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Abul K, Yilgor C, Yucekul A, Alanay NA, Yavuz Y, Zulemyan T, Boissiere L, Bourghli A, Obeid I, Pizones J, Kleinstueck F, Perez-Grueso FJS, Pellise F, Alanay A. Long-term opioid medication profile of European adult spinal deformity patients: minimum five years follow-up study. Spine J 2023; 23:209-218. [PMID: 36336253 DOI: 10.1016/j.spinee.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/03/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND CONTEXT There remains significant variability in the use of postoperative opioids. On one end, it is proven that appropriate pain control is a critical aspect of patient management; on the other end, past few decades have been associated with major increases in opioid-related overdoses and addiction treatment. We hypothesized that several pre- and postoperative risk factors affecting long-term opioid use could be identified. PURPOSE Evaluation of factors associated with minimum 5-year postoperative opioid use following adult spinal deformity surgery. STUDY DESIGN/SETTING Prospectively followed study group database. PATIENT SAMPLE Adult spinal deformity patients who underwent elective spine surgery between 2009 and 2016 were included. OUTCOME MEASURES Opioid usage or otherwise at minimum 5 years follow-up. Use of nonopioid analgesics, weak and strong opioids METHODS: Retrospective analysis of patients undergoing elective spinal deformity surgery. A total of 37 factors comprising patient characteristics, radiographic measurements, operative details, preoperative and early postoperative opioid use, and mechanical complications and revisions were analyzed. Details on identified factors were provided. RESULTS A total of 265 patients (215F, 50M) from five sites were included. The mean follow-up duration was 68.4±11.7 (60-102) months. On average, 10.6±3.5 levels were fused. Preoperatively, 64 (24.2%) patients were using opioids. The rate of opioid users increased to 33.6% at 6 weeks and decreased to 21.5% at 6 months. During follow-up, there were patients who discontinued opioids, while others have started and/or restarted using opioids. As a result, 59 (22.3%) patients were still on opioids at the latest follow-up. Multivariate analyses showed that factors independently affecting opioid use at an average of 68 months postoperatively, in order of significance, were opioid use at sixth weeks, preoperative opioid use and opioid use at sixth months with the odds ratios of 2.88, 2.51, and 2.38 respectively. At these time points, factors such as age, number of comorbidities, tobacco use, the time of the last prior spine surgery and postoperative sagittal plane alignment affected opioid usage rates. CONCLUSIONS Opioid usage at 6 weeks was found to be more predictive of long-term opioid use compared to preoperative use. Patients should be well informed to have realistic expectations regarding opioid use when considering adult spinal deformity surgery.
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Affiliation(s)
- Kadir Abul
- Clinic of Orthopedics and Traumatology, Basaksehir Pine and Sakura City Hospital, Olimpiyat Bulvarı Yolu, 34480 Basaksehir, Istanbul, Turkey
| | - Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey
| | - Altug Yucekul
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey
| | - Nezih Arin Alanay
- Lycée Français Notre Dame de Sion, Cumhuriyet Cad 127, 34373 Sisli, Istanbul, Turkey
| | - Yasemin Yavuz
- Department of Biostatistics, Ankara University School of Medicine, Adnan Saygun Cad., 06230 Altindag, Ankara, Turkey
| | - Tais Zulemyan
- Comprehensive Spine Center, Acibadem University Maslak Hospital, Buyukdere Cad 40, 34457 Sariyer, Istanbul, Turkey
| | - Louis Boissiere
- Clinique du Dos, Elsan Jean Villar Private Hospital, 2 Av. de Terrefort, 33520 Bruges, Bordeaux, France
| | - Anouar Bourghli
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Al Mathar Ash Shamali, 11564 Riyadh, Saudi Arabia
| | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, 2 Av. de Terrefort, 33520 Bruges, Bordeaux, France
| | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain
| | - Frank Kleinstueck
- Spine Center Division, Department of Orthopedics and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008 Zurich, Switzerland
| | | | - Ferran Pellise
- Spine Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey.
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Sabesan V, Dawoud M, Chatha K, Koen S, Khoury L. What do patients think about opioids? a survey of patient perceptions regarding pain control after shoulder surgery. JSES Int 2021; 5:920-924. [PMID: 34505106 PMCID: PMC8411061 DOI: 10.1016/j.jseint.2020.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background There is an increasing need to understand what barriers are present to reduce opioid consumption in orthopedic practice. The purpose of this study was to better understand patient perceptions and understanding of opioid use after shoulder surgery. Methods Eighty-five patients who underwent shoulder surgery anonymously completed a 27-question survey adapted from the Maryland Public Opinion Survey on Opioids with additional demographics. The patients were asked about pain expectations after surgery, use of and access to opioids, opioid perceptions, and information provided regarding safe use, storage, and disposal of opioids. Results When asked about receiving information regarding opioids, only 36% of the patients reported having a conversation with their physician. When asked about appropriate use, 10% agree it is permissible to take more than the recommended dosage of prescription narcotics if they are feeling more pain than usual and 8.5% of the patients reported taking an opioid to get high multiple times in the past year. Furthermore, a majority agreed that opioids may lead to other substance abuse with 76% reporting the risk of harm to be great, and only 55% believing that opioid abuse may lead to overdose or death. Conclusions Surgeons need to be aware that most patients expect to have significant pain after shoulder surgery and expect to be given necessary and continued amounts of opioids. This highlights the need for better counseling and innovative nonopioid pain management protocols. At the institutional level, more effort needs to be made on providing adequate education and disposal mechanisms to help reduce diversion and misuse.
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Affiliation(s)
- Vani Sabesan
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Mirelle Dawoud
- Charles E Schmidt School of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Kiran Chatha
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Sandra Koen
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Laila Khoury
- Charles E Schmidt School of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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McKay RE, Kohn MA, Larson MD. Pupillary unrest, opioid intensity, and the impact of environmental stimulation on respiratory depression. J Clin Monit Comput 2021. [PMID: 33651243 DOI: 10.1007/s10877-021-00675-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 02/12/2021] [Indexed: 11/24/2022]
Abstract
Opioid-induced respiratory depression (OIRD) confers significant morbidity, but its onset can be challenging to recognize. Pain or stimulation effects of conversation may mask or attenuate common clinical manifestations of OIRD. We asked whether pupillary unrest could provide an objective signal of opioid exposure, and whether this signal would be independent from the confounding influence of extrinsic stimulation. We conducted a cross-over trial of healthy volunteers using identical remifentanil infusions separated by a washout period; in both, pupillary unrest in ambient light (PUAL) was measured at 2.5-min intervals. During one infusion, investigators continuously engaged the subject in conversation, while in the other, a quiet environment was maintained; measures of respiratory depression were compared under each condition. We tested PUAL’s relationship to estimated opioid concentration under quiet conditions, measured PUAL’s discrimination of lower versus higher opioid exposure using receiver operating characteristic (ROC) analysis, and assessed the effect of stimulation on PUAL versus opioid using mixed effects regression. Respiratory depression occurred more frequently under quiet conditions (p < 0.0001). Under both conditions, PUAL declined significantly over the course of the remifentanil infusion and rose during recovery (p < 0.0001). PUAL showed excellent discrimination in distinguishing higher versus absent-moderate opioid exposure (AUROC = 0.957 [0.929 to 0.985]), but was unaffected by interactive versus quiet conditions (mean difference, interactive – quiet = − 0.007, 95% CI − 0.016 to 0.002). PUAL is a consistent indicator of opioid effect, and distinguishes higher opioid concentrations independently of the stimulating effects of conversational interaction. Under equivalent opioid exposure, conversational interaction delayed the onset and minimized the severity of OIRD. Clinical trial registration: NCT 04301895
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Baird J, Faul M, Green TC, Howland J, Adams CA, George A, Mello MJ. A retrospective review of unintentional opioid overdose risk and mitigating factors among acutely injured trauma patients. Drug Alcohol Depend 2017; 178:130-135. [PMID: 28647680 PMCID: PMC6070343 DOI: 10.1016/j.drugalcdep.2017.04.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 04/25/2017] [Accepted: 04/29/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Opioid medication to treat acutely injured patients is usual care in trauma settings. A higher prevalence of alcohol and other substance misuse in this population compared to the general population increases the vulnerability of such patients to both misuse of their prescribed opioids, and also unintentional opioid overdose. The primary purpose of this study was to assess the prevalence of substance use and unintentional opioid overdose risk among acutely injured trauma patients, and to examine the frequency and predictors of high opioid dose at discharge. METHODS A retrospective electronic medical record (EMR) review of three-months of data from two Level 1 trauma centers. We assessed the prevalence of substance misuse, unintentional opioid overdose risk, and presence of documentation of clinical strategies to mitigate these risks, such as co-prescription of the opioid agonist naloxone. RESULTS In total, 352 patient EMRs were examined. Over 40% of the patients reviewed had at least one indication of substance misuse (42.5% [95%CI: 37.3, 47.7]); at least 1 unintentional opioid overdose risk factor was identified in 240 EMR reviewed (68.2% [95%CI: 63.3, 73.1]). Dose of opioid medication was not significantly different for patients with substance misuse versus those without. There was no co-prescription of naloxone for any of the discharged patients. CONCLUSIONS Our results indicate that despite the high rates of substance misuse, the potential for misuse, dependence and unintentional overdose risk from prescribed opioid medications are prevalent among acutely injured trauma patients. Prescribing after acute trauma care should address these risk factors.
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Affiliation(s)
- Jannette Baird
- Warren Alpert School of Medicine at Brown University, United States.
| | - Mark Faul
- Centers for Disease Control and Prevention, United States
| | - Traci C Green
- Warren Alpert School of Medicine at Brown University, United States; Boston University School of Medicine, United States
| | - Jonathan Howland
- Warren Alpert School of Medicine at Brown University, United States; Boston University School of Medicine, United States
| | - Charles A Adams
- Rhode Island Hospital, Division of Trauma and Surgical Critical Care, United States
| | - Ann George
- University Surgical Associates, United States
| | - Michael J Mello
- Warren Alpert School of Medicine at Brown University, United States; Brown University School of Public Health, United States
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Micalizzi RA, Williams LA, Pignataro S, Sethna NF, Zurakowski D. Review of outcomes in pediatric patients undergoing anterior cruciate ligament repairs with regional nerve blocks. J Pediatr Nurs 2014; 29:670-8. [PMID: 25089833 DOI: 10.1016/j.pedn.2014.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 07/02/2014] [Accepted: 07/03/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE This article compared the outcomes of pediatric patients undergoing ACL repairs receiving intravenous opioids versus regional nerve blocks for pain management. It was hypothesized that compared to intravenous opioids the use of regional nerve blocks would decrease pain, opioid consumption, and opioid-related side effects. METHOD A random retrospective chart review was conducted on a total of 93 pediatric patients who underwent ACL repairs either in 2004 prior to the implementation of regional nerve blocks for pain management [pre-protocol cohort, (n=44)] or in 2009/2010, after the implementation of regional nerve block use [post-protocol cohort, (n=49)]. FINDINGS The two cohorts were comparable in age, weight and gender. The post-protocol cohort had a significantly lower total opioid consumption (p<0.001). A sensitivity analysis excluding patients who received patient controlled analgesia (PCA) further validated the findings of significantly lower total opioid consumption adjusted for body weight [mg/kg] (p=0.02) and reduction in the highest numerical rating score (NRS) reported on post-operative day (POD) 1 (p=0.01). The cohorts were not significantly different in incidence of common opioid-related side effects or median length of stay (LOS). CONCLUSIONS There was evidence that regional nerve blocks reduced opioid consumption and also impacted pain reduction on POD 1 but demonstrated no significant change on opioid-related side effects or readiness for discharge. In view of the retrospective nature of the study the potential benefits of regional nerve blocks suggested a clinical equipoise to conduct a controlled trial in children.
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Affiliation(s)
| | | | | | - Navil F Sethna
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA
| | - David Zurakowski
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA
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