Use Of Analgesics In Patients Research Articles

Efficacy of Pulsed Electromagnetic Field Therapy for Pain Management After Impacted Mandibular Third Molar Surgery. A Randomized Clinical Trial

BackgroundPostoperative pain and swelling associated with the removal of the third molar (M3) adversely affect the patient’s quality of life. PurposeThe study aims to measure pain reduction and analgesic use in patients treated with pulsed electromagnetic field therapy (PEMF) following M3 removal and compare it to patients who did not receive PEMF. Study design, setting, sampleThe single-center study was designed as a randomized, prospective, controlled, double-blinded trial on a sample of patients with impacted mandibular M3 ascertained by x-ray orthopantomography and computed tomography (CT). Predictor/exposure/independent variablesThe predictor variable is postoperative pain management. It was assigned randomly to each subject who received either PEMF or standard therapy. Main outcome variablesThe pain was quantified using a 100 mm visual analog scale (VAS) and the number of analgesics taken. Each subject kept a daily clinical diary for 7 days, recording the amount of pain using the VAS scale and the number of analgesic tablets taken. CovariatesThe study covariates were age, sex, tobacco use, and Pell and Gregory's classification of M3s. AnalysesA t-student test was used, placing the statistical significance for p-value values < 0.05. The primary planned analysis was a two-group, continuity-corrected, chi-square test of equality of proportions. ResultsThe study sample included 90 patients, 47 men and 43 women, with an average age of 32.43 ± 8.80 years. PEMF was statistically associated with improved pain reduction (2.08 vs 5.04 with a p-value = 0.0002) and consumption of fewer analgesics than the control group (2.6 vs 5.8 with a p-value = 0.0062). Conclusions and RelevanceThe study’s results attest to the effectiveness of PEMF therapy in pain control after third molar surgery.

Psychological Barriers to the Use of Opioid Analgesics for Treating Pain in Patients With Advanced Recurrent Cancer: A Multicenter Cohort Study.

We aimed to gain insight into psychological barriers toward initiation of strong opioid analgesic use in patients with advanced recurrent cancer. This study included 46 patients who were prescribed with opioid analgesics for advanced recurrent cancer. The primary outcome was psychological barriers assessed using the Japanese version of the Barriers Questionnaire-II (JBQ-II). The secondary outcomes were psychological changes and pain relief one week after the induction of strong opioid analgesics. The mean age of participants was 63.6 years. Furthermore, 26.1% had an Eastern Cooperative Oncology Group (ECOG) performance status of ≥3. The mean JBQ-II total score was 1.97 (95% confidence interval: 1.75-2.19). At the initiation of opioid therapy, there was no difference in the total scores between the baseline and one week later. Nevertheless, there was a significant difference in the subscale "disease progression" score (mean 2.97 vs. 2.59, difference in means 0.38, standard error 0.16, p = 0.026). Personalized Pain Goal (PPG) was achieved in about half of the participants, and a trend toward a higher score in the subscale "harmful effects" (concern about adverse events) was observed in those who did not achieve PPG. This study showed that patients with advanced recurrent cancer have psychological barriers to opioid induction. The relationship between the presence of psychological barriers before and after induction of opioid analgesics and the speed of pain improvement was determined. The results may provide fundamental information for prospective intervention studies to develop individualized education programs for patients with psychological barriers to opioids.Clinical Trial Registration Number UMIN000042443.

Analgesic Use in Patients during Cardio-Pulmonary Resuscitation.

Cardiopulmonary resuscitation-induced consciousness is a newly recognized phenomenon with an increasing incidence. A return of consciousness during cardiopulmonary resuscitation affects up to 0.9% of cases. Patients may also experience physical pain associated with chest compressions, as most victims of cardiac arrest who are subjected to resuscitative efforts sustain ribs or sternum fractures. A rapid review was carried out from August 2021 to December 2022. Thirty-two articles were included in the rapid review. Of these, eleven studies focused on the return of consciousness during CPR, and twenty-one on CPR-induced chest injuries. A small number of studies that have dealt with the return of consciousness associated with cardiopulmonary resuscitation made it hard to clearly determine how often this occurs. There were more studies that dealt with chest trauma during resuscitation, but no study considered the use of analgesics. Of note, there was no standardized therapeutic approach as far as the use of analgesics and/or sedatives was considered. This is probably due to the lack of guidelines for analgesic management during cardiopulmonary resuscitation and peri-resuscitative period.

Silodosin as a medical expulsive therapy for distal ureteral stones: A systematic review and meta-analysis.

Tamsulosin is the most commonly used medical expulsive therapy (MET). However, it does not alleviate ureteral colic. It is important to develop MET that can reduce ureteral colic while maintaining a high stone clearance rate. Silodosin is an α1A adrenoceptor with high affinity and selectivity for the distal ureter, which may reduce ureteral colic and enable stone expulsion for distal ureteral stones. Therefore, we performed this systematic review and meta-analysis to evaluate the efficacy of silodosin as MET and its role in reducing ureteral colic among patients with distal ureteral stones. This research was conducted in accordance with the Cochrane Handbook for Systematic Review and Intervention, in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42021249003). A comprehensive literature search was performed in several databases including Medline, EMBASE, and Scopus up to July 2021 for randomized trials comparing silodosin with placebo for MET. RevMan 5.4 was used for data analysis. A total of six randomized controlled trials were included in this analysis with a total of 907 patients. Our analysis revealed that the patients who received silodosin had significantly higher stone expulsion rate (SER) (odds ratio [OR] 3.33, 95% confidence interval [CI] 2.34, 4.76, P < 0.01), significantly shorter stone expulsion time (SET) (mean difference -3.79, 95% CI -4.51, -3.06, P < 0.01), and lower analgesic use (OR 0.4, 95% CI 0.23, 0.69, P < 0.01) compared to the group receiving placebo. Silodosin showed significantly higher SER, lower SET and lower analgesic use in patients with distal ureteral stones as compared to a placebo.

Chronic pain and continuity of analgesic treatment during the COVID-19 pandemic.

Chronic pain can trigger both physical and mental health complications. During the COVID-19 pandemic, patients with chronic diseases have had reduced access to some medications. To determine the pharmacological management of patients with chronic pain and its continuity during the COVID-19 pandemic. This was a retrospective longitudinal study of the continuity of analgesic use in patients with chronic pain between September 1, 2019 and February 28, 2021 based on a drug dispensing database. Survival analysis was performed until the discontinuation of chronic analgesics. A total of 12,701 patients who were being treated for chronic pain were identified. Their median age was 70.3 years, and 74.4% were women. The pain of rheumatological origin was the most frequent etiology (46.1%); the most used medications were nonopioid analgesics (78.9%), pain modulators (24.8%) and opioid analgesics (23.3%). A total of 76.1% of the patients experienced interruptions in their management during the study period. The median time to the first interruption of treatment was 5.0months (95% CI: 4.8-5.2). Those who were treated for oncological pain experienced a greater number of interruptions in their management. The pharmacological management of patients with chronic pain is heterogeneous, and this real-world study showed that a high proportion of patients experienced an interruption of pain management during the 12 months following the onset of the COVID-19 pandemic.

Opioid Analgesic Use in Patients with Sleep Disorders: A Retrospective Cohort Study Using Electronic Health Records

The objective of this study was to utilize electronic health records to determine the incidence of opiate prescription following diagnosis of a sleep related disorder. Opiate use disrupts sleep architecture triggering sleep disturbances, and neurobiological mechanisms exist through which sleep disorders modify opiate reward pathways. We hypothesized patients with sleep disorders will have increased opiate prescriptions following diagnosis. We used data from the TriNetX electronic health records network which includes over 80 million patients from 57 health care organizations across the world. We compared adult patients with the most common sleep disorders against adults with negative polysomnography. Patients with a sleep disorder were more likely to use opioids than those without a sleep disorder (RR 1.39, 95% CI 1.35, 1.44). Patients with a sleep disorder also had significantly more unique opiate uses in their medical record (2.56, sd 12.18, p &lt; 0.001) compared to individuals without a sleep disorder (1.101, sd 5.57). Sleep disorder patients also used an opiate closer to the date of their sleep assessment compared to patients without a sleep disorder (median 2078 and 3345 days, respectively). These results support our hypothesis of increased opiate use by patients with a sleep disorder. Sleep disorder patients are more likely to receive opiates, receive a higher quantity, and receive them closer to their sleep assessment. These results support that the association between opiates and nighttime breathing disorders is bidirectional.

Opioid Use After Elective Otolaryngologic Surgery at a Teaching Institution

Background: Awareness of the opioid epidemic is promoting opioid stewardship in health care. For many commonly performed procedures in general surgery and gynecology, regimented opioid prescribing practices and/or multimodal nonopioid regimens are adequate for optimizing pain management and minimizing opioid dependence. We investigated opioid prescribing patterns for otolaryngology procedures at a tertiary hospital with the aim of characterizing postoperative pain and opioid use.Methods: This cross-sectional study with a patient survey was conducted in a tertiary care academic otolaryngology practice. Patients ≥18 years who underwent 1 of 41 common surgical procedures at an academic hospital between 2013 and 2017 were enrolled. Patients with any diagnosis of malignancy were excluded. Patients were analyzed according to surgery type (rhinoplasty, sinonasal surgery, tonsillectomy, parotidectomy, thyroidectomy, otologic surgery, and laryngoscopy), and those who had surgery in 2017 were surveyed via telephone interview using a standardized questionnaire.Results: A total of 3,152 patients met the study criteria, of whom 95.7% received an opioid prescription. Commonly prescribed opioid agents were hydrocodone-acetaminophen, oxycodone-acetaminophen, and acetaminophen-codeine. A median of 30 pills was prescribed per surgery, with little variation between different surgery types. Reported patient utilization was highest for parotid surgery and tonsillectomy and lowest for laryngoscopic, thyroid, and otologic surgery. Among all patients who received a prescription for opioids, 5.8% required a refill. Among the surveyed patients, 19.6% reported that they did not obtain the prescribed opioid, while 58.4% said they took half, less than half, or none of the prescribed opioid supply. Only 10.8% of surveyed patients disposed of the excess drugs in a recommended fashion.Conclusion: Our findings showed that the quantity of opioid prescriptions does not reflect actual patient analgesic use for elective surgeries in otolaryngology. Differential analgesic requirements for specific surgeries should be considered when prescribing postoperative analgesia.

Integrated analysis of pain, health-related quality of life, and analgesic use in patients with metastatic castration-resistant prostate cancer treated with Radium-223

BackgroundRadium-223 (Ra-223), an alpha-emitting radiopharmaceutical, established an improved overall survival and health-related quality of life (HRQoL) in symptomatic metastatic castration-resistant prostate cancer (mCRPC) patients. However, effects on pain were not specifically evaluated. Here we assess integrated HRQoL, pain, and opioid use in a contemporary, more extensively pretreated, symptomatic and asymptomatic mCRPC population.MethodsmCRPC patients scheduled for Ra-223 treatment were included and analyzed for HRQoL, pain, and opioid use, using Functional Assessment of Cancer Therapy-Prostate (FACT-P) and Brief Pain Inventory-Short Form (BPI-SF) questionnaires and recording of opioid use and dosage, respectively. Primary outcome measure was the percentage of patients experiencing a complete pain response (score of 0 on the BPI-SF Worst pain item and no increase in daily use of analgesics). A complete or partial pain response (better BPI-SF score and decrease in opioid use) and a better or no change in HRQoL was evaluated as an integrated overall clinical response (IOCR). Secondary endpoints included the time to pain progression (TPP) and Total FACT-P deterioration (TTFD), defined as time from first Ra-223 treatment to clinical meaningful increase in BPI-SF Worst pain item score and Total FACT-P score, respectively.ResultsThis registry included 300 patients, of whom 105 (35%) were evaluable for FACT-P and BPI-SF during Ra-223 treatment. Forty-five (43%) patients had pain at baseline (PAB) (BPI-SF Worst pain score 5–10 points) and 60 (57%) had no pain at baseline (no-PAB) (BPI-SF Worst pain score 0–4 points). Complete pain response was achieved in 31.4% of the patients, while 58% had an IOCR. The median TTP and TTFD were 5.6 and 5.7 months, respectively, while the difference between PAB and no-PAB patients was not significant.ConclusionsIn contemporary, extensively pretreated mCRPC patients, Ra-223 treatment induced complete pain responses while integrated analysis of HRQoL, pain response, and opioid use demonstrated that the majority of patients derive clinical benefit.

Disease burden, symptoms, and use of analgesics in patients with psoriasis with or without psoriatic arthritis: A cross-sectional study

Patients with psoriasis have an impaired quality of life and higher use of analgesics than the general population. Whether such use is due to skin pain or a consequence of joint pain resulting from psoriatic arthritis (PsA) is not clear. To assess symptoms, disease burden, and use of analgesics in patients with psoriasis with and without PsA. Symptoms, general health (EurQol 5-dimension and 5-levels), and use of analgesics were assessed in patients with psoriasis and the general population from the Danish Skin Cohort. We included 4016 patients with psoriasis (847 with concomitant PsA) and 3490 reference individuals. For patients with psoriasis having PsA, itch, skin pain, and/or joint pain was associated with worse general health. Use of opioids within 12months was observed among 9.0% of the general population, 14.2% of patients with psoriasis without PsA, and 22.7% of patients with concomitant PsA. Of the symptoms, only joint pain was associated with use of analgesics (odds ratio, 3.72 (2.69-5.14); P<.0001). Cross-sectional design. Patients with psoriasis (especially concomitant PsA) have a higher use of analgesics compared with the general population, which appears to be a result of increased joint pain.

Preemptive Intravenous Nalbuphine for the Treatment of Post-Operative Visceral Pain: A Multicenter, Double-Blind, Placebo-Controlled, Randomized Clinical Trial.

IntroductionPost-operative visceral pain is common in early postoperative period after laparoscopic surgery. As a kappa opioid receptor agonist, the antinociceptive effects of nalbuphine in visceral pain are consistent across a multitude of experimental conditions irrespective of species. We hypothesized that preemptive nalbuphine can decrease the visceral pain for patients with incisional infiltration of ropivacaine after laparoscopic cholecystectomy.MethodsIn a multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial, 2094 participants scheduled for laparoscopic cholecystectomy were randomly assigned to receive nalbuphine (Nal group, n = 1029) or placebo (Con group, n = 1027). The Nal group received intravenous nalbuphine 0.2 mg·kg−1 and the Con group received saline in a similar way. The primary endpoint was the effect of nalbuphine on post-operative visceral pain intensity scores within 24 h postoperatively. The total amount of analgesic as well as complications were recorded.ResultsA total of 1934 participants were analyzed. Nalbuphine reduced the visceral pain both at rest (β = − 0.1189, 95% CI − 0.23 to − 0.01, P = 0.037) and movement (β = − 0.1076, 95% CI − 0.21 to − 0.01, P = 0.040) compared with placebo. Patients in the Nal group required less frequent supplemental analgesic administration during the first 24 h after surgery. There were fewer patients in the Nal group who experienced nausea and vomiting (PONV) (P = 0.008).ConclusionsPreemptive nalbuphine administered at a dose of 0.2 mg·kg−1 was safe and effective at reducing the postoperative visceral pain and supplemental analgesic use in patients undergoing laparoscopic cholecystectomy.Trial RegistrationChinese Clinical Trial Registry; ChiCTR1800014379.

MO485PREVALENCE OF ANALGESICS USE AND ASSOCIATED ADVERSE OUTCOMES IN THE CHRONIC KIDNEY DISEASE POPULATION: A SYSTEMATIC REVIEW AND META-ANALYSIS*

Abstract Background and Aims Pain is one of the commonest symptoms in patients with chronic kidney disease (CKD), with a large proportion undertreated. Managing chronic pain in CKD patients is problematic due to the altered pharmacokinetic and pharmacodynamic related to the reduced renal clearance making it challenging for physicians to find appropriate pain management strategies. The aim of this systematic review was to estimate the overall prevalence of different types of analgesia in patients with CKD and investigate their safety. Method The population comprised of all adult patients with CKD defined as an estimated glomerular filtration rate (eGFR) less than 60mL/min/1.73m2 which included CKD-non dialysis (CKD-ND), kidney transplant recipients (KTR), patients undergoing dialysis and those receiving palliative care. Analgesics investigated included opioids, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), gabapentinoids and acetaminophen. All studies reporting a prevalence of analgesic use and/or exploring the association between analgesic consumption and adverse outcomes were included. Medline, Embase, CENTRAL, CINAHL and the grey literature were searched up to December 2020. Random-effect meta-analyses were conducted using a Generalised Linear Mixed Model approach to estimate the overall prevalence of analgesics use in the CKD population, displayed in forest-plots. Evidence gathered from studies investigating the adverse outcomes related to analgesics consumption was synthesised in ‘harvest plots’. Results Sixty-three studies reporting a prevalence of analgesic use in patients with CKD were included. The overall prevalence of analgesic consumption was 42% (95% CI, 35-50%) in the general CKD population and 70% (95% CI, 62-68%) among those experiencing chronic pain. Seventeen studies reported a prevalence of opioid use with 36% (95% CI, 23-51%) of patients with CKD receiving at least one opioid prescription while 16% (95% CI, 11-22%) were on chronic opioid therapy. The chronic use of oxycodone, tramadol, propoxyphene, fentanyl and hydromorphone were 3.6%, 2.0%, 1.3%, 1.1% and 0.05% respectively. NSAIDs usage was estimated to 20% (95% CI, 15-25%) among patients with CKD (ibuprofen 4.6%, diclofenac 1.7%) and 8% (95% CI, 5-12%) took NSAIDs chronically, with a higher prevalence among dialysis patients (17%) compared with CKD-ND (7%) and KTR (5%) (p&amp;lt;0.01). Prevalence of gabapentin and pregabalin use was estimated at 10% and 3.5% respectively, on pooling of 3 studies. Finally, five studies yielded an overall prevalence of 24% for acetaminophen use. Twenty studies assessing the association between analgesic use and adverse outcomes were included (Figure 1). Five of them demonstrated an association between opioid use and increased mortality, in all CKD subgroups; and three out of four studies reported more hospitalizations in opioid-users.Four studies highlighted an increased risk of gastro-intestinal bleeding associated with NSAIDs consumption and three studies found a significant association between gabapentin use and neurologic adverse events. Conclusion Only 70% of CKD patients experiencing chronic pain received an analgesic, suggesting that pain remains a significant public health burden. Despite limited evidence, opioids, NSAIDs and gabapentinoids seem to be associated with major adverse events. Their use requires cautious prescription, consideration of optimal dosage, and the development of therapeutic patient education to promote risk awareness. More evidence is warranted to better understand the adverse outcomes associated with long-term analgesic consumption and provide safe pain management strategies for patient with CKD.

Analgesic and Opioid Use for Patients Discharged from the Emergency Department with Ureteral Stones.

Objective: The aim of this study was to describe and characterize the analgesic and opioid use for patients discharged from the emergency department (ED) with renal colic due to ureteral stone. Methods: This is a secondary analysis of a multicenter prospective trial of ED patients diagnosed by CT scan as having a symptomatic ureteral stone <9 mm in diameter. Participants were contacted after randomization on days 2, 7, 15, 20, and 29 and reported opioid and nonopioid analgesic use and stone passage. CT scan was repeated on day 29 to 36 to confirm passage. Results: Of 403 participants, 314 (77.9%) took an analgesic after discharge and 199 (49.4%) took opioids. Opioids were more commonly used by younger patients (p = 0.04) and those with a family history of stones (p = 0.003). Stone size and tamsulosin use were not associated with analgesic utilization. Shorter time to passage and more distal stone location were associated with less analgesic and opioid use. For those who did not expel a stone, 55.0% took opioids at any time, and for those who did expel a stone, 31.9% took opioids before the stone was expelled and 15.7% took opioids at any time after the stone was expelled. Conclusions: Factors associated with increased use of analgesics in patients discharged from the ED include a longer time to stone passage, no spontaneous passage, and proximal position of the stone in the ureter. Some patients continued to use analgesics after the stone had passed, but most stopped using analgesics by day 29. The study has been registered at https://clinicaltrials.gov (NCT00382265).

The relationship between the level of \u03bc-opioid receptor (\u03bcORs) and postoperative analgesic use in patients undergoing septoplasty: a prospective randomized controlled trial

BackgroundIn this study, the μ-Opioid receptor activity was assessed pre-operatively for its association with postoperative pain level and second analgesic requirement in patients undergoing septoplasty.MethodsIn our prospective study, 120 adult patients underwent septoplasty from June 2015 to January 2019 were randomly divided into 2 pre-operative groups. The first group (n = 60) was patients given tramadol (1–2 mg/kg) for post-operative analgesia, and the second group (control group) (n = 60) was initially prescribed only fentanyl (1 μg/ kg-i.v.) in the induction. Acetaminophen with codeine analgesic 325/30 mg (p.o.) was used as an rescue painkiller in the post-operative period. The μ-Opioid receptor activity was investigated in pre-operative blood samples and compared to post-operative pain level and time required for second round of analgesic administration. The visual analogue score (VAS) was used to evaluate the post-operative pain degree (0 no pain; 10 worst pain). The patients’ post-operative VAS scores were evaluated upon arrival to recovery room, and at the 1st, 3rd, 7th, 10th, and 24th hour post-operative period.ResultsDemographic data and peri-operative variables were similar in both study group (p < 0.05).There was no significant difference between the receptor levels in both groups and the mean receptor level was 200.94 ± 15.34 pg/mL (max:489.92 ± 22.36 pg/mL, min: 94.56 ± 11.23 pg/mL).In patients who used tramadol as the levels of μ-Opioid receptors increased, VAS scores of patients and second analgesic use decreased in post-operative period.The VAS scores in patients with higher receptor levels were lower in the recovery room (p < 0.05), 1st (p < 0.05) and 3rd hours (p < 0.05).The VAS scores were lower in the tramadol group compared to the control group (p < 0.05).Number of secondary analgesic requirement was significantly lower in patients of the tramadol group with higher receptor levels compared to the ones with lower receptor (p < 0.05) for arrival at the recovery room and 1st hour. Patients in the tramadol group needed a second pain killer much later than patients in the control group.ConclusionsOur study demonstrates that patients with higher μOR levels have a higher efficacy of opioid analgesic agents and an lesser need for additional analgesic agents.Trial registrationThis trial was registered retrospectively (The ACTRN: ACTRN12619001652167, registration date: 26/11/2019).

Lower opioid and higher adjuvant analgesic use in patients on haemodialysis: A single-centre cross-sectional study.

Opioids are often used to treat chronic non-cancer pain (CNCP) in patients on haemodialysis. Altered pharmacokinetics in this population increases risk for opioid-related adverse events. Although useful in pain management, there is a lack of opioid prescribing guidance for end-stage kidney disease. To characterize opioid usage for CNCP in an outpatient haemodialysis unit. Cross-sectional, single-centre, retrospective cohort study of 272 patients receiving outpatient haemodialysis between 01 June and 31 December 2017. Prevalence of prescription or non-prescription opioids, formulation, indication, dosing, prescriber type and therapeutic effectiveness were evaluated. A total of 27 (10%, aged 58+12.1years, 59% women) patients received opioids for CNCP during the study period. Pain aetiology was diverse; 14 (52%) patients experienced multiple concurrent chronic pain conditions. Hydromorphone (55%) and oxycodone (37%) were the most common prescriptions. A majority (85%) of patients used non-opioid analgesics as adjunct therapy, while half (48%) used benzodiazepines or zopiclone concurrently. Patients who completed a pain scale (n=10) reported a median pain intensity of 6.8/10 ([IQR], 4.5-7.3). Opioid usage was lower than expected despite a higher prevalence of concurrent chronic pain conditions. Though this was within opioid usage guidelines, pain may not be sufficiently controlled. High concomitant use of benzodiazepines and Z-drugs introduces the potential for additive adverse effects. Judicious opioid usage can be facilitated with stewardship to effectively treat pain while avoiding associated harms and manage potential drug-drug interactions with common concomitant medications. The prevalence of chronic opioid use for non-cancer pain in haemodialysis patients was lower than expected at our centre. Despite following the recommended guidelines, pain management was relatively ineffective, and concomitant use of non-opioid analgesics was widespread. Opioid stewardship is recommended to optimize pain treatment and mitigate drug interaction risks.

Analgesic Use in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis.

Background:Pain is common in patients with chronic kidney disease (CKD). Analgesics may be appropriate for some CKD patients.Objectives:To determine the prevalence of overall analgesic use and the use of different types of analgesics including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvants, and opioids in patients with CKD.Design:Systematic review and meta-analysis.Setting:Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity.Patients:Adults with stage 3-5 CKD including dialysis patients and those managed conservatively without dialysis.Measurements:Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of analgesic use, and the types of analgesics prescribed.Methods:Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of analgesic use and the I2 statistic was computed to measure heterogeneity. Random-effects models were used to account for variations in study design and sample populations, and a double arcsine transformation of the prevalence variables was used to accommodate potential overweighting of studies with very large or very small prevalence measurements. Sensitivity analyses were performed to determine the magnitude of publication bias and assess possible sources of heterogeneity.Results:Forty studies were included in the analysis. The prevalence of overall analgesic use in the random-effects model was 50.8%. The prevalence of acetaminophen, NSAIDs, and adjuvant use was 27.5%, 17.2%, and 23.4%, respectively, while the prevalence of opioid use was 23.8%. Due to the possibility of publication bias, the actual prevalence of acetaminophen use in patients with advanced CKD may be substantially lower than this meta-analysis indicates. A trim-and-fill analysis decreased the pooled prevalence estimate of acetaminophen use to 5.4%. The prevalence rate for opioid use was highly influenced by 2 large US studies. When these were removed, the estimated prevalence decreased to 17.3%.Limitations:There was a lack of detailed information regarding the analgesic regimen (such as specific analgesics used within each class and inconsistent accounting for patients on multiple drugs and the use of over-the-counter analgesics such as acetaminophen and NSAIDs), patient characteristics, type of pain being treated, and the outcomes of treatment. Data on adjuvant use were very limited. These results, therefore, must be interpreted with caution.Conclusions:There was tremendous variability in the prescribing patterns of both nonopioid and opioid analgesics within and between countries suggesting widespread uncertainty about the optimal pharmacological approach to treating pain. Further research that incorporates robust reporting of analgesic regimens and links prescribing patterns to clinical outcomes is needed to guide optimal clinical practice.

Prevalence of analgesic use in patients with chronic pain referred to a multidisciplinary pain centre and its correlation with patient-reported outcome measures: A cross-sectional, registry-based study.

Chronic pain is prevalent in Sweden, nearing 20% in the adult population. Treatment often requires a multimodal approach, with medication, physical therapy and psychological interventions. However, the frequency of medication in patients with chronic pain in Sweden, and its correlation with patient-reported outcome measures (PROMs), are currently unknown. To investigate the frequency of use of analgesics and other medication in patients with chro-nic pain referred to a multidisciplinary pain centre, and how opioid treatment relates to PROMs. Cross-sectional, registry-based study. New referral visits (n = 1,275) to the Pain and Rehabilitation Center in Linköping, Sweden in 2015. 441 patients had complete medication and PROM data. Patient-reported analgesic and other medications were matched with patient PROM data from the Swedish Quality Registry for Pain Rehabilitation. Univariate analysis was conducted with IBM Statistical Package for the Social Sciences (SPSS; IBM Corporation, Somers, NY, USA) version 24.0, and multivariate analysis with SIMCA-P+ (version 13, Umetrics AB, Umeå, Sweden), with a special emphasis on opioids. n = 132 (30%) patients used opioids daily, and this group differed from other patients on many PROMs, with medium effect sizes for pain severity, interference, health-related quality of life, activity engagement, and satisfaction with social life. Multivariate analysis identified four groups and showed that daily use of opioids was significantly correlated with high pain intensity and low physical functioning. Prevalence of daily opioid use was 30% and daily opioid use did not correlate with better outcome of PROMs. Longitudinal studies are warranted (e.g. on the clinical effect of tapering), as are studies that can better explain the medication variability in patients with complex chronic pain.

Oral Arginine Therapy As a Novel Adjuvant in the Management of Acute Pain in Children with Sickle Cell Anemia in Nigeria: A Randomized Placebo-Controlled Trial

Introduction: Severe vaso-occlusive pain episodes (VOE) are a major cause of morbidityand mortality in sickle cell anemia (SCA). Low arginine bioavailability is associated with pain severity and predicts need for pediatric hospitalization (Morris et al, 2000). Arginine supplementation has opioid-sparing effects and was found to significantly decrease pain scores in children hospitalized with SCA-VOE compared to placebo in a phase-2 randomized placebo-controlled trial (RCT) performed in the United States (US, Morris et al, 2013). Its role to treat acute SCA-related pain in a Sub-Saharan African country is unknown. Objectives: To determine the role of oral arginine as adjuvant in the management of SCA-VOE. Methods: A double-blind RCT of oral L-arginine (100 mg/kg/dose every 8 hours until discharge; up to 5 days/15 doses maximum) was performed in children with SCA hospitalized with severe VOE defined as a Numerical Pain Scale Score (PS) of at least 7 on a scale of 0-10, at one of two hospitals in Abuja, Nigeria. All patients received pain management (both opioids and non-opioid analgesics) per institutional practice. Demographics, clinical characteristics, length of hospital stay (LOS), pain scores, time-to-crisis-resolution (time-to-PS&amp;lt;4), analgesia medications required, and plasma amino acids levels were obtained before and after supplementation. Mean total analgesic medication quantification scale score (MQS), a sensitive measure to quantify analgesic use in patients with SCA, was utilized as previously described (Jacob et al, 2007). Opioid doses were calculated based on morphine equivalents in milligrams (mg). The study was performed after obtaining the National Agency for Food &amp; Drug Administration &amp; Control (NAFDAC) approval, Ref No. NAF/DER/CT/LAG/2017. The protocol was approved by the Human Research Ethics Committees of the University of the Witwatersrand, University of Abuja Teaching Hospital, Abuja &amp; the National Hospital. The study was registered at the Pan African Clinical Trial Registry (PACTR 201611001864290). Results: Sixty-eight children with SCA were recruited, aged 5-17 years (mean: 10.6±0.4 years; 35 children randomized into the arginine arm &amp; 33 into the placebo arm). Baseline characteristics were similar between arms (Table 1). MQS was significantly lower in the arginine group vs. placebo (73 [95% CI: 62-84] vs. 120 [97-143]; p&amp;lt;0.001). By day 5, 54% of children treated with arginine had been discharged compared to 24% in the placebo arm. Although PS were similar in both groups prior to study drug delivery (8.7±1.1 vs. 8.4±1.2, arginine vs placebo; p=0.30), worst reported PS on day 5 were lower in children treated with arginine compared to placebo (1.2±0.4 vs. 3.0±0.5; p&amp;lt;0.0001). The mean rate of PS decline was also greater in the arginine arm vs. placebo (1.5 [1.2-1.8) vs. 1.1 [0.9-1.2] cm/day; p=0.009). Plasma arginine levels increased by 125% vs 29% in the arginine arm vs. placebo; percent increase in arginine bioavailable inversely correlated with MSQ (r=-0.35;p=0.02). There was a non-statistically significant decrease in mean total opioid dose used in the arginine group vs. placebo (3.8 [2.7-4.9] vs 5.1 [3.8-6.5) mg/kg, p = 0.11). Patients receiving arginine had shorter time-to-crisis-resolution (p=0.0216, Fig1A), shorter LOS (p=0.015; Fig1B) and had no serious adverse events. There was 1 death in the placebo group on the second day of admission. There were no differences between groups in development of adverse events, however there was a trend towards more vomiting in the arginine arm compared to placebo (20% vs. 3%, p=0.07). Conclusion: Arginine deficiency plays a role in acute pain requiring hospitalization in Nigerian children with SCA, similar to what has been reported in the US. Plasma arginine levels significantly increased with arginine supplementation, and improved global arginine bioavailability was inversely associated with total analgesia and opioids used in VOE management. Total mean analgesia use and pain scores were lower, while time-to-crisis-resolution and LOS were shorter in children treated with arginine compared to placebo. No serious adverse events occurred in the arginine arm, while rates of adverse events were similar to placebo, providing further support for the safety of arginine therapy in children with SCA. Oral arginine is a promising adjuvant therapy for SCA-VOE management. Disclosures Morris: Pfizer: Consultancy; UCSF-Benioff Oakland: Patents &amp; Royalties: Patents owned by UCSF-Benioff Children's Hospital Oakland regarding biomarkers and therapies that target arginine bioavailability; none are licensed and there is no royalties generated; UCSF-Benioff Children's Hospital Oakland: Patents &amp; Royalties: Patents owned by UCSF-Benioff Children's Hospital Oakland, licensed by Lifetrients, generating royalties for nutritional supplement for autism/apraxia. OffLabel Disclosure: Oral L-arginine for treatment of acute sickle cell disease vaso-occlusive pain

Use of Opioids and Other Analgesics Before and After Primary Surgery for Adult Spinal Deformity: A 10-Year Nationwide Study.

ObjectiveTo report the 1-year pre and postoperative analgesic use in patients undergoing primary surgery for adult spinal deformity (ASD) and assess risk factors for chronic postoperative opioid use. MethodsPatients > 18 years undergoing primary instrumented surgery for ASD in Denmark between 2006 and 2016 were identified in the Danish National Patient Registry. Information on analgesic use were obtained from the Danish National Health Service Prescription Database. Use of analgesics was calculated one year before and after surgery for each patient, per quarter (-Q4 to -Q1 before and Q1 to Q4 after). Users were defined as patient with one or more prescriptions in the given quarter. ResultsWe identified 892 patients. Preoperatively, 28% (n = 246) of patients were opioid users in -Q4 and 33% (n = 295) in -Q1. Postoperatively, 85% (n = 756) of patients were opioid users in Q1 and 31% (n = 280) in Q4. Proportions of users of other analgesics (paracetamol, antidepressants, and anticonvulsants) were stable before and after surgery. Use of nonsteroidal anti-inflammatory drug decreased postoperatively by 40% (-Q1 vs. Q4). 26% of patients had chronic preoperative opioid use (one or more prescriptions in each -Q2 and -Q1) and 24% had chronic postoperative use (prescription each of Q1–Q4). Multivariate logistic regression analysis showed age increment per 10 years and preoperative chronic opioid use as risk factors for chronic postoperative opioid use. ConclusionOne year after ASD surgery, opioid use was not reduced compared to preoperative usage.

Is dextrose prolotherapy effective in reducing analgesic use in patients with chronic musculoskeletal pain?

Department of Family and Community Medicine, University of Oklahoma—Tulsa, School of Community Medicine, Tulsa, OK The author declares no conflicts of interest.

The effects of Turkish classical music on physiological parameters, pain and analgesic use in patients with myocardial infarction: A non-randomized controlled study

IntroductionCardiovascular diseases are one of the most important causes of morbidity and mortality worldwide. The purpose of the current study was to investigate the effect of listening to music on pain, analgesic use and physiological states on Turkish people with myocardial infarction. MethodsThis study was a non-randomized controlled clinical trial and was conducted in a coronary intensive care unit in a university hospital. The study was conducted with a total of 500 patients; 250 in the experimental group; 250 in the control group; participants were aged between 18 and 79 years; and able to speak, read and write Turkish. The control group received routine care after myocardial infarction while the experimental group listened instrumental Turkish classical music for 30 min in coronary intensive care. The choice of music was made by the researchers. The music, a classical instrumental Turkish music, (Zirgülemakamı) was soft, relaxing, and included instrumental melodies of 60–80 beats per minute (bpm) and was for 30 min with a volume of 50–60 dB. Face-to-face interviews and then Personal Sociodemographic characteristics and Visual Analog Scale were used to collect data. ResultsAfter the music listening, pain, analgesic use, systolic and diastolic blood pressure, pulse averages of the patients were decreased and oxygen saturation averages between the groups were increased and differences between groups was statistically significant (p < 0.001). ConclusionsThese findings support the use of music as an independent nursing intervention to manage pain, analgesic use and physiological states in patients after myocardial infarction. Listening to music during and after myocardial infarction can effectively reduce pain, analgesic use, systolic and diastolic blood pressure, pulse levels. Thus listening music may be a useful tool for coronary intensive care nursing.