Patient-Controlled Transdermal Fentanyl Versus Intravenous Morphine Pump After Spine Surgery

Efficacy of Acupuncture Combined with Patient-Controlled Analgesia in the Treatment of Acute Pain after Back Surgery: A Meta-Analysis

Objectives. Acupuncture is used worldwide to relieve both acute and chronic pain. Patient-controlled analgesia (PCA) is also frequently used for postoperative pain relief. However, there are few meta-analyses of the efficacy of acupuncture with PCA in reducing acute postoperative pain. This meta-analysis aimed to assess the effectiveness of acupuncture with PCA in relieving acute pain after back surgery. Methods. We searched seven databases (Cochrane Library, Web of Science, PubMed, China National Knowledge Infrastructure (CNKI), Wanfang database, Chongqing VIP (VIP), and Chinese BioMedical Literature Database (CBM)-from 1949 until now) without language restrictions for randomized controlled trials, including patients undergoing back surgery and receiving PCA alone or treated with acupuncture/sham acupuncture + PCA for pain relief. This meta-analysis assessed pain intensity, with visual analogue scale (VAS) score and postoperative opioid dosage as primary outcomes. Results. A total of 12 randomized controlled trials (n = 904) met the inclusion criteria. Compared with the control group (standard mean difference (SMD) = ‒0.42, 95% CI = ‒0.60 to ‒0.25, $P<0.01$ ) or sham acupuncture + PCA (SMD = ‒0.7, 95% CI = ‒0.94 to ‒0.46, $P<0.01$ ), acupuncture + PCA treatment reduced the VAS score in patients after back surgery. Acupuncture + PCA decreased the use of opioids after surgery compared to sham acupuncture + PCA (SMD = −0.35, 95% CI = ‒0.63 to ‒0.07, $P=0.01$ ) or control group (SMD = ‒0.82, 95% CI = ‒1.03 to ‒0.61, $P<0.01$ ). Furthermore, the use of acupuncture with PCA reduced the incidence of postoperative PCA-related total complications (odds ratio = 0.44, 95% CI = 0.23 to 0.85, $P=0.01$ ), but may not reduce the incidence of postoperative nausea and vomiting (odds ratio =0.82 , 95% CI =0.49 to 1.36, $P=0.44$ ). Conclusion. This systematic review found that acupuncture with PCA relieved acute pain after back surgery more effectively than PCA alone and could reduce opioid use and the incidence of postoperative PCA-related total complications

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

The Effects of Locally Administered Morphine Over the Dura on Postoperative Morphine Consumption and Pain After Lumbar Disc Surgery: A Prospective, Randomised, Double-Blind and Placebo-Controlled Study

Objective

Effective pain management by avoiding side effects in the perioperative period is essential for patient outcome. Lumbar disc surgery is associated with moderate to severe postoperative pain, and opioids are widely used. The primary aim of the present study was to compare the effects of 1 mg and 2 mg morphine-impregnated absorbable cellulose haemostat material placed over the dura on morphine consumption, and the secondary aims were to compare pain scores and opioid-related side effects during postoperative 24 h.

Methods

The study included 44 patients (American Society of Anesthesiologists I and II). After the discectomy procedure and before the closure, in Group A (n=15), 1 mg morphine-impregnated absorbable cellulose haemostat material placed over the dura was used. In Group B (n=14), 2 mg morphine was used for the same technique, and in Group C (n=15) (control), normal saline was used. All patients used intravenous morphine patient-controlled analgesia pumps for 24 h following lumbar disc surgery. Morphine consumption, pain scores and opioid-related side effects were recorded at 10 min, 1, 2, 6, 12 and 24 h postoperatively.

Results

Morphine consumption, pain scores and opioid-related side effects were similar among the groups.

Conclusion

Morphine-impregnated absorbable cellulose haemostat material placement over the dura after single level lumbar discectomy did not reduce postoperative morphine consumption, pain scores and incidence of opioid-related side effects.

Endogenous Opiates and Behavior: 2016

This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Comparative study of the efficacy of transdermal buprenorphine patches and prolonged-release tramadol tablets for postoperative pain control after spinal fusion surgery: a prospective, randomized controlled non-inferiority trial

PURPOSE

To compare the efficacy of a transdermal buprenorphine patch (5, 10, 15, and 20 μg/h) with that of oral tramadol (150, 200, 250, and 300 mg) for postoperative pain control after single level spinal fusion surgery.

METHODS

The present study (ClinicalTrials.gov, number NCT02416804) was a prospective, randomized controlled non-inferiority trial designed to determine the efficacy of buprenorphine TDS for alleviating postoperative pain following patient controlled analgesia (PCA) in persons underwent a single level posterior lumbar interbody fusion surgery through 1:1 allocation. The primary outcome was the Visual Analog Pain Scale (VAS) score for postoperative back pain at 7 days after surgery. The non-inferior margin of the VAS was set at δ = 1.5 points.

RESULTS

The VAS score (primary outcome) for postoperative back pain at 7 days after surgery in the Buprenorphine group was not inferior compared to the Tramadol group. The overall changes in VAS scores for postoperative pain during follow-up assessments over a 2-week period did not differ between both groups. However, the VAS scores for postoperative pain significantly improved with time after surgery in both groups. The patterns of changes in the VAS scores for postoperative pain during the follow-up period were not significantly different between the both groups.

CONCLUSIONS

The efficacy of buprenorphine TDS was not inferior to that of oral tramadol medication for alleviating postoperative pain in the subacute period from 72 h after surgery, following PCA administration. In addition, adverse events were similar between both groups.

Effectiveness of Digital Medicines to Improve Clinical Outcomes in Patients with Uncontrolled Hypertension and Type 2 Diabetes: Prospective, Open-Label, Cluster-Randomized Pilot Clinical Trial

Background

Hypertension and type 2 diabetes mellitus are major modifiable risk factors for cardiac, cerebrovascular, and kidney diseases. Reasons for poor disease control include nonadherence, lack of patient engagement, and therapeutic inertia.

Objective

The aim of this study was to assess the impact on clinic-measured blood pressure (BP) and glycated hemoglobin (HbA1c) using a digital medicine offering (DMO) that measures medication ingestion adherence, physical activity, and rest using digital medicines (medication taken with ingestible sensor), wearable sensor patches, and a mobile device app.

Methods

Participants with elevated systolic BP (SBP ≥140 mm Hg) and HbA1c (≥7%) failing antihypertensive (≥2 medications) and oral diabetes therapy were enrolled in this three-arm, 12-week, cluster-randomized study. Participants used DMO (includes digital medicines, the wearable sensor patch, and the mobile device app) for 4 or 12 weeks or received usual care based on site randomization. Providers in the DMO arms could review the DMO data via a Web portal. In all three arms, providers were instructed to make medical decisions (medication titration, adherence counseling, education, and lifestyle coaching) on all available clinical information at each visit. Primary outcome was change in SBP at week 4. Other outcomes included change in SBP and HbA1c at week 12, and low-density lipoprotein cholesterol (LDL-C) and diastolic blood pressure (DBP) at weeks 4 and 12, as well as proportion of patients at BP goal (<140/90 mm Hg) at weeks 4 and 12, medical decisions, and medication adherence patterns.

Results

Final analysis included 109 participants (12 sites; age: mean 58.7, SD years; female: 49.5%, 54/109; Hispanic: 45.9%, 50/109; income ≤ US $20,000: 56.9%, 62/109; and ≤ high school education: 52.3%, 57/109). The DMO groups had 80 participants (7 sites) and usual care had 29 participants (5 sites). At week 4, DMO resulted in a statistically greater SBP reduction than usual care (mean –21.8, SE 1.5 mm Hg vs mean –12.7, SE 2.8 mmHg; mean difference –9.1, 95% CI –14.0 to –3.3 mm Hg) and maintained a greater reduction at week 12. The DMO groups had greater reductions in HbA1c, DBP, and LDL-C, and a greater proportion of participants at BP goal at weeks 4 and 12 compared with usual care. The DMO groups also received more therapeutic interventions than usual care. Medication adherence was ≥80% while using the DMO. The most common adverse event was a self-limited rash at the wearable sensor site (12%, 10/82).

Conclusions

For patients failing hypertension and diabetes oral therapy, this DMO, which provides dose-by-dose feedback on medication ingestion adherence, can help lower BP, HbA1c, and LDL-C, and promote patient engagement and provider decision making.

Trial Registration

Clinicaltrials.gov NCT02827630; https://clinicaltrials.gov/show/NCT02827630 (Archived by WebCite at http://www.webcitation.org/6rL8dW2VF)

Sedation and Analgesia in Transportation of Acutely and Critically Ill Patients

Transportation of acutely or critically ill patients is a challenge for health care providers. Among the difficulties that providers face is the balance between adequate sedation and analgesia for the transportation event and maintaining acceptable respiratory and physiologic parameters of the patient. This article describes common challenges in providing sedation and analgesia during various phases of transport.

Implantable polymeric microneedles with phototriggerable properties as a patient-controlled transdermal analgesia system

Adequate pain control can be achieved using a patient-controlled drug delivery system that can provide analgesia to patients as needed. To achieve this objective, we developed a phototriggered microneedle (MN) system that enables the on-demand delivery of pain medications to the skin under external near-infrared (NIR) light stimulation. In this system, polymeric MNs, containing NIR absorbers and analgesics, are combined with a poly(l-lactide-co-d,l-lactide) supporting array. A "removable design" of the supporting array enables the quick implantation of the MNs into the skin to act as a drug depot, thus shortening the patch application time. Upon irradiation with NIR light, the NIR absorbers in the implanted MNs can absorb light energy and induce a phase transition in the MNs to activate drug release. We demonstrated that lidocaine release can be modulated or repeatedly triggered by varying the duration of irradiation and controlling the on and off status of the laser. Lidocaine delivered by the implanted MNs can be rapidly absorbed into the blood circulation within 10 min and has a bioavailability of at least 95% relative to the subcutaneous injection, showing that the proposed system has the potential to provide a rapid onset of pain relief. Such an implantable device may allow pain sufferers receiving the painkiller without the need for multiple needle injections, and may enable controlling pain more conveniently and comfortably.

Clinical Usefulness of Long-term Application of Fentanyl Matrix in Chronic Non-Cancer Pain: Improvement of Pain and Physical and Emotional Functions

BACKGROUND

Opioids are recently recommended for those who do not gain adequate pain relief from the use of acetaminophen or nonsteroidal anti-inflammatory drugs. Medical opioids are administered in various routes, and transdermal opioid products that can make up for the weaknesses of the oral or intravenous products have been developed. This study is to evaluate the clinical usefulness of fentanyl matrix in terms of the long-term improvement in pain and physical and mental functions.

METHODS

This was a multicenter, open, prospective, observational study that was conducted in 54 institutions in Korea. Patients with non-cancerous chronic pain completed questionnaires, and investigators also completed questionnaires. A total of 1,355 subjects participated in this study, and 639 subjects completed the study. Subjects received transdermal fentanyl matrix (12 µg/hr, 25 µg/hr, or 50 µg/hr depending on the patient's response and demand). Subjects visited at 29 ± 7 days, 85 ± 14 days, and 169 ± 14 days after administration, respectively, to receive drug titration and fill out the questionnaires. The results were analyzed using the intention-to-treat (ITT) analysis, full analysis set (FAS), and per-protocol (PP) analysis. The FAS analysis included only 451 participants; the PP analysis, 160 participants; and the ITT analysis, 1,355 participants.

RESULTS

The intensity of pain measured by the Numeric Rating Scale decreased from 7.07 ± 1.78 to 4.93 ± 2.42. The physical assessment score and mental assessment score of the Short-Form Health Survey 12 improved from 28.94 ± 7.23 to 35.90 ± 10.25 and from 35.80 ± 11.76 to 42.52 ± 10.58, respectively. These differences were significant, and all the other indicators also showed improvement. Adverse events with an incidence of ≥ 1% were nausea, dizziness, vomiting, and pruritus.

CONCLUSIONS

The long-term administration of fentanyl matrix in patients with non-cancerous pain can reduce the intensity of pain and significantly improves activities of daily living and physical and mental capabilities.