in an opioid-tolerant patient. FINDINGS Of 25, 23 anesthesiologists and 18/25 surgeons responded to the survey. Demographics were similar between the 2 groups. Most of the participant surgeons and anesthesiologists believed that pain management may be challenging in an opioid-tolerant patient. However, only 56% of surgeons would recommend a preoperative pain consultation. Most surgeons and anesthesiologists believed in the efficacy of regional anesthetics. However, 43% of surgeons would not advocate for a regional block, perhaps due to their perception of the added perioperative time. Multimodal analgesics were widely accepted by both surgeons and anesthesiologists. CONCLUSIONS There is an urgent need to reinforce the importance of patient-centered care, with a specific focus on addressing knowledge gaps and improving perceptions for all the members of the team, including surgeons, anesthesiologists, and perioperative nursing teams, if optimal outcomes are to be achieved for our patients.
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Affiliation(s)
- Daniel Haddad
- Department of Anesthesiology and Pain Medicine, Yale University School of Medicine, New Haven, CT
| | - Victor Yu
- Department of Anesthesiology and Pain Medicine, Yale University School of Medicine, New Haven, CT
| | - Robert Chow
- Department of Anesthesiology and Pain Medicine, Yale University School of Medicine, New Haven, CT
| | - David Yanez
- Department of Anesthesiology and Pain Medicine, Yale University School of Medicine, New Haven, CT
| | - Kanishka Rajput
- Department of Anesthesiology and Pain Medicine, Yale University School of Medicine, New Haven, CT.
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Cazzaniga S, Real G, Finazzi S, Lorini LF, Forget P, Bugada D. How to Modulate Peripheral and Central Nervous System to Treat Acute Postoperative Pain and Prevent Pain Persistence. Curr Neuropharmacol 2024; 22:23-37. [PMID: 37563811 DOI: 10.2174/1570159x21666230810103508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 08/12/2023] Open
Abstract
Chronic postoperative pain (CPSP) is a major issue after surgery, which may impact on patient's quality of life. Traditionally, CPSP is believed to rely on maladaptive hyperalgesia and risk factors have been identified that predispose to CPSP, including acute postoperative pain. Despite new models of prediction are emerging, acute pain is still a modifiable factor that can be challenged with perioperative analgesic strategies. In this review we present the issue of CPSP, focusing on molecular mechanism underlying the development of acute and chronic hyperalgesia. Also, we focus on how perioperative strategies can impact directly or indirectly (by reducing postoperative pain intensity) on the development of CPSP.
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Affiliation(s)
- Sara Cazzaniga
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, 24127, Bergamo, Italy
| | - Giovanni Real
- Department of Health Sciences, University of Milan, 20122, Milan, Italy
| | - Simone Finazzi
- Department of Health Sciences, University of Milan, 20122, Milan, Italy
| | - Luca F Lorini
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, 24127, Bergamo, Italy
| | - Patrice Forget
- School of Medicine, Medical Sciences and Nutrition, Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Scotland, United Kingdom
- Department of Anaesthesia, NHS Grampian, Aberdeen AB25 2ZD, Scotland, United Kingdom
| | - Dario Bugada
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, 24127, Bergamo, Italy
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Lane O, Ambai V, Bakshi A, Potru S. Alcohol use disorder in the perioperative period: a summary and recommendations for anesthesiologists and pain physicians. Reg Anesth Pain Med 2023:rapm-2023-104354. [PMID: 38050177 DOI: 10.1136/rapm-2023-104354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 09/26/2023] [Indexed: 12/06/2023]
Abstract
Excessive alcohol consumption and alcohol use disorder (AUD) increase the risk of perioperative morbidity and mortality. Aspiration, malnutrition, coagulopathies, seizures, and hemodynamic alterations are only a few of the major concerns related to acute alcohol intoxication and AUD. There are also numerous physiological effects, changes in medication metabolism and pharmacology, and adverse events related to chronic alcohol consumption. These are all important considerations for the anesthesiologist in the perioperative management of a patient with AUD. Pain perception and thresholds are altered in patients with acute and chronic alcohol use. Medications used to manage AUD symptoms, particularly naltrexone, can have significant perioperative implications. Patients on naltrexone who continue or stop this medication in the perioperative period are at an increased risk for undertreated pain or substance use relapse. This review highlights key considerations for the anesthesiologist and pain physician in the perioperative management of patients with active AUD (or those in recovery). It discusses the effects of acute and chronic alcohol use on pain perception and thresholds, provides guidance on the perioperative management of naltrexone and low-dose naltrexone, and reviews a multimodal approach to pain management.
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Affiliation(s)
- Olabisi Lane
- Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vats Ambai
- Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arjun Bakshi
- Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sudheer Potru
- Atlanta VA Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA
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Moryl N, Mendoza TR, Horn SD, Eustaquio JC, Cleeland CS, Inturrisi C. Should We Use COMM (Current Opioid Misuse Measure) to Screen for Opioid Abuse in Patients With Cancer Pain? J Natl Compr Canc Netw 2023; 21:1132-1140.e3. [PMID: 37935105 PMCID: PMC11110681 DOI: 10.6004/jnccn.2023.7054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/26/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Growing concerns about opioid use disorder (OUD) and the resulting decrease in opioid availability for patients with cancer pain highlight the need for reliable screening tools to identify the subset of patients at increased risk for aberrant opioid use. Our study examines the utility of Current Opioid Misuse Measure (COMM) recommended by the NCCN Clinical Practice Guidelines in Oncology for Adult Cancer Pain. PATIENTS AND METHODS We analyzed prospectively collected patient-reported outcomes of 444 consecutive patients with cancer seen in pain clinics of a cancer center at 2 time points within 100 days. The relationship of COMM to other OUD screening tools, pain, opioid doses, patient demographics, and mortality was examined using univariate and multivariable logistic regression. We also examined individual items of COMM for face validity. RESULTS Among 444 patients who completed pain surveys at 2 time points, 157 (35.4%) did not complete COMM surveys. Using a COMM cutoff of ≥13, a total of 84 patients (29.3%; 84/287) scored positive for aberrant drug use. As patients remained on opioids for 49 to 100 days, the likelihood of improving COMM score (turning from positive to negative) was 6.1 times greater than the reverse. The number of patients with COMM ≥13 was 3.8 times higher than the number of patients with CPT diagnostic codes for OUD, 5.3 times higher than those with a positive urine drug screening, and 21 times higher than those with a positive CAGE (Cut Down, Annoyed, Guilty, Eye-Opener Questionnaire) score. COMM ≥13 was not associated with pain relief response (worst pain intensity score ≥2 points on the Brief Pain Inventory), opioid doses, gender, or age. Contrary to the intended use of COMM to identify aberrant opioid use, COMM ≥13 predicted mortality: patients with COMM ≥13 were 1.9 times more likely to die within 12 months. CONCLUSIONS Our study found that using COMM in a cancer population may significantly overestimate the risk of opioid misuse. Using COMM without modifications can create an additional barrier to cancer pain management, such as limiting appropriate opioid use.
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Affiliation(s)
- Natalie Moryl
- Supportive Care Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tito R Mendoza
- Division of Internal Medicine, Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan D Horn
- Health System Innovation and Research Division, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jelyn C Eustaquio
- Jacobs School of Medicine and Biomedical Sciences, State University of New York, University at Buffalo, Buffalo, New York
- Supportive Care Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles S Cleeland
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charles Inturrisi
- Department of Pharmacology, Weill Cornell Medical College, New York, New York
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8
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Pavone K, Gorgol H, Rust V, Bronski M, Labelle C, Compton P. Exploring the postoperative pain experiences of individuals with opioid use disorder and the nurses providing care in the USA: A qualitative descriptive study protocol. BMJ Open 2023; 13:e072187. [PMID: 37848308 PMCID: PMC10583043 DOI: 10.1136/bmjopen-2023-072187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 09/06/2023] [Indexed: 10/19/2023] Open
Abstract
INTRODUCTION The goal of this study is to gain firsthand insights from individuals with a history of opioid use disorder (OUD) using medication for OUD on their experiences with postoperative pain care. This study also seeks to describe the experiences of nurses caring for individuals with OUD, and the challenges they may face managing complaints of pain in this population. Research suggests that hospitals can significantly enhance the quality of the care they deliver by investigating an individual's experience in the care setting. These insights will allow for the development of strategies for nurses to deepen their understanding of and, therefore, advocate and improve care for, this vulnerable and often stigmatised population. METHODS AND ANALYSIS A qualitative descriptive study will be conducted consisting of a prescreening and demographics questionnaire, and individual semistructured interviews with approximately 10-15 individuals with OUD having recently undergone surgery and 10-15 nurses providing care for this population for a total of 20-30 interviews. This approach involves the collection of separate but complementary data (ie, perceptions of individuals with OUD and nurses) concerning the phenomena of postoperative pain management. Sampling will continue until data saturation is reached. Descriptive statistics and thematic analysis will then be used. Reporting will adhere to the Standards for Reporting Qualitative Research checklist. ETHICS AND DISSEMINATION This study received approval from the Institutional Review Board at Northeastern University. Alongside peer-reviewed journal publications, the findings will be presented at relevant conferences, and a plain language summary will be distributed to the study participants.
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Affiliation(s)
- Kara Pavone
- College of Nursing, University of Rhode Island, Kingston, RI, USA
| | - Hilary Gorgol
- Bouve College of Health Sciences, School of Nursing, Northeastern University, Boston, Massachusetts, USA
| | - Victoria Rust
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, Massachusetts, USA
| | - Mary Bronski
- Bouve College of Health Sciences, School of Nursing, Northeastern University, Boston, Massachusetts, USA
| | - Colleen Labelle
- Grayken Center for Addiction Training and Technical Assistance, Boston Medical Center, Boston, Massachusetts, USA
| | - Peggy Compton
- College of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Martin LF, Cheng K, Washington SM, Denton M, Goel V, Khandekar M, Largent-Milnes TM, Patwardhan A, Ibrahim MM. Green Light Exposure Elicits Anti-inflammation, Endogenous Opioid Release and Dampens Synaptic Potentiation to Relieve Post-surgical Pain. THE JOURNAL OF PAIN 2023; 24:509-529. [PMID: 36283655 PMCID: PMC9991952 DOI: 10.1016/j.jpain.2022.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022]
Abstract
Light therapy improves multiple conditions such as seasonal affective disorders, circadian rhythm dysregulations, and neurodegenerative diseases. However, little is known about its potential benefits in pain management. While current pharmacologic methods are effective in many cases, the associated side effects can limit their use. Non-pharmacological methods would minimize drug dependence, facilitating a reduction of the opioid burden. Green light therapy has been shown to be effective in reducing chronic pain in humans and rodents. However, its underlying mechanisms remain incompletely defined. In this study, we demonstrate that green light exposure reduced postsurgical hypersensitivity in rats. Moreover, this therapy potentiated the antinociceptive effects of morphine and ibuprofen on mechanical allodynia in male rats. Importantly, in female rats, GLED potentiated the antinociceptive effects of morphine but did not affect that of ibuprofen. We showed that green light increases endogenous opioid levels while lessening synaptic plasticity and neuroinflammation. Importantly, this study reveals new insights into how light exposure can affect neuroinflammation and plasticity in both genders. Clinical translation of these results could provide patients with improved pain control and decrease opioid consumption. Given the noninvasive nature of green light, this innovative therapy would be readily implementable in hospitals. PERSPECTIVE: This study provides a potential additional therapy to decrease postsurgical pain. Given the safety, availability, and the efficacy of green light therapy, there is a significant potential for advancing the green light therapy to clinical trials and eventual translation to clinical settings.
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Affiliation(s)
- Laurent F Martin
- Department of Pharmacology, College of Medicine, The University of Arizona, Tucson, Arizona; Department of Anesthesiology, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Kevin Cheng
- Department of Pharmacology, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Stephanie M Washington
- Department of Anesthesiology, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Millie Denton
- Department of Anesthesiology, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Vasudha Goel
- Department of Anesthesiology, The University of Minnesota Medical School, Minneapolis, Minnesota
| | - Maithili Khandekar
- Department of Anesthesiology, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Tally M Largent-Milnes
- Department of Pharmacology, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Amol Patwardhan
- Department of Pharmacology, College of Medicine, The University of Arizona, Tucson, Arizona; Department of Anesthesiology, College of Medicine, The University of Arizona, Tucson, Arizona; Department of Neurosurgery, College of Medicine, The University of Arizona, Tucson, Arizona; Comprehensive Pain and Addiction Center, The University of Arizona, Tucson, Arizona
| | - Mohab M Ibrahim
- Department of Pharmacology, College of Medicine, The University of Arizona, Tucson, Arizona; Department of Anesthesiology, College of Medicine, The University of Arizona, Tucson, Arizona; Department of Neurosurgery, College of Medicine, The University of Arizona, Tucson, Arizona; Comprehensive Pain and Addiction Center, The University of Arizona, Tucson, Arizona.
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Coluzzi F, LeQuang JAK, Sciacchitano S, Scerpa MS, Rocco M, Pergolizzi J. A Closer Look at Opioid-Induced Adrenal Insufficiency: A Narrative Review. Int J Mol Sci 2023; 24:ijms24054575. [PMID: 36902007 PMCID: PMC10003084 DOI: 10.3390/ijms24054575] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Among several opioid-associated endocrinopathies, opioid-associated adrenal insufficiency (OIAI) is both common and not well understood by most clinicians, particularly those outside of endocrine specialization. OIAI is secondary to long-term opioid use and differs from primary adrenal insufficiency. Beyond chronic opioid use, risk factors for OIAI are not well known. OIAI can be diagnosed by a variety of tests, such as the morning cortisol test, but cutoff values are not well established and it is estimated that only about 10% of patients with OIAI will ever be properly diagnosed. This may be dangerous, as OIAI can lead to a potentially life-threatening adrenal crisis. OIAI can be treated and for patients who must continue opioid therapy, it can be clinically managed. OIAI resolves with opioid cessation. Better guidance for diagnosis and treatment is urgently needed, particularly in light of the fact that 5% of the United States population has a prescription for chronic opioid therapy.
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Affiliation(s)
- Flaminia Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, 04100 Latina, Italy
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
- Correspondence:
| | | | - Salvatore Sciacchitano
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00189 Rome, Italy
- Laboratory of Biomedical Research, Niccolò Cusano University Foundation, 00166 Rome, Italy
| | - Maria Sole Scerpa
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
| | - Monica Rocco
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
- Department of Surgical and Medical Science and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
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11
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Forghani M, Nasr Esfahani M, Vali M. Comparison of the Effect of Intravenous Fentanyl with Low-Dose Ketamine on Pain Relief in Patients Taking Methadone and Suffering from Limb Fractures. Adv Biomed Res 2023; 12:7. [PMID: 36926435 PMCID: PMC10012033 DOI: 10.4103/abr.abr_166_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/15/2021] [Accepted: 01/02/2022] [Indexed: 02/05/2023] Open
Abstract
Background Given the significance of pain control in addicted patients and the prominence of not using opioids due to patient's drug dependence, the present study aimed at comparing and evaluating the effect of intravenous fentanyl with low-dose ketamine on pain relief in patients taking methadone and suffering from limb fractures. Materials and Methods The present double-blind randomized clinical trial was performed on 100 patients taking methadone and suffering from limb fractures. The patients were divided into two groups receiving 1 μg/kg single dose of fentanyl and 0.3 mg/kg single dose of ketamine (low-dose ketamine). Patients' pain scores and the incidence rate of complications were recorded before the intervention, and 15, 30, and 60 min after drug administration and were then compared between the two groups. Results The mean pain score of patients 15 min after the intervention was significantly lower in the low-dose ketamine group with a mean of 2.50 ± 1.34 as compared with the fentanyl group with a mean of 7.10 ± 1.43 (P < 0.001). However, the mean pain score was not significantly different between the two groups 30 and 60 min after the intervention (P > 0.05). In addition, the incidence rate of complications was not significantly different between the two groups (P > 0.05). Conclusion According to the results of this study, low-dose ketamine as compared with fentanyl relieves pain in the mentioned patients with a faster effect and in a shorter time although no difference can be found between the pain scores of the two groups 30 and 60 min after the intervention.
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Affiliation(s)
- Mohsen Forghani
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Marzie Vali
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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12
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Hargett J, Criswell A, Palokas M. Nonpharmacological interventions for acute pain management in patients with opioid abuse or opioid tolerance: a scoping review. JBI Evid Synth 2022; 20:2697-2720. [PMID: 36065876 DOI: 10.11124/jbies-21-00169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The objective of this scoping review was to identify and map the evidence on nonpharmacological interventions for acute pain management in patients with opioid tolerance or opioid abuse. INTRODUCTION Opioid therapy is the mainstay of pain management for adults experiencing moderate-to-severe acute pain. However, considering the known risks of opioid use and the growing number of patients with opioid tolerance or opioid abuse, nonpharmacological pain management interventions are of increasing interest to health care providers. Nonpharmacological techniques have shown potential in reducing postoperative pain, opioid consumption, stress, and anxiety. INCLUSION CRITERIA Eligible studies included participants in either inpatient or outpatient health care settings who were experiencing acute pain and a tolerance to opioid medications or opioid abuse. Studies that examined nonpharmacological interventions for treating acute pain in these patients were considered. Nonpharmacological interventions included, but were not limited to, acupuncture, electroacupuncture, massage, mindfulness, electroanalgesia, low-level light therapy, meditation, biofeedback, hypnosis, and relaxation techniques. METHODS MEDLINE, CINAHL, Scopus, Embase, Europe PubMed Central, PsycINFO, Cochrane Central Register of Controlled Trials, and the US National Library of Medicine ( https://ClinicalTrials.gov/ ) were searched, as were sources of unpublished studies on December 30, 2020. Only studies published in English were included, and there was no limit on date of publication. After screening the titles and abstracts of identified citations, 2 independent reviewers retrieved potentially relevant full-text studies and extracted data. Data are presented in diagrammatic format, and accompany the narrative synthesis. RESULTS Fourteen articles were included in the study, including 10 expert opinion papers or chapters, 3 case reports, and 1 implementation report. The most common setting was the perioperative setting, specifically orthopedic surgery. Nonpharmacological pain interventions identified in the literature included physical interventions such as acupuncture, physical therapy, therapeutic exercise, yoga, bracing, heat, cold, elevation, compression, chiropractic interventions, massage, manual therapy, transcutaneous electrical nerve stimulation, and pulsed electromagnetic field therapy. Behavioral and psychological modalities included positive affirmations, cognitive behavioral therapy, acceptance and commitment therapy, mindfulness, distraction, guided imagery, meditation, biofeedback, relaxation, hypnosis, breathing exercises, and energy healing. Many expert opinions included only brief mentions or recommendations for nonpharmacological interventions without full explanations, evidence from the literature, or discussion of the level of support for the recommendation. CONCLUSIONS The findings of this review indicate that nonpharmacological interventions for patients with opioid tolerance or dependence include physical, psychological, and multimodal approaches. Nonpharmacological interventions in this scoping review were often presented as combined with opioid or non-opioid medications for a pain management regimen that is opioid-sparing, opioid-free, or drug-free. More primary research is needed on the nonpharmacological acute pain management of patients with opioid dependence or opioid tolerance.
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Affiliation(s)
- Jennifer Hargett
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
| | - Amanda Criswell
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
| | - Michelle Palokas
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
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13
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Dahlem CH, Schepis TS, McCabe SE, Rank AL, Teter CJ, Kcomt L, McCabe VV, Voepel-Lewis T. Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications. J Addict Nurs 2022; 33:218-232. [PMID: 37140410 PMCID: PMC10162467 DOI: 10.1097/jan.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
ABSTRACT The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.
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Affiliation(s)
- Chin Hwa Dahlem
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Ty S. Schepis
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychology, Texas State University, San Marcos, Texas, USA
| | - Sean Esteban McCabe
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Research on Women and Gender, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron L. Rank
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Regional One Physicians, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christian J. Teter
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Research Pharmacy Core, McLean Hospital, Belmont, Massachusetts, USA
- Marblehead NeuroPsychiatric Rx, LLC, Marblehead, Massachusetts, USA
| | - Luisa Kcomt
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Vita V. McCabe
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Terri Voepel-Lewis
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
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14
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Liu M, Ni R, Huang S, Yang X, Lin Q, Lin P, Yang J. Efficacy of non-pharmacological interventions in pain relief and opioid consumption after cardiac surgery: A systematic review and Bayesian network meta-analysis. J Clin Nurs 2022. [PMID: 35949177 DOI: 10.1111/jocn.16482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate and rank the evidence for the efficacy of non-pharmacological interventions in relieving pain after cardiac surgery using comprehensive comparisons. BACKGROUND Although several previous systematic reviews and meta-analyses showed that non-pharmacological interventions effectively control and reduce pain after cardiac surgery, none quantitatively compared the effect of these different types of interventions. DESIGN Systematic review and Bayesian network meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analysis guidelines. METHODS Six databases were searched from inception to April 2021 to collect all published evidence from randomised clinical trials. One author extracted the relevant information from the eligible trials; a second author independently reviewed the data. Before analysing the extracted data, two investigators independently assessed the quality of the included studies. Conventional meta-analysis was conducted using either fixed- or random-effects models according to statistical heterogeneity. The Bayesian network meta-analysis was conducted using the consistency model. RESULTS We identified 42 randomised clinical trials comparing 14 groups with 4253 patients. Transcutaneous electrical nerve stimulation, acupressure, music and massage were effective for pain relief, with transcutaneous electrical nerve stimulation being associated with the best probability of successful pain relief after cardiac surgery (cumulative ranking curve surface, 0.97; probability, 77.03%). Acupressure (cumulative ranking curve surface, 0.79; probability, 30.69%) was the second-best option. However, there was no evidence that any pair-up intervention significantly reduced opioid use or anxiety. CONCLUSIONS These findings suggest that transcutaneous electrical nerve stimulation, acupressure, music and massage may effectively alleviate postoperative cardiac pain, with transcutaneous electrical nerve stimulation representing the best choice for pain relief. RELEVANCE TO CLINICAL PRACTICE The results of this network meta-analysis can guide patients after cardiac surgery and healthcare providers to make optimal decisions in managing postoperative cardiac pain. TRIAL REGISTRATION PROSPERO CRD42021246183.
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Affiliation(s)
- Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Ruping Ni
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Shunmin Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Xin Yang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Qinghua Lin
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
| | - Pengtao Lin
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jing Yang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
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15
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Meyer-Frießem CH, Lipke E, Weibel S, Kranke P, Reichl S, Pogatzki-Zahn EM, Zahn PK, Schnabel A. Perioperative ketamine for postoperative pain management in patients with preoperative opioid intake: A systematic review and meta-analysis. J Clin Anesth 2022; 78:110652. [DOI: 10.1016/j.jclinane.2022.110652] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 01/24/2023]
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16
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Coluzzi F, Rullo L, Scerpa MS, Losapio LM, Rocco M, Billeci D, Candeletti S, Romualdi P. Current and Future Therapeutic Options in Pain Management: Multi-mechanistic Opioids Involving Both MOR and NOP Receptor Activation. CNS Drugs 2022; 36:617-632. [PMID: 35616826 PMCID: PMC9166888 DOI: 10.1007/s40263-022-00924-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 12/24/2022]
Abstract
Opioids are widely used in chronic pain management, despite major concerns about their risk of adverse events, particularly abuse, misuse, and respiratory depression from overdose. Multi-mechanistic opioids, such as tapentadol and buprenorphine, have been widely studied as a valid alternative to traditional opioids for their safer profile. Special interest was focused on the role of the nociceptin opioid peptide (NOP) receptor in terms of analgesia and improved tolerability. Nociceptin opioid peptide receptor agonists were shown to reinforce the antinociceptive effect of mu opioid receptor (MOR) agonists and modulate some of their adverse effects. Therefore, multi-mechanistic opioids involving both MOR and NOP receptor activation became a major field of pharmaceutical and clinical investigations. Buprenorphine was re-discovered in a new perspective, as an atypical analgesic and as a substitution therapy for opioid use disorders; and buprenorphine derivatives have been tested in animal models of nociceptive and neuropathic pain. Similarly, cebranopadol, a full MOR/NOP receptor agonist, has been clinically evaluated for its potent analgesic efficacy and better tolerability profile, compared with traditional opioids. This review overviews pharmacological mechanisms of the NOP receptor system, including its role in pain management and in the development of opioid tolerance. Clinical data on buprenorphine suggest its role as a safer alternative to traditional opioids, particularly in patients with non-cancer pain; while data on cebranopadol still require phase III study results to approve its introduction on the market. Other bifunctional MOR/NOP receptor ligands, such as BU08028, BU10038, and AT-121, are currently under pharmacological investigations and could represent promising analgesic agents for the future.
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Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Latina, Italy
- Unit Anesthesia, Intensive Care and Pain Medicine, Sant'Andrea University Hospital, Rome, Italy
| | - Laura Rullo
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum - University of Bologna, Irnerio 48, Bologna, 40126, Italy
| | - Maria Sole Scerpa
- Unit Anesthesia, Intensive Care and Pain Medicine, Sant'Andrea University Hospital, Rome, Italy
| | - Loredana Maria Losapio
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum - University of Bologna, Irnerio 48, Bologna, 40126, Italy
| | - Monica Rocco
- Department of Surgical and Medical Science and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Sanzio Candeletti
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum - University of Bologna, Irnerio 48, Bologna, 40126, Italy.
| | - Patrizia Romualdi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum - University of Bologna, Irnerio 48, Bologna, 40126, Italy
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17
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Opioid Requirements After Intercostal Cryoanalgesia in Thoracic Surgery. J Surg Res 2022; 274:232-241. [DOI: 10.1016/j.jss.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 01/12/2022] [Accepted: 01/22/2022] [Indexed: 11/23/2022]
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18
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Hargett JL, McElwain SD, McNair ME, Palokas MJ, Martin BS, Adcock DL. Virtual Reality Based Guided Meditation for Patients with Opioid Tolerance and Opioid Use Disorders. Pain Manag Nurs 2022; 23:259-264. [PMID: 35331652 DOI: 10.1016/j.pmn.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/13/2021] [Accepted: 02/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The management of acute pain in patients with pre-existing opioid tolerance or opioid use disorders presents unique challenges. In light of the concerns regarding opioid use, safe and effective alternatives to opioid medications are of increasing interest. AIMS This study was conducted to determine if the use of guided meditation delivered through immersive virtual reality can reduce pain in patients with opioid tolerance or opioid use disorders, including opioid abuse or opioid dependence. DESIGN A quasi-experimental pre-test and post-test study design was used. SETTINGS A 31-bed inpatient orthopedic/trauma unit in the southeastern United States. PARTICIPANTS/SUBJECTS Subjects of the pilot study were hospitalized adults over the age of 18 with pre-existing opioid tolerance or opioid use disorder who were experiencing acute pain. METHODS This pilot study examined the effect of a 10-minute guided meditation activity through immersive virtual reality on the reported acute pain of hospitalized adults (n = 11) with pre-existing opioid tolerance or opioid use disorders. The Calm® application on an Oculus Go® virtual reality head-mounted display was used for the meditation activity. RESULTS Before the intervention, the mean patient-reported pain rating was 6.68, and the mean pain score after the virtual reality experience was 3.36. Using the Wilcoxon signed rank test, this was a statistically significant difference (p = .003). Patients were also observed and queried regarding any significant side effects or other incidental findings, none of which were reported. CONCLUSIONS This study demonstrates that the use of guided meditation through virtual reality can result in statistically significant reductions in patient-reported pain scores.
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Affiliation(s)
- Jennifer L Hargett
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Sharon D McElwain
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mary E McNair
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michelle J Palokas
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Bradford S Martin
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Dorothy L Adcock
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
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19
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Deiling B, Mullen K, Shilling AM. Continuous Catheter Techniques. Clin Sports Med 2022; 41:317-328. [PMID: 35300843 DOI: 10.1016/j.csm.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.
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Affiliation(s)
- Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA.
| | - Kenneth Mullen
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
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20
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Abstract
Purpose of Review To present new findings in order to aid in the provision of high-quality symptom management and psychosocial care for adolescents and young adults with advanced cancer at the end of life. Recent Findings Behavioral health providers support patients by teaching them symptom control skills, building legacies, and making meaning of their lives. Integration of cultural values is essential for comprehensive assessment and decision-making. Effective management of physiological symptoms and psychological distress begins with accurate communication about prognosis and goals of care that focus on patient preferences and priorities. Oncology teams promote quality of life and the successful management of fatigue, pain, decreased mobility, poor appetite, and dyspnea with the early inclusion of palliative care. Summary While provision of end-of-life care in a young person with cancer presents challenges, multidisciplinary teams can effectively accompany patients in this journey by prioritizing patient and family preferences to promote quality of life.
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21
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Rajan N, Rosero EB, Joshi GP. Patient Selection for Adult Ambulatory Surgery: A Narrative Review. Anesth Analg 2021; 133:1415-1430. [PMID: 34784328 DOI: 10.1213/ane.0000000000005605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.
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Affiliation(s)
- Niraja Rajan
- From the Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
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22
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De Aquino JP, Parida S, Avila-Quintero VJ, Flores J, Compton P, Hickey T, Gómez O, Sofuoglu M. Opioid-induced analgesia among persons with opioid use disorder receiving methadone or buprenorphine: A systematic review of experimental pain studies. Drug Alcohol Depend 2021; 228:109097. [PMID: 34601272 PMCID: PMC8595687 DOI: 10.1016/j.drugalcdep.2021.109097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Treating acute pain among persons with opioid use disorder (OUD) on opioid agonist therapy (OAT) is complex, and the therapeutic benefits of opioids remain unclear when weighted against their abuse potential and respiratory depressant effects. METHODS We conducted a systematic review of experimental pain studies examining opioid-induced analgesia among persons with OUD on OAT. We searched multiple databases from inception to July 30, 2021. Study quality was assessed by previously established validity measures. RESULTS Nine studies were identified, with a total of 225 participants, of whom 63% were male, and 37% were female. Six studies included methadone-maintained persons with OUD; four studies included buprenorphine-maintained persons with OUD; and three studies included healthy persons as comparison groups. Either additional doses of OAT or other opioids - morphine, oxycodone, hydromorphone, or remifentanil - were administered. In seven studies, persons with OUD on OAT did not experience analgesia, despite receiving opioid doses up to 20 times greater than those clinically used to treat severe pain among the opioid naïve. Conversely, in two studies, high-potency opioids did produce analgesia, albeit with greater abuse potential. Notably, persons with OUD on OAT remained vulnerable to respiratory depression. CONCLUSIONS Although persons with OUD on OAT can derive analgesic effects from opioids, high-potency compounds may be required to achieve clinically significant pain relief. Further, persons with OUD on OAT may remain vulnerable to opioid-induced abuse potential and respiratory depression. Together, these finding have clinical, methodological, and mechanistic implications for the treatment of acute pain in the context of OAT.
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Affiliation(s)
- Joao P De Aquino
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA.
| | - Suprit Parida
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Victor J Avila-Quintero
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Jose Flores
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Peggy Compton
- Department of Family and Community Health, University of Pennsylvania, 418 Curie Boulevard, Room 402, Philadelphia, PA 19104, USA
| | - Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Anesthesiology, 333 Cedar Street, New Haven, CT 06520, USA
| | - Oscar Gómez
- Department of Physiological Sciences, Faculty of Medicine, Pontificia Universidad Javeriana, 7th Street, 46-62, Bogota, Colombia
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
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23
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Mallow PJ, Belk KW. Cost-utility analysis of single nucleotide polymorphism panel-based machine learning algorithm to predict risk of opioid use disorder. J Comp Eff Res 2021; 10:1349-1361. [PMID: 34672212 DOI: 10.2217/cer-2021-0115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To conduct a cost-utility analysis of a novel genetic diagnostic test (OUDTEST) for risk of developing opioid use disorder for elective orthopedic surgery patients. Materials & Methods: A simulation model assessed cost-effectiveness and quality-adjusted life-years (QALYs) for OUDTEST from private insurer and self-insured employer perspectives over a 5-year time horizon for a hypothetical patient population. Results: OUDTEST was found to cost less and increase QALYs, over a 5-year period for private insurance (savings US$2510; QALYs 0.02) and self-insured employers (-US$2682; QALYs 0.02). OUDTEST was a dominant strategy in 71.1% (private insurance) and 72.7% (self-insured employer) of model iterations. Sensitivity analyses revealed robust results except for physician compliance. Conclusion: OUDTEST was expected to be a cost-effective solution for personalizing postsurgical pain management in orthopedic patients.
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Affiliation(s)
- Peter J Mallow
- Department of Health Services Administration, Xavier University, 3800 Victory Parkway, Cincinnati, OH 45207, USA
| | - Kathy W Belk
- Health Clarity Solutions, LLC, Mooresville, NC 28115, USA
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Wu B, Hand W, Alexov E. Opioid Addiction and Opioid Receptor Dimerization: Structural Modeling of the OPRD1 and OPRM1 Heterodimer and Its Signaling Pathways. Int J Mol Sci 2021; 22:ijms221910290. [PMID: 34638633 PMCID: PMC8509015 DOI: 10.3390/ijms221910290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022] Open
Abstract
Opioid addiction is a complex phenomenon with genetic, social, and other components. Due to such complexity, it is difficult to interpret the outcome of clinical studies, and thus, mutations found in individuals with these addictions are still not indisputably classified as opioid addiction-causing variants. Here, we computationally investigated two such mutations, A6V and N40D, found in the mu opioid receptor gene OPRM1. The mutations are located in the extracellular domain of the corresponding protein, which is important to the hetero-dimerization of OPRM1 with the delta opioid receptor protein (OPRD1). The hetero-dimerization of OPRD1-OPRM1 affects the signaling pathways activated by opioids and natural peptides and, thus, could be considered a factor contributing to addiction. In this study, we built four 3D structures of molecular pathways, including the G-protein signaling pathway and the β-arrestin signaling pathway of the heterodimer of OPRD1-OPRM1. We also analyzed the effect of mutations of A6V and N40D on the stability of individual OPRM1/OPRD1 molecules and the OPRD1-OPRM1 heterodimer with the goal of inferring their plausible linkage with opioid addiction. It was found that both mutations slightly destabilize OPRM1/OPRD1 monomers and weaken their association. Since hetero-dimerization is a key step for signaling processes, it is anticipated that both mutations may be causing increased addiction risk.
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Affiliation(s)
- Bohua Wu
- Department of Physics, College of Science, Clemson University, Clemson, SC 29634, USA;
| | - William Hand
- Department of Anesthesiology and Perioperative Medicine, Prisma Health, Greenville, SC 29605, USA;
| | - Emil Alexov
- Department of Physics, College of Science, Clemson University, Clemson, SC 29634, USA;
- Correspondence:
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Management of Sedation and Analgesia in Critically Ill Patients Receiving Long-Acting Naltrexone Therapy for Opioid Use Disorder. Ann Am Thorac Soc 2021; 17:1352-1357. [PMID: 32866026 DOI: 10.1513/annalsats.202005-554cme] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The explosion of the opioid epidemic in the United States and across the world has been met with advances in pharmacologic therapy for the treatment of opioid use disorder. Long-acting naltrexone is a promising strategy, but its use has important implications for critical care, as it may interfere with or complicate sedation and analgesia. Currently, there are two available formulations of long-acting naltrexone, which are distinguished by different administration routes and distinct pharmacokinetics. The use of long-acting naltrexone may be identified through a variety of strategies (such as physical examination, laboratory testing, and medical record review), and is key to the safe provision of sedation and analgesia during critical illness. Perioperative experience caring for patients receiving long-acting naltrexone informs management in the intensive care unit. Important lessons include the use of multimodal analgesia strategies and anticipating patients' demonstrating variable sensitivity to opioids. For the critically ill patient, however, there are important distinctions to emphasize, including changes in drug metabolism and medication interactions. By compiling and incorporating the currently available literature, we provide critical care physicians with recommendations for the sedation and analgesia for critically ill patients receiving long-acting naltrexone therapy.
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Kohan L, Potru S, Barreveld A, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay S, Viscusi E. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med 2021; 46:840-859. [PMID: 34385292 DOI: 10.1136/rapm-2021-103007] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The past two decades have witnessed an epidemic of opioid use disorder (OUD) in the USA, resulting in catastrophic loss of life secondary to opioid overdoses. Medication treatment of opioid use disorder (MOUD) is effective, yet barriers to care continue to result in a large proportion of untreated individuals. Optimal analgesia can be obtained in patients with MOUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected OUD at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives. METHODS The Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, American Academy of Pain Medicine, American Society of Addiction Medicine and American Society of Health System Pharmacists approved the creation of a Multisociety Working Group on Opioid Use Disorder, representing the fields of pain medicine, addiction, and pharmacy health sciences. An extensive literature search was performed by members of the working group. Multiple study types were included and reviewed for quality. A modified Delphi process was used to assess the literature and expert opinion for each topic, with 100% consensus being achieved on the statements and each recommendation. The consensus statements were then graded by the committee members using the United States Preventive Services Task Force grading of evidence guidelines. In addition to the consensus recommendations, a narrative overview of buprenorphine, including pharmacology and legal statutes, was performed. RESULTS Two core topics were identified for the development of recommendations with >75% consensus as the goal for consensus; however, the working group achieved 100% consensus on both topics. Specific topics included (1) providing recommendations to aid physicians in the management of patients receiving buprenorphine for MOUD in the perioperative setting and (2) providing recommendations to aid physicians in the initiation of buprenorphine in patients with suspected OUD in the perioperative setting. CONCLUSIONS To decrease the risk of OUD recurrence, buprenorphine should not be routinely discontinued in the perioperative setting. Buprenorphine can be initiated in untreated patients with OUD and acute pain in the perioperative setting to decrease the risk of opioid recurrence and death from overdose.
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Affiliation(s)
- Lynn Kohan
- Division of Pain Medicine/Department of Anesthesia, University of Virginia, Charlottesville, Virginia, USA
| | - Sudheer Potru
- Atlanta VA Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Antje Barreveld
- Tufts University School of Medicine-and Newton Wesley Hospital, Boston and Newton, Massachusetts, USA
| | - Michael Sprintz
- Division of Geriatrics and Palliative Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Olabisi Lane
- Division of Pain Medicine, Department of Anestheisology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anuj Aryal
- Cedar Recovery and Deparment of Anesthesiolgy and Pain Medicine, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Trent Emerick
- Department of Anesthesiolgoy and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anna Dopp
- American Society Health System Pharmacists, Bethesda, Maryland, USA
| | - Sophia Chhay
- American Society Health System Pharmacists, Bethesda, Maryland, USA
| | - Eugene Viscusi
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
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Rim F, Donofrio J, Peterson C, Liu S. Impact of Structured Patient-Centered Preoperative Pain Consult and Interventions From a Dedicated Perioperative Pain Service: A Case Series of 4 Patients. A A Pract 2021; 14:e01279. [PMID: 32909722 DOI: 10.1213/xaa.0000000000001279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Opioid-tolerant individuals have greater risk of perioperative complications and worse clinical outcomes. A preoperative screening process and structured approach to opioid-tolerant patients was developed to identify and optimize these patients before elective surgery.
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Affiliation(s)
- Faye Rim
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York.,Department of Rehabilitation Medicine, Weill Cornell Medical College, New York, New York
| | - Justin Donofrio
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Christine Peterson
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Spencer Liu
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York
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Impact of opioid use disorder on resource utilization and readmissions after operative trauma. Surgery 2021; 171:541-548. [PMID: 34294450 DOI: 10.1016/j.surg.2021.06.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/27/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although patients with opioid use disorder have been shown to be more susceptible to traumatic injury, the impact of opioid use disorder after trauma-related admission remains poorly characterized. The present nationally representative study evaluated the association of opioid use disorder on clinical outcomes after traumatic injury warranting operative intervention. METHODS The 2010 to 2018 Nationwide Readmissions Database was used to identify adult trauma victims who underwent major operative procedures. Injury severity was quantified using International Classification of Diseases Trauma Mortality Prediction Model. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were developed to assess the association of opioid use disorder on in-hospital mortality, perioperative complications, resource utilization, and readmissions. RESULTS Of an estimated 5,089,003 hospitalizations, 54,097 (1.06%) had a diagnosis of opioid use disorder with increasing prevalence during the study period. Compared with others, opioid use disorder had a lower proportion of extremity injuries and falls but greater predicted mortality measured by Trauma Mortality Prediction Model. After adjustment, opioid use disorder was associated with decreased odds of in-hospital mortality (adjusted odds ratio: 0.61; 95% confidence interval, 0.53-0.70) but had greater likelihood of pneumonia, infectious complications, and acute kidney injury. Additionally, opioid use disorder was associated with longer hospitalization duration as well as greater index costs and risk of readmission within 30 days (adjusted odds ratio: 1.36; 95% confidence interval, 1.25-1.49). CONCLUSION Opioid use disorder in operative trauma has significantly increased in prevalence and is associated with decreased in-hospital index mortality but greater resource utilization and readmission.
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Hill BL, Lefkowits C. Strategies for Optimizing Perioperative Pain Management for the Cancer Patient. Surg Oncol Clin N Am 2021; 30:519-534. [PMID: 34053666 DOI: 10.1016/j.soc.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Effective management of pain in patients with cancer impacts quality of life and willingness to receive disease-directed treatment. This review focuses on preoperative, intraoperative, and postoperative strategies for management of perioperative pain in the patient with cancer. Managing perioperative pain in special populations, including patients with preoperative opioid use, those with a history of substance abuse, and patients near the end of life are also addressed.
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Affiliation(s)
- Breana L Hill
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Carolyn Lefkowits
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Colorado School of Medicine, Aurora, CO, USA
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30
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Huepenbecker S, Hillman RT, Iniesta MD, Chen T, Cain K, Mena G, Lasala J, Wang XS, Williams L, Taylor JS, Lu KH, Ramirez PT, Meyer LA. Impact of a tiered discharge opioid algorithm on prescriptions and patient-reported outcomes after open gynecologic surgery. Int J Gynecol Cancer 2021; 31:1052-1060. [PMID: 34135073 DOI: 10.1136/ijgc-2021-002674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/17/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To compare discharge opioid refills, prescribed morphine equivalent dose and quantity, and longitudinal patient-reported outcomes before and after implementation of a tiered opioid prescribing algorithm among women undergoing open gynecologic surgery within an enhanced recovery after surgery program. METHODS We compared opioid prescriptions, clinical outcomes, and patient-reported outcomes among 273 women. Post-discharge symptom burden was collected up to 42 days after discharge using the validated 27-item MD Anderson Symptom Inventory and analyzed using linear mixed effects models and Kaplan-Meier curves for symptom recovery. RESULTS Among 113 pre-implementation and 160 post-implementation patients there was no difference in opioid refills (9.7% vs 11.3%, p=0.84). The post-implementation cohort had a significant reduction in median morphine equivalent dose (112.5 mg vs 225 mg, p<0.01), with no difference in median hospital length of stay (3 days vs 3 days, p=1.0) or 30-day readmission rate (9.4% vs 7.1%, p=0.66). There was no difference in patient-reported pain between the pre- and post-implementation cohorts on the day of discharge (severity 4.93 vs 5.14, p=0.53) or in any patient-reported symptoms, interference measures, or composite scores by post-discharge day 7. The median recovery time for most symptoms was 7 days, except for pain (14 days), fatigue (18 days), and physical interference (21 days), with no differences between cohorts. CONCLUSIONS After implementation of a tiered opioid prescribing algorithm, the quantity and dose of discharge opioids prescribed decreased with no change in post-operative refills and without negatively impacting patient-reported symptom burden or interference, which can be used to educate and reassure patients and providers.
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Affiliation(s)
- Sarah Huepenbecker
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tsun Chen
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xin Shelley Wang
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Loretta Williams
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Karen H Lu
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future. J Clin Med 2021; 10:jcm10122568. [PMID: 34200695 PMCID: PMC8229260 DOI: 10.3390/jcm10122568] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/05/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program.
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O'Rourke MJ, Keshock MC, Boxhorn CE, Correll DJ, O'Glasser AY, Gazelka HM, Urman RD, Mauck K. Preoperative Management of Opioid and Nonopioid Analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2021; 96:1325-1341. [PMID: 33618850 DOI: 10.1016/j.mayocp.2020.06.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/15/2020] [Accepted: 06/29/2020] [Indexed: 01/31/2023]
Abstract
There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.
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Affiliation(s)
- Michael J O'Rourke
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL; Department of Anesthesia, Edward Hines Jr Veteran Affairs Hospital, Hines, IL.
| | - Maureen C Keshock
- Department of Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH
| | - Christine E Boxhorn
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Boston, MA
| | - Darin J Correll
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Avital Y O'Glasser
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Halena M Gazelka
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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Starr MR, Patel LG, Ammar M, Yonekawa Y. Opioids and ophthalmology: review of the current literature. Curr Opin Ophthalmol 2021; 32:209-213. [PMID: 33710008 DOI: 10.1097/icu.0000000000000753] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW The number of opioid-related overdose deaths has rapidly increased since 2000, increasing more than five-fold from 1999 to 2016. Although surgeons only write 10% of opioid prescriptions annually, with ophthalmologists writing only a fraction of this amount, all physicians need to be cognizant of the current opioid epidemic and ways to decrease unnecessary opioid prescriptions. RECENT FINDINGS Previous work within ophthalmology has shown that retrobulbar anesthesia along with peri-operative intravenous or oral nonopioid analgesics can lead to decreased postoperative opioid use following ophthalmic surgery. Recent literature has shifted focus towards the use of opioid prescription guidelines in managing postoperative pain and decreasing the number of unnecessary opioids being prescribed by ophthalmologists. Overall, the frequency of opioid prescriptions may have gradually declined the past few years with such efforts, increased awareness, and new healthcare policies to monitor opioid prescriptions. However, ophthalmologists still continue to prescribe a substantial number of opioid medications, much of which may not be necessary. SUMMARY This review serves as a tool to aid all ophthalmologists in managing postoperative pain. There is a recent trend in addressing the opioid epidemic and efforts are being made to limit the overprescribing of opioids. Continued efforts are still required by all ophthalmologists to address the current opioid epidemic.
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Affiliation(s)
- Matthew R Starr
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Ahmadi-Soleimani SM, Azizi H, Abbasi-Mazar A. Intermittent REM sleep deprivation attenuates the development of morphine tolerance and dependence in male rats. Neurosci Lett 2021; 748:135735. [PMID: 33592307 DOI: 10.1016/j.neulet.2021.135735] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 02/04/2023]
Abstract
Opioid agonists are used in clinic for pain management, however this application is challenged by development of tolerance and dependence following prolonged exposure. Various approaches have been suggested to address this concern, however, there is still no consensus among the researchers. Neural processing of sleep and nociception are co-regulated through shared brain regions having bidirectional interplays. Thus, we aimed to investigate whether application of REM sleep deprivation (REM-SD) could affect morphine analgesic tolerance and dependence. To this end, adult male rats underwent sleep deprivation during light and dark phases (LSD and DSD, respectively) using the inverted flower pot method and then tolerance and dependence was induced by repeated injection of morphine for 7 days (10 mg/kg, daily, i.p.). Results indicated that REM-SD delays the development of tolerance to morphine during both phases; however this effect was more potent following LSD. Moreover, LSD decreased the baseline thermal threshold and total withdrawal score. One possible hypothesis for our observations is REM-SD-induced attenuation of orexin system which is still controversial among the researchers. Other stronger possibilities might be down-regulation of opioid receptors in response to sleep loss experience. Finally, it seems that modification of sleep periods may assist to decrease the severity of opioid tolerance and dependence.
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Affiliation(s)
- S Mohammad Ahmadi-Soleimani
- Deparment of Physiology, School of Paramedical Sciences, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran; Neuroscience Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
| | - Hossein Azizi
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Alireza Abbasi-Mazar
- Student Research Committee, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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Inoue S, Miyoshi H, Hieda K, Hayashi T, Tsutsumi YM, Teishima J. Postoperative around-the-clock administration of intravenous acetaminophen for pain control following robot-assisted radical prostatectomy. Sci Rep 2021; 11:5174. [PMID: 33664398 PMCID: PMC7933238 DOI: 10.1038/s41598-021-84866-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/19/2021] [Indexed: 11/09/2022] Open
Abstract
The objective of this study was to examine the impact of around-the-clock (ATC) administration of intravenous (IV) acetaminophen following robot-assisted radical prostatectomy (RARP). Intravenous infusion of acetaminophen was started on the day of the operation at 1000 mg/dose every 6 h, and the infusion was continued on a fixed schedule until postoperative day 2 a.m. In a retrospective observational study, we compared 127 patients who were administered IV acetaminophen on a fixed schedule (ATC group) with 485 patients who were administered analgesic drugs only as needed (PRN group). We investigated postoperative pain intensity and additional analgesic consumption on postoperative day 0, 1, 2, 3, and 5 between the two groups. Postoperative pain scores were significantly lower in the ATC group than in the PRN group at 1 and 2 days, and this period matched the duration of ATC administration of IV acetaminophen. Postoperative frequency of rescue analgesia was significantly lower in the ATC group than in the PRN group at postoperative 0, 1, and 2 days. ATC administration of IV acetaminophen has the potential to be a very versatile and valuable additional dose to achieve appropriate postoperative analgesia in patients with RARP.
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Affiliation(s)
- Shogo Inoue
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Hirotsugu Miyoshi
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, Hiroshima, Japan
| | - Keisuke Hieda
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tetsutaro Hayashi
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yasuo M Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, Hiroshima, Japan
| | - Jun Teishima
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Martinez R. Challenges in the management of pain in hospital patients with opioid use disorder. Nurs Stand 2021; 36:55-60. [PMID: 33522721 DOI: 10.7748/ns.2021.e11521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 11/09/2022]
Abstract
This article explores the challenges and barriers to the effective nursing management of pain in patients with a history of opioid use disorder. It also identifies recommendations for improving patient care and possible areas for further research. The author examined the relevant literature, which revealed that patients with opioid use disorder may experience stigmatisation by nurses; such negative attitudes are often in conflict with nurses' professional and ethical duties. This issue is compounded by a lack of knowledge and understanding of dependence, addiction and withdrawal. It was also identified that patients often recognise the effects of stigma and this can cause resentment, frustration and anxiety, in some cases leading to aggressive or disruptive behaviours that reinforce negative stereotypes of people who use opioids. A breakdown in the nurse-patient relationship can result in suboptimal pain management in this often-marginalised patient group. Therefore, effective pain management relies on a nurse-patient relationship that minimises anxiety, as well as multidisciplinary team collaboration.
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Affiliation(s)
- Rebecca Martinez
- Brighton and Sussex University Hospitals NHS Trust, Brighton, England
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38
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Vo AX, Ko OS, Hofer MD, Kim RJ, Benson JS, Halpern JA, Auffenberg GB. Evaluation of Opioid Prescribing Patterns and Drivers of Variation Following Endoscopic Procedures for Benign Prostatic Hyperplasia Across an Integrated Academic Health System. Urology 2021; 153:132-138. [PMID: 33482131 DOI: 10.1016/j.urology.2020.10.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/27/2020] [Accepted: 10/06/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system to drive improvement efforts. METHODS Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed. RESULTS We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9±33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%-66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval [CI] 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.65-23.45, P < .001) were associated with higher rates of opioid prescribing, while prescribing decreased with increasing patient age (OR 0.97; CI 0.95-0.99, P = 0.016). Multivariable linear regression analysis demonstrated an association between surgery at satellite facilities, having a surgeon in practice for at least 20 years, and higher surgeon volume with increased MMEs prescribed. CONCLUSIONS Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing.
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Affiliation(s)
- Amanda X Vo
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Oliver S Ko
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Matthias D Hofer
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ronald J Kim
- Northwestern Lake Forest Hospital, Lake Forest, IL; UroPartners LLC, Lake Forest, IL
| | - Jonas S Benson
- Northwestern Medicine Central DuPage Hospital, Winfield, IL; Northwestern Medicine Delnor Hospital, Geneva, IL; UroPartners LLC, Winfield, IL
| | - Joshua A Halpern
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gregory B Auffenberg
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Cavaliere F, Allegri M, Apan A, Calderini E, Carassiti M, Cohen E, Coluzzi F, Di Marco P, Langeron O, Rossi M, Spieth P, Turnbull D. A year in review in Minerva Anestesiologica 2019. Anesthesia, analgesia, and perioperative medicine. Minerva Anestesiol 2021; 86:225-239. [PMID: 32118384 DOI: 10.23736/s0375-9393.20.14424-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Massimo Allegri
- Unità Operativa Terapia del Dolore della Colonna e dello Sportivo, Policlinic of Monza, Monza, Italy.,Italian Pain Group, Milan, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Giresun, Giresun, Turkey
| | - Edoardo Calderini
- Unit of Women-Child Anesthesia and Intensive Care, Maggiore Polyclinic Hospital, Ca' Granda IRCCS and Foundation, Milan, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio-Medico University Hospital, Rome, Italy
| | - Edmond Cohen
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Flaminia Coluzzi
- Unit of Anesthesia, Department of Medical and Surgical Sciences and Biotechnologies, Intensive Care and Pain Medicine, Sapienza University, Rome, Italy
| | - Pierangelo Di Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Henri Mondor University Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Marco Rossi
- Institute of Anesthesia and Intensive Care, Sacred Heart Catholic University, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Dresden, Dresden, Germany
| | - David Turnbull
- Department of Anaesthetics and Neuro Critical Care, Royal Hallamshire Hospital, Sheffield, UK
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40
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Veazie S, Mackey K, Peterson K, Bourne D. Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review. J Gen Intern Med 2020; 35:945-953. [PMID: 33145688 PMCID: PMC7728869 DOI: 10.1007/s11606-020-06256-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Managing acute pain in patients with opioid use disorder (OUD) on medication (methadone, buprenorphine, or naltrexone) can be complicated by patients' higher baseline pain sensitivity and need for higher opioid doses to achieve pain relief. This review aims to evaluate the benefits and harms of acute pain management strategies for patients taking OUD medications and whether strategies vary by OUD medication type or cause of acute pain. METHODS We systematically searched multiple bibliographic sources until April 2020. One reviewer used prespecified criteria to assess articles for inclusion, extract data, rate study quality, and grade our confidence in the body of evidence, all with second reviewer checking. RESULTS We identified 12 observational studies-3 with control groups and 9 without. Two of the studies with control groups suggest that continuing buprenorphine and methadone in OUD patients after surgery may reduce the need for additional opioids and that ineffective pain management in patients taking methadone can result in disengagement in care. A third controlled study found that patients taking OUD medications may need higher doses of additional opioids for pain control, but provided insufficient detail to apply results to clinic practice. The only case study examining naltrexone reported that postoperative pain was managed using tramadol. We have low confidence in these findings as no studies directly addressed our question by comparing pain management strategies and few provided adequate descriptions of the dosage, timing, or rationale for clinical decisions. DISCUSSION We lack rigorous evidence on acute pain management in patients taking medication for OUD; however, evidence supports the practice of continuing methadone or buprenorphine for most patients during acute pain episodes. Well-described, prospective studies of adjuvant pain management strategies when OUD medications are continued would add to the existing literature base. Studies on nonopioid treatments are also needed for patients taking naltrexone. PROTOCOL REGISTRATION PROSPERO; CRD42019132924.
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Affiliation(s)
- Stephanie Veazie
- Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA.
| | - Katherine Mackey
- Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
| | - Kim Peterson
- Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
| | - Donald Bourne
- Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
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41
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Boltunova A, Bailey C, Weinberg R, Ma X, Thalappillil R, Tam CW, White RS. Preoperative Opioid Use Disorder Is Associated With Poorer Outcomes After Coronary Bypass and Valve Surgery: A Multistate Analysis, 2007–2014. J Cardiothorac Vasc Anesth 2020; 34:3267-3274. [DOI: 10.1053/j.jvca.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/31/2020] [Accepted: 06/03/2020] [Indexed: 11/11/2022]
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42
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Krajina Kmoniček I, Kvolik S, Pinotić K, Ištvanić T, Mraovic B, Marjanovic K. Epidural analgesia for acute ischemic pain after intra-arterial zolpidem injection in opioid-addicted patient-A case report. Clin Case Rep 2020; 8:3445-3449. [PMID: 33363949 PMCID: PMC7752646 DOI: 10.1002/ccr3.3445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/13/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023] Open
Abstract
A patient taking opioid maintenance therapy unintentionally injected dissolved zolpidem pills into the femoral artery and suffered acute limb ischemia. High amounts of opioids with supplemental therapies were inefficient for intractable ischemic pain, suggesting the presence of opioid-induced hyperalgesia (OIH). Epidural analgesia efficiently relieved pain and symptoms of OIH.
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Affiliation(s)
| | - Slavica Kvolik
- Department of AnesthesiologyOsijek University HospitalOsijekCroatia
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
| | - Kresimir Pinotić
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of SurgeryOsijek University HospitalOsijekCroatia
| | - Tomislav Ištvanić
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of SurgeryOsijek University HospitalOsijekCroatia
| | - Boris Mraovic
- Department of Anesthesiology & Perioperative MedicineSchool of MedicineUniversity of MissouriColumbiaMOUSA
| | - Ksenija Marjanovic
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of PathologyOsijek University HospitalOsijekCroatia
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43
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Mazer LS, Lovett PJ, Miller JM, Pitruzzello NE, Boone MK, Irizarry Alvarado JM. Improving satisfaction with postoperative pain management for patients with persistent pain: a preoperative pain medicine consultation intervention. J Perioper Pract 2020; 30:345-351. [PMID: 31694473 DOI: 10.1177/1750458919886720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Preoperative pain medicine consultations with opioid-tolerant patients allow for an accurate medication history, patient involvement in the postoperative plan, and realistic goal setting. The purpose of this quality improvement project was to increase attendance at preoperative pain consultations, thereby increasing patient satisfaction. METHODS Retrospective chart reviews identified patients who had a preoperative pain consultation ordered from May through July 2016. Patient interviews determined reasons for not attending appointments, involvement in goal setting, engagement in pain management planning, and satisfaction with postoperative pain management. RESULTS Retrospective chart reviews and interviews were conducted after the intervention (May-July 2017). Scheduling changes increased attendance at preoperative pain consultations by 14 percentage points (50% vs 64%). Those who attended consultations were more involved in goal setting and decisions and were more satisfied. CONCLUSIONS Preoperative pain consultations with opioid-tolerant patients can increase satisfaction through realistic goal setting and involvement in the pain management plan.
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Affiliation(s)
- Laura S Mazer
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic, Jacksonville, FL, USA
| | - Pamela J Lovett
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic, Jacksonville, FL, USA
| | - Joanne M Miller
- Department of Adult Health and Gerontological Nursing Rush University, Chicago, IL, USA
| | - Nancy E Pitruzzello
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic, Jacksonville, FL, USA
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44
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Ray V, Waite MR, Spexarth FC, Korman S, Berget S, Kodali S, Kress D, Guenther N, Murthy VS. Addiction Management in Hospitalized Patients With Intravenous Drug Use–Associated Infective Endocarditis. PSYCHOSOMATICS 2020; 61:678-687. [DOI: 10.1016/j.psym.2020.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
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45
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In Response. Anesth Analg 2020; 131:e79-e80. [PMID: 33031673 DOI: 10.1213/ane.0000000000004863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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46
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Jacobs BL, Rogers D, Yabes JG, Bandari J, Ayyash OM, Maganty A, Armann KM, Worku HA, Pace NM, Shah A, Pekala KR, Yu M, Chelly JE, Macleod LC, Davies BJ. Large reduction in opioid prescribing by a multipronged behavioral intervention after major urologic surgery. Cancer 2020; 127:257-265. [PMID: 33002197 DOI: 10.1002/cncr.33200] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/15/2020] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Surgeons play a pivotal role in combating the opioid crisis that currently grips the United States. Changing surgeon behavior is difficult, and the degree to which behavioral science can steer surgeons toward decreased opioid prescribing is unclear. METHODS This was a single-institution, single-arm, pre- and postintervention study examining the prescribing of opioids by urologists for adult patients undergoing prostatectomy or nephrectomy. The primary outcome was the quantity of opioids prescribed in oral morphine equivalents (OMEs) after hospital discharge. The primary exposure was a multipronged behavioral intervention designed to decrease opioid prescribing. The intervention had 3 components: 1) formal education, 2) individual audit feedback, and 3) peer comparison performance feedback. There were 3 phases to the study: a pre-intervention phase, an intervention phase, and a washout phase. RESULTS Three hundred eighty-two patients underwent prostatectomy, and 306 patients underwent nephrectomy. The median OMEs decreased from 195 to 19 in the prostatectomy patients and from 200 to 0 in the nephrectomy patients (P < .05 for both). The median OMEs prescribed did not increase during the washout phase. Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (P < .05). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity levels, psychiatric symptoms, or somatic symptoms (P > .05 for all). CONCLUSIONS Implementing a multipronged behavioral intervention significantly reduced opioid prescribing for patients undergoing prostatectomy or nephrectomy without compromising patient-reported outcomes.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Devin Rogers
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jathin Bandari
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Omar M Ayyash
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Avinash Maganty
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kody M Armann
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hermoon A Worku
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Natalie M Pace
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anup Shah
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelly R Pekala
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michelle Yu
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacques E Chelly
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Liam C Macleod
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
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47
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Alvaro D, Caraceni AT, Coluzzi F, Gianni W, Lugoboni F, Marinangeli F, Massazza G, Pinto C, Varrassi G. What to Do and What Not to Do in the Management of Opioid-Induced Constipation: A Choosing Wisely Report. Pain Ther 2020; 9:657-667. [PMID: 32940898 PMCID: PMC7648765 DOI: 10.1007/s40122-020-00195-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Despite the essential utility of opioids for the clinical management of pain, opioid-induced constipation (OIC) remains an important obstacle in clinical practice. In patients, OIC hinders treatment compliance and has negative effects on quality of life. From a clinician perspective, the diagnosis and management of OIC are hampered by the absence of a clear, universal diagnostic definition across disciplines and a lack of standardization in OIC treatment and assessment. Methods A multidisciplinary panel of physician experts who treat OIC was assembled to identify a list of ten corrective actions—five “things to do” and five “things not to do”—for the diagnosis and management of OIC, utilizing the Choosing Wisely methodology. Results The final list of corrective actions to improve the diagnosis and clinical management of OIC emphasized a need for: (i) better physician and patient education regarding OIC; (ii) systematic use of diagnostically validated approaches to OIC diagnosis and assessment (i.e., Rome IV criteria and Bristol Stool Scale, respectively) across various medical contexts; and (iii) awareness about appropriate, evidence-based treatments for OIC including available peripheral mu-opioid receptor antagonists (PAMORAs). Conclusions Physicians who prescribe long-term opioids should be forthcoming with patients about the possibility of OIC and be adequately versed in the most recent guideline recommendations for its management.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision Medicine, Gastroenterology Division, Sapienza University of Rome, Rome, RM, Italy
| | - Augusto Tommaso Caraceni
- Palliative Care, Pain Therapy, and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, MI, Italy
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, LT, Italy.
- Anesthesiology, Intensive Care, and Pain Medicine Unit, Sant'Andrea University Hospital, Rome, RM, Italy.
| | - Walter Gianni
- Department of Internal Medicine and Geriatry, University Hospital Policlinico Umberto I, Rome, RM, Italy
| | - Fabio Lugoboni
- Department of Medicine, Addiction Unit, University Hospital of Verona, Verona, VR, Italy
| | - Franco Marinangeli
- Department of Anesthesiology, Pain Medicine, and Palliative care, University of L'Aquila, L'Aquila, AQ, Italy
| | - Giuseppe Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin and "Città della Salute e della Scienza" University Hospital, Turin, TO, Italy
| | - Carmine Pinto
- Medical Oncology Unit, Clinical Cancer Center, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, RE, Italy
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48
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Coluzzi F, Caputi FF, Billeci D, Pastore AL, Candeletti S, Rocco M, Romualdi P. Safe Use of Opioids in Chronic Kidney Disease and Hemodialysis Patients: Tips and Tricks for Non-Pain Specialists. Ther Clin Risk Manag 2020; 16:821-837. [PMID: 32982255 PMCID: PMC7490082 DOI: 10.2147/tcrm.s262843] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022] Open
Abstract
In patients suffering from moderate-to-severe chronic kidney disease (CKD) or end-stage renal disease (ESRD), subjected to hemodialysis (HD), pain is very common, but often underestimated. Opioids are still the mainstay of severe chronic pain management; however, their prescription in CKD and HD patients is still significantly low and pain is often under-treated. Altered pharmacokinetics and the lack of clinical trials on the use of opioids in patients with renal impairment increase physicians' concerns in this specific population. This narrative review focused on the correct and safe use of opioids in patients with CKD and HD. Morphine and codeine are not recommended, because the accumulation of their metabolites may cause neurotoxic symptoms. Oxycodone and hydromorphone can be safely used, but adequate dosage adjustments are required in CKD. In dialyzed patients, these opioids should be considered as second-line agents and patients should be carefully monitored. According to different studies, buprenorphine and fentanyl could be considered first-line opioids in the management of pain in CKD; however, fentanyl is not appropriate in patients undergoing HD. Tapentadol does not need dosage adjustment in mild-to-moderate renal impairment conditions; however, no data are available on its use in ESRD. Opioid-related side effects may be exacerbated by common comorbidities in CKD patients. Opioid-induced constipation can be managed with peripherally-acting-μ-opioid-receptor-antagonists (PAMORA). Unlike the other PAMORA, naldemedine does not require any dose adjustment in CKD and HD patients. Accurate pain diagnosis, opioid titration and tailoring are mandatory to minimize the risks and to improve the outcome of the analgesic therapy.
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Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Latina, Italy
- Unit of Anesthesia, Intensive Care and Pain Medicine, Sant’Andrea University Hospital, Rome, Italy
| | | | - Domenico Billeci
- Division of Neurosurgery, Ca’Foncello Hospital, ASL Marca Trevigiana, University of Padova, Treviso, Italy
| | - Antonio Luigi Pastore
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Latina, Italy
- Unit of Urology, Sapienza c/o I.C.O.T, Polo Pontino, Latina, Italy
| | - Sanzio Candeletti
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum University, Bologna, Italy
| | - Monica Rocco
- Unit of Anesthesia, Intensive Care and Pain Medicine, Sant’Andrea University Hospital, Rome, Italy
- Department of Clinical and Surgical Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Patrizia Romualdi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum University, Bologna, Italy
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49
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Azad AD, Bozkurt S, Wheeler AJ, Curtin C, Wagner TH, Hernandez-Boussard T. Acute pain after breast surgery and reconstruction: A two-institution study of surgical factors influencing short-term pain outcomes. J Surg Oncol 2020; 122:623-631. [PMID: 32563208 PMCID: PMC7749807 DOI: 10.1002/jso.26070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/31/2020] [Accepted: 06/03/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Acute postoperative pain following surgery is known to be associated with chronic pain development and lower quality of life. We sought to analyze the relationship between differing breast cancer excisional procedures, reconstruction, and short-term pain outcomes. METHODS Women undergoing breast cancer excisional procedures with or without reconstruction at two systems: an academic hospital (AH) and Veterans Health Administration (VHA) were included. Average pain scores at the time of discharge and at 30-day follow-up were analyzed across demographic and clinical characteristics. Linear mixed effects modeling was used to assess the relationship between patient/clinical characteristics and interval pain scores with a random slope to account for differences in baseline pain. RESULTS Our study included 1402 patients at AH and 1435 at VHA, of which 426 AH and 165 patients with VHA underwent reconstruction. Pain scores improved over time and were found to be highest at discharge. Time at discharge, 30-day follow-up, and preoperative opioid use were the strongest predictors of high pain scores. Younger age and longer length of stay were independently associated with worse pain scores. CONCLUSIONS Younger age, preoperative opioid use, and longer length of stay were associated with higher levels of postoperative pain across both sites.
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Affiliation(s)
- Amee D. Azad
- Stanford University School of Medicine, Stanford, California
| | - Selen Bozkurt
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Amanda J. Wheeler
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Catherine Curtin
- Department of Surgery, Stanford University School of Medicine, Stanford, California
- Department of Surgery, VA Palo Alto Health Care System, Palo Alto, California
| | - Todd H. Wagner
- Department of Surgery, Stanford University School of Medicine, Stanford, California
- Department of Surgery, VA Palo Alto Health Care System, Palo Alto, California
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
- Department of Medicine (Biomedical Informatics), Stanford University School of Medicine, Stanford, California
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50
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Shondell L, Foli KJ, Erler C. Effects of Education on Nurses' Knowledge and Attitudes of Pain Management in a Postoperative Cardiovascular Unit. J Contin Educ Nurs 2020; 51:377-383. [PMID: 32722816 DOI: 10.3928/00220124-20200716-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 02/26/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND This project explores the impact of an educational in-service on nurses' knowledge and attitudes toward pain on a postoperative cardiovascular unit. METHOD A convenience sample of nurses employed on the postoperative cardiovascular intensive care unit (n = 82) were asked to participate in this project, with 74 nurses attending the in-service training. Surveys that were 70% complete were used for analysis (preeducation, n = 22; posteducation, n = 24). RESULTS The results from this project demonstrated that the use of a brief educational in-service is effective and efficient in increasing nurses' knowledge and attitudes related to pain management in this group of nurses. Posteducation survey scores were significantly higher than preeducation survey scores (p < .001). CONCLUSION These findings suggest that a brief educational in-service on pain management can improve nurses' knowledge and attitudes on pain management in this postoperative cardiovascular unit. [J Contin Educ Nurs. 2020;51(8):377-383.].
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