Opioid Group Research Articles

Prenatal Opioid and Alcohol Exposures: Association with Altered Placental Serotonin Transporter Structure and/or Expression.

Fetal exposures to many drugs of abuse, e.g., opioids and alcohol (EtOH), are associated with adverse neurodevelopmental problems in early childhood, including abnormalities in activity of the serotonin (5HT) transporter (SERT), which transports 5HT across the placenta. Little is known about the effects of these drugs on SERT expression. Pregnant women who used EtOH or opioids were compared to gestational age-matched controls using a structured questionnaire to determine prenatal substance exposure. Following elective pregnancy termination, placental membranous vesicles and exosomes were prepared from first and second trimester human placentas. Changes in EtOH- or opioid-exposed placental SERT expression and modifications were assessed by quantitative western blot. Novel SERT isoforms were sequenced and analyzed. Opioid-exposed but not EtOH-exposed maternal placentas showed SERT cleavage and formation of new SERT fragments (isoforms). Alcohol-exposed cases showed reduced SERT levels. Antibodies to the N-terminal SERT region did not recognize either of the two cleavage products, while antibodies to the central and C-terminal regions recognized both bands. The secondary band seen in the opioid group may represent a hypophosphorylated SERT fragment. These changes in SERT modifications and expression may result in altered fetal brain serotonergic neurotransmission, which could have neurodevelopmental implications.

Socio-demographic, clinical variables and pain among Egyptian patients of opioid use disorder with and without comorbid gabapentin use

IntroductionThere is increased clinical use of gabapentin, these trends appear to chronologically align with the opioid overdose crisis and particularly with the increased restrictions on opioid prescription.ObjectivesThe study aimed to assess the clinical variables, pain quality, and severity among patients with opioid use disorder as the main substance with and without gabapentin comorbid use.MethodsThe research involved 60 patients diagnosed with substance use disorder, divided into two groups: opioid use as the main substance and opioid use with comorbid gabapentin. All participants were assessed using a semi-structured clinical addiction interview, the structured clinical interview for diagnostic and statistical manual of mental disorders, the Addiction Severity Index, urine drug test, McGill Pain Questionnaire, and Douleur Neuropathique en 4 Questionnaire, in one interview setting.ResultsThe study showed that pain relief was the main desirable effect in the gabapentin group, with 66.2% of the group experiencing it. Euphoria was the desirable effect in the opioid group, while overdose was more common in the gabapentin group. Respiratory complications were also more common in the Gabapentin group.ConclusionThe study concluded that patients with comorbid gabapentin use disorder had a higher frequency of overdose, history of pain, and significant neuropathic pain, while less abstinence.

Application value of opioid-free anesthesia in renal cyst decompression by laparoscopy.

The objective of the study was to analyze the application value of opioid-free anesthesia (OFA) in renal cyst decompression by laparoscopy. A total of 124 patients undergoing renal cyst decompression by laparoscopy in our hospital were selected and divided into opioid anesthesia (OA) and OFA groups (n = 62). Fentanyl and remifentanil were used for anesthesia induction in the OA group, while lidocaine and dexmedetomidine were employed for anesthesia induction in the OFA group. The homeostasis indicators (cortisol [Cor], adrenocorticotropic hormone [ACTH], C-reactive protein [CRP], and interleukin-6 [IL-6]) were also compared 10 min before anesthesia (Ta), at the end of operation (Tb), and 24 h after operation (Tc). At T1-T3, heart rate, mean arterial pressure, mean airway pressure, and partial pressure of end-tidal carbon dioxide were all lower in OFA group than those in OA group (p < 0.05). At Tb-Tc, the levels of Cor, ACTH, CRP, and IL-6 were all higher in both groups than those at Ta (p < 0.05), while they were lower in OFA group than those in OA group (p < 0.05). OFA is more beneficial to the respiratory and circulatory system and homeostasis of patients, and has higher anesthetic safety.

Analgesic efficacy of sacral neuromodulation for chronic pelvic cancer pain

Background: Neuromodulation has provided promising results in chronic pain management. Sacral neurostimulation (SNS) is a neuromodulatory technique, where the sacral nerve roots are electrically stimulated. Objective: Evaluate the efficacy of the trial phase to control severe cancer pain in pelvic organs. Design: Pilot study. Methods: Chronic pelvic cancer pain patients were managed with morphine ≥ 60 mg daily, duloxetine 30 mg, and celecoxib 200 mg twice daily. Twenty-two adults were divided randomly into two equal groups: the SNS group (N = 11), received a sacral neurostimulator device and opioid analgesics, and the opioid group (N = 11), received increased opioid analgesics to control pain. Results: Visual analog scale scores were decreased in the SNS group at 24 h, 4 days, 1, and 2 weeks in SNS compared to the opioid group, medians (IQR) [4 (3–5) vs 6 (5–7), 3 (3–4) vs 5 (5–6), 3 (3–4) vs 5 (5–6), and 3 (3–3) vs 5 (4–6) P &lt; 0.001], daily morphine consumption was reduced in the SNS group compared to the opioid group, median (IQR) [90 (60–90) mg vs 120 (120–150) mg, P &lt; 0.001] and [30 (30–60) mg vs 150 (120–180) mg] during the first and second weeks. The SNS group had a better life quality compared to the opioid group after 2 weeks, median (IQR) was (123 (122.5–124) vs 117 (117–118.5) P &lt; 0.001), respectively. Conclusion: The SNS trial device showed effectiveness in managing severe chronic pelvic cancer pain.

Adverse respiratory events during treatment with gabapentin and opioids among older adults with spine-related conditions: a propensity-matched cohort study in the US Medicare population.

Recent work indicates no increased mortality risk with concurrent gabapentin and opioid use when using an active comparator control design. However, concurrent gabapentin and opioid prescriptions have been associated with greater risk of respiratory depression in some studies. To compare the risk of respiratory events among Medicare enrollees with spine-related diagnoses treated with gabapentin + opioids vs those treated with tricyclic antidepressants (TCA) or duloxetine + opioids. We hypothesized that enrollees treated with gabapentin + opioids would have increased risk of adverse respiratory events compared to those treated with an active control + opioids. Propensity score-matched cohort study with an incident user, active comparator (TCA/duloxetine) control design. The primary analysis included those who concurrently (within 30 days) filled ≥1 incident gabapentin + ≥1 opioid or ≥1 incident TCA/duloxetine + ≥1 opioid prescription. U.S. Medicare beneficiaries with spine-related diagnoses 2017-2019. People treated with gabapentin + opioids (n=66,580) were matched on demographic and clinical factors to people treated with TCAs/duloxetine + opioids (n=66,580). Time to a composite respiratory outcome consisting of mechanical ventilation, intubation, respiratory failure, pneumonia, or acute respiratory distress syndrome. Cox proportional hazard regression was used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (95% CIs). Among 133,160 Medicare enrollees (median age 73.3 years; 66.7% female), 6089 (4.6%) experienced respiratory events before the end of follow-up. A total of 3297 (5.0%) of people who were treated with gabapentin + opioids (median initial dose/day of gabapentin was 338 mg) had respiratory events compared to 2792 (4.2%) of those treated with an active control + opioids. The increased risk in those treated with gabapentin + opioids was statistically significant after adjustment (HR 1.14; 95% CI 1.09, 1.20; p<0.0001). The most common respiratory events were pneumonia (3.5% of people in the gabapentin + opioids group versus 3.0% of people in the TCA/duloxetine + opioids group) and respiratory failure (2.2% in the gabapentin + opioids group versus 1.8% in the TCA/duloxetine + opioids group). Results were similar in analyses (a) restricted to ≤30-day follow-up and (b) that required ≥2 fills of each prescription. While recent work has indicated no increased mortality risk with concurrent gabapentin and opioid use, the current findings suggest clinicians should exercise caution in prescribing gabapentin to people experiencing pain who are also being treated with opioids, due to the potentially increased risk of respiratory events.

Unveiling the impact of opioid-free postoperative regimens in ureteroscopy: a comprehensive systematic review and meta-analysis.

Ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) are minimally invasive urologic procedures that are commonly used to treat kidney stones. However, they often result in significant postoperative pain. Historically, patients undergoing these surgeries have predominantly been managed with opioids, which has contributed to the escalating global complications associated with these drugs, including abuse and addiction. As a result, over the recent years, many healthcare centers have made efforts to minimize opioid use, opting instead for safer alternative medications. In this study, we aim to compare the efficacy of both opioid and opioid-free pain management regimens following URS or RIRS procedures. A systematic search was conducted in MEDLINE, Embase, Scopus, Cochrane, LILACS, and Google Scholar. We included studies that compared opioid-based and opioid-free postoperative care for managing pain in patients who underwent URS or RIRS for lithotripsy. Our primary outcome of interest was the frequency of postoperative emergency department (ED) visits. Secondary outcomes included pain-related phone calls, postoperative unexpected encounters, need for opioids at discharge, and patients with opioid refills. We retrieved 10 articles, encompassing 6786 patients in the opioid group and 5276 patients in the opioid-free group. Overall, our findings lean towards favoring the opioid-free regimen, revealing notable differences between the groups. Opioid-free regimen was associated with less ED visits (OR=0.67; 95% CI: 0.58, 0.77; P=0.00001; I2=0%) and required less opioids at discharge (OR=0.11; 95% CI 0.02, 0.64; P=0.01; I2=89%). Through statistically superior results, our meta-analysis suggests that an opioid-free regimen outperforms the use of opioids after URS or RIRS, particularly in terms of pain management.

Structural elucidation of tramadol, its derivatives, and metabolites using chemical derivatization and liquid chromatography-high-resolution tandem mass spectrometry.

Tramadol (T) is a strong painkiller drug that belongs to the opioid analgesic group. Several accidental intoxication cases after oral administration of T have been reported in the past decade. Tramadol, its derivatives, and metabolites present information-limited mass spectra with one prominent peak representing the amine-containing residue; therefore, their structural determination based on both electron impact mass spectrometry (EI-MS) and ESI-MS/MS spectra could be misleading. A novel analytical method for the structural elucidation of tramadol, its four homologs, and its two main phase I metabolites (N-desmethyltramadol and O-desmethyltramadol) was developed using chemical modification and liquid chromatography-high-resolution tandem mass spectrometry (LC-HR-MS/MS) with Orbitrap technology. After chemical derivatization, each of the investigated T series exhibited informative mass spectra that enabled better exposition of their structures. The developed method was successfully implemented to explicitly identify the structures of tramadol and its N-desmethyltramadol metabolite in urine samples at low ng/mL levels. An efficient derivatization-aided strategy was developed for rapidly elucidating the structure of tramadol-like compounds. The method is intended to assist forensic chemists in better diagnosing T and its analogs and metabolites in clinical or forensic toxicology laboratories.

The Effects of Opioid Administration on Clostridioides Difficile Infection: A Retrospective Cohort Study.

Background: Clostridioides difficile (C. difficile) is a leading cause of healthcare-associated infections. Using opioids while infected with C. difficile may hypothetically lead to reduced clearance of the organism and higher risk of progressing to severe or fulminant infection. Objective: The objective of this study was to determine if opioid use leads to worsening of C. difficile infection. Methods: This was a single-center, retrospective cohort study of patients with C. difficile infection. The primary endpoint was progression to severe or fulminant disease, defined as serum creatinine greater than 1.5mg/dL or over 50% of baseline, white blood cells above 15,000 cells/mm3, shock requiring vasopressors, ileus, toxic megacolon, or vancomycin dose increase. Secondary outcomes included hospital length of stay and time to resolution of diarrhea. The groups were stratified based on average morphine milligram equivalents received during the treatment. Results: A total of 73 patients were included in the non-opioid group and 93 patients in the opioid group. The composite outcome occurred in 16 patients (21.9%) without opioids vs 26 patients (28.0%) with opioids; (P = 0.37). The average length of stay was 7.2 days without opioids and 9.3 days with opioids (P = 0.11) and the average time to resolution of diarrhea was 3.5 days without opioids and 5.5 days with opioids (P = 0.40). Conclusion: There was no significant difference in the rate of progression to severe or fulminant disease. There was a numerical trend towards increase in progression in patients who had opioids, primarily driven by those who had higher dosages of opioids used.

Certified Community Behavioral Health Clinic Services for Clients With Co-occurring Disorders: A Latent Class Approach.

Certified community behavioral health clinics (CCBHCs) are designed to provide comprehensive care for individuals with co-occurring mental and substance use disorders. The authors classified outpatient mental health treatment facilities on the basis of provision of services for clients with co-occurring disorders and assessed whether CCBHCs differed from other outpatient mental health facilities in services provided. The authors used latent class analysis to identify distinct services for clients with co-occurring disorders in 5,692 outpatient mental health facilities in the 2021 National Substance Use and Mental Health Services Survey. Nine indicators were included: treatment for clients with substance or alcohol use disorder co-occurring with serious mental illness or serious emotional disturbance, specialized programs or groups for such clients, medication-assisted treatment (MAT) for alcohol use disorder, MAT for opioid use disorder, detoxification, individual counseling, group counseling, case management, and 12-step groups. A multinomial logistic regression was used to estimate whether CCBHCs were associated with any identified classes after analyses controlled for facility characteristics. A four-class solution provided a model with the best fit, comprising comprehensive services (23.4%), case management services (17.7%), counseling and self-help services (58.6%), and professional services (4.3%). Regressing class membership on facility type and covariates, the authors found that compared with community mental health clinics (CMHCs), CCBHCs were more likely to belong to the comprehensive services class than to the case management services, counseling and self-help services, and professional services classes. CCBHCs were more likely than other outpatient programs to offer comprehensive care, and CCBHC status of a CMHC facilitated enhanced service provisions.

Comparison of Butorphanol, Methadone, and Pethidine in Combination with Alfaxalone for Premedication in Isoflurane-Anesthetized Cats Undergoing Ovariectomy.

The aim of this study was to compare three different anesthetic protocols administered intramuscularly (IM) in cats undergoing elective ovariectomy, while evaluating the quality of sedation, antinociceptive, isoflurane-sparing effect, and analgesia in the intra-operative and post-operative phases. A total of 71 female cats were sedated IM with alfaxalone (3 mg/kg) combined with either butorphanol (0.3 mg/kg), methadone (0.3 mg/kg), or pethidine (5 mg/kg). During surgery, vital parameters were constantly monitored; at the end of the procedure, the quality of recovery was assessed through a specific form and each cat was scored for perceived pain using the UNESP-Botucatu scale for 5 days, and rescue analgesia was provided with buprenorphine IM when indicated. Moreover, differences between two different post-operative resting regimens (hospital kennels vs. home) were also assessed. A significant difference emerged for the amount of IM dexmedetomidine required to achieve an adequate level of sedation for intravenous catheterization, highlighting a greater need in the pethidine group (p = 0.021). There was no significant difference between opioid groups for the requirement of intra-operative rescue analgesia, and the clinical parameters were kept within physiological ranges regardless of the opioid used in premedication. Lastly, differences between the UNESP-Botucatu scores were detected from day 3 to day 5 post-operatively, with lower scores in cats with home resting regimens compared to the hospitalized animals, likely due to the presence of an unfamiliar condition and the absence of a cat-friendly environment.

High-frequency, high-intensity TENS compared to standard treatment with opioids for postoperative pain relief after laparoscopic cholecystectomy: A multicentre randomized controlled trial.

Adverse effects of opioids could prolong the duration of stay in the post-anaesthesia care unit (PACU). This study aimed to assess time in the PACU and the pain-relieving effect of high-frequency, high-intensity transcutaneous electrical nerve stimulation (HFHI TENS) versus standard treatment with intravenous (IV) opioids. Patients undergoing laparoscopic cholecystectomy at two Swedish hospitals were invited to participate. Patients reporting postoperative pain intensity ≥3 according to the Numeric Rating Scale (NRS) in the PACU were randomized to receive standard treatment with IV opioids or HFHI TENS, administered with an intensity of 40-60 mA for 1 min, repeated once if insufficient pain relief. If NRS remained ≥3 after two TENS stimulation the patients received IV opioids. In total, 163 patients were randomized to receive HFHI TENS (n = 85) or IV opioids (n = 78). There was no difference between the HFHI TENS group versus the opioid group regarding time in the PACU (138 min [SD 69] vs. 142 min [SD 95], mean difference -4.42 [95% CI-30:22], p = 0.74), time to pain relief NRS < 3 (median 10 min) and pain intensity at PACU discharge (NRS 1.7 [SD 1.45] vs. 1.6 [SD 1.20], p = 0.58). In the HFHI TENS group, 39 patients (46%) needed additional treatment with IV opioids. Mean opioid consumption was significantly lower in the HFHI TENS group than in the opioid group (4.5 vs. 11.0 morphine equivalents; p < 0.001). HFHI TENS may be an opioid-sparing alternative for postoperative pain relief. In this multicentre, RCT time in the PACU and the pain-relieving effect of HFHI TENS was compared to standard treatment with IV opioids. There were no differences between the groups regarding time in the PACU, time to pain relief and side effects but opioid consumption in the HFHI TENS group was significantly lower. Both groups reported high satisfaction with pain treatment and care. In summary, HFHI TENS should be considered a safe, fast-onsetting, opioid-sparing option for postoperative pain relief.

The Impact of Opioid Prescription on the Occurrence and Outcome of Pneumonia: A Nationwide Cohort Study in South Korea.

Opioids are known to cause respiratory depression, aspiration, and to suppress the immune system. This study aimed to investigate the relationship between short- and long-term opioid use and the occurrence and clinical outcomes of pneumonia in South Korea. The data for this population-based retrospective cohort analysis were obtained from the South Korean National Health Insurance Service. The opioid user group consisted of those prescribed opioids in 2016, while the non-user group, who did not receive opioid prescriptions that year, was selected using a 1:1 stratified random sampling method. The opioid users were categorized into short-term (1-89 d) and long-term (≥90 d) users. The primary end point was pneumonia incidence from January 1, 2017-December 31, 2021, with secondary end points including pneumonia-related hospitalizations and mortality rates during the study period. In total, 4,556,606 adults were enrolled (opioid group, 2,070,039). Opioid users had a 3% higher risk of pneumonia and an 11% higher risk of pneumonia requiring hospitalization compared to non-users. Short-term users had a 3% higher risk of pneumonia, and long-term users had a 4% higher risk compared to non-users (P < .001). Additionally, short-term users had an 8% higher risk of hospital-treated pneumonia, and long-term users had a 17% higher risk compared to non-users (P < .001). Both short- and long-term opioid prescriptions were associated with higher incidences of pneumonia and hospital-treated pneumonia. In addition, long-term opioid prescriptions were linked to higher mortality rates due to pneumonia.

Current trends in the medical treatment of neuropathic low back pain: a Swedish registry-based study of 1.7 million people

BackgroundLow back pain, a common problem worldwide, causes more global disability than any other condition and is associated with high costs to society. This observational registry-based study describes the current trends in the medical treatment of neuropathic low back pain in the Swedish region of Västra Götaland, which has a population of 1.7 million. The study aims to; (1) identify the prevalence of neuropathic low back pain within the study population; (2) to explore the patterns of medical treatment utilization, including the prevalence and distribution of opioids (OG) and analgesics specified for neuropathic low back pain (NG) and (3) to evaluate the long-term trends and changes in medical treatment practice for neuropathic low back pain over the study period.MethodsThis study includes a descriptive analysis of aggregated data extracted from the Swedish primary care registry VEGA and the pharmaceutical prescription registry Digitalis between the years 2017 and 2021. The data were stratified by year, age, gender, pharmaceutical code (ATC), and sub-diagnoses and presented as the prevalence of unique patients retrieving prescribed medication within six months before or after a registered diagnosis of neuropathic low back pain. The pharmaceutical codes were furthermore grouped into two groups depending on their mechanism of action; opioid group (OG) and neuropathic group (NG).ResultsIn all four diagnosis groups, more patients used opioid analgesics than neuropathic analgesics. The greatest difference between the opioid group and neuropathic group was in the lumbar spinal stenosis diagnosis group (67.1% vs. 40.6%), followed by the lumbar root canal stenosis diagnosis (65.9% vs. 44.2%), the nerve root and plexus compressions in intervertebral disc disorders diagnosis (57.5% vs. 40.8%), and lumbago with sciatica diagnosis (38.4% vs. 22.7%).ConclusionsThe trends suggest a general increase in the prescription rate and therefore patients’ use of neuropathic analgesics for neuropathic pain associated with the studied diagnoses. However, opioid treatment remains the most common. The results indicate that the treatment for neuropathic low back pain needs to be improved.

Trajectories of Opioid Use Before and After Cancer Diagnosis: A Population-Based Cohort Study

BackgroundOpioid use prior to cancer diagnosis increases the likelihood of long-term use during survivorship, however, patterns of use before and after diagnosis are not understood. MethodsWe used population-based dispensing data linked with cancer and death notifications to identify two cohorts of adults residing in New South Wales initiating opioids within 24 months prior to a first cancer diagnosed between 2014 and 2016: ‘survivors’ (alive 24 months following diagnosis) and ‘decedents’ (died within 24 months). We used group-based trajectory modelling to identify trajectories of monthly opioid dispensings and dispensed oral morphine equivalent milligrams (OMEmg) during the 24 months before/after cancer diagnosis. ResultsThere were 21,843 survivors with four prediagnosis opioid dispensing trajectories: infrequent (58% of the cohort), late increasing (26%), moderate (10%), and sustained dispensing (6%). We observed an overall increase in dispensed OMEmg of 83 OMEmg (95% CI: 76–91) during the month of diagnosis, with strong opioid formulations comprising most treatment postdiagnosis. Within each prediagnosis opioid trajectory group, we observed five to six postdiagnosis trajectory groups, including no opioid dispensing. Moderate and sustained prediagnosis groups had large proportions of people continuing or increasing opioid dispensing after diagnosis, while small proportions discontinued opioid treatment. We observed similar trajectories in the decedent cohort. ConclusionsThere is considerable heterogeneity in opioid use before and after cancer diagnosis. Our findings suggest noncancer factors drive a significant proportion of postdiagnosis opioid use, but use increased significantly from the month of cancer diagnosis and never returned to prediagnosis levels.

Evaluation of Postoperative Efficacy and Safety of Celecoxib in Children Hospitalized After Adenotonsillectomy.

The choice of optimal analgesia following an adenotonsillectomy is a clinical issue because of the risk of respiratory depression and bleeding. The objective of this study was to assess the effect of celecoxib on opioid use and pain scores in children hospitalized after adenotonsillectomy and to document its adverse effects. This retrospective study was conducted in a tertiary care pediatric hospital. We compared a group of subjects aged 1 to 17 years who were prescribed celecoxib and opioids between January 2017 and June 2020 following an adenotonsillectomy during a 3-day or less hospitalization to a group of matched controls for sex, age, and length of stay who were prescribed opioids. A total of 228 patients were identified (76 in the celecoxib + opioids group, 152 in the control group). Opioid use, in oral morphine equivalent daily dose, was lower in the celecoxib + opioids group at 0 to 24 hours of hospitalization (0.15 vs 0.20 mg/kg/day, p = 0.05). Initiating celecoxib within 24 hours of surgery (n = 60) significantly reduced opioid requirement for up to 48 hours compared with controls (0-24 hours: 0.12 vs 0.20 mg/kg/day, p = 0.002; 25-48 hours: 0.02 vs 0.09 mg/kg/day, p = 0.001). A shorter length of stay was observed for patients receiving celecoxib + opioids during the first 24-hour post--operative period (27 vs 32 hours, p = 0.01). With celecoxib use, no significant change in pain scores and occurrence of adverse effects including bleeding was found. Using celecoxib early after an adenotonsillectomy has reduced both opioid use and duration of hospital stay without increasing adverse effects or bleeding.

Preoperative opioid use and its association with postoperative complications

ABSTRACT Background The negative impact of opioid use in the U.S. has led providers to seek alternative methods for pain control. More specifically, preoperative opioid usage has been demonstrated to adversely affect patients and clinical outcomes. This study aims to assess the extent of the relationship between preoperative opioid use on postoperative outcomes across surgical disciplines using statewide population databases. Methods The study used the Utah All Payers Claims Database and Utah Population Database to identify a cohort of adult patients who underwent a single surgery between 2013 and 2016 and had continuous insurance enrollment. Preoperative opioid prescription within one year prior to the index surgery was the independent variable, while complications and hospital admissions one year following the index surgery were the primary outcomes. Results Our model of 18,647 patients found that the odds of any complication with preoperative opioid use was 1.28. Depression (OR 1.17) and drug misuse (OR 1.41) were also associated with a higher risk of postoperative complications. Rates of hospital readmission in the preoperative opioid use group compared to the opioid naïve group were increased (19.43% vs. 12.44%, p < .01). Conclusion The data can be used to guide patient-physician conversations and better inform prescribing habits perioperatively.

Opioid-free anesthesia using a combination of ketamine and dexmedetomidine in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial.

Opioids administered as bolus doses or continuous infusions are widely used for major and daycare surgeries. Opioid-free anesthesia is multimodal anesthesia and analgesia that does not use opioids, benefiting patients from opioid-related adverse effects. We compared the postoperative analgesic requirements of patients scheduled for elective laparoscopic cholecystectomy under opioid-free and opioid-based anesthesia. Study included 88 patients aged 18-60 years with American Society of Anesthesiologists physical status 1 and 2 who underwent elective laparoscopic cholecystectomy. Participants were randomly divided into two groups with 44 in each. The opioid-free group was administered an intravenous bolus of ketamine and dexmedetomidine, whereas fentanyl was used in opioid group. Primary outcome was to compare the total amount of fentanyl consumed by both groups during 6 h postoperative period. Episodes of postoperative nausea and vomiting (PONV) and vital signs were noted throughout the postoperative period to analyze the secondary outcomes. Both groups had similar demographic characteristics. The opioid-free group required lesser analgesia within the first 2 h (61.4 ± 17.4 vs. 79.0 ± 19.4 of fentanyl, P < 0.001), which was statistically significant. However, fentanyl consumption was comparable between the groups at 6 h (152 ± 28.2 vs. 164 ± 33.4, P = 0.061). Compared with 4.5% of the participants in the opioid-free group, 34% of those in the opioid-based group developed moderate PONV. Opioid-free anesthesia in patients undergoing laparoscopic cholecystectomy reduced the requirement of analgesia in first two-hour postoperative period and was associated with decreased PONV.

Unplanned Postoperative Phone Calls and Electronic Messages for Patients With and Without Opioid Prescriptions After Carpal Tunnel Release

The purpose of our study was to compare unplanned postoperative patient communication in the form of phone calls and/or electronic patient portal messages (EPPM) after carpal tunnel release (CTR) for patients with and without a postoperative opioid prescription. We identified all patients ≥18 years of age who underwent primary CTR between 2017 and 2022 without an opioid ordered within 90 days prior to surgery. The following two groups were created: cases with and without an opioid prescribed on the day of surgery. We recorded baseline demographics for all patients and recorded all unplanned communication (phone calls and EPPM) sent from a patient to the surgeon's office within 14 days after surgery. Unadjusted associations between unplanned communication and case characteristics were evaluated. Multiple logistic regression models were used to assess the relationship between opioid status and unplanned communication. A total of 5,735 CTRs were included, and 54% of the patients were prescribed an opioid on the day of surgery. Forty-two percent of cases had unplanned postoperative communication, and 48.1% of cases, without an opioid prescription, had unplanned communication compared with 36.8% in the opioid group. Patients who were prescribed opioids were 0.62 times less likely to contact the surgeon's office via phone calls or EPPM (95% confidence interval [CI]: 0.56, 0.70). Increased age was associated with a reduction in the odds of unplanned contact (odds ratios [OR]= 0.95, 95% CI: 0.93, 0.97), whereas higher body mass index was significantly associated with increased communication (OR= 1.05, 95% CI: 1.01, 1.09). Patients prescribed opioids after CTR are 0.62 times less likely to contact the surgeon's office after surgery. Considering the 11% increase in unplanned postoperative communication after CTR, surgeons should consider alternative methods that have previously been demonstrated to reduce opioid consumption. Prognostic II.

Opioid-Sparing Nonsteroid Anti-inflammatory Drugs Protocol in Patients Undergoing Intramedullary Nailing of Tibial Shaft Fractures: A Randomized Control Trial.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics commonly used in fracture management. Although previously associated with delayed fracture healing, multiple studies have demonstrated their safety, with minimal risks of fracture healing. Given the current opioid crisis in the United States, alternate pain control modalities are essential to reduce opioid consumption. This study aims to determine whether the combination of oral acetaminophen and intravenous ketorolac is a viable alternative to opioid-based pain management in closed tibial shaft fractures treated with intramedullary nailing. We conducted a randomized controlled trial evaluating postoperative pain control and opioid consumption in patients with closed tibial shaft fractures who underwent intramedullary nailing. Patients were randomized into an NSAID-based pain control group (52 patients) and an opioid-based pain control group (44 patients). Visual analog scale (VAS) scores and morphine milligram equivalents (MMEs) were evaluated at 12-hour postoperative intervals during the first 48 hours after surgery. Nonunion and delayed healing rates were recorded for both groups. A statistically significant decrease in MMEs was noted at every measured interval (12, 24, 36, and 48 hours) in the NSAID group compared with the opioid group ( P -value 0.001, 0.001, 0.040, 0.024, respectively). No significant change in visual analog scale scores was observed at 12, 36, and 48 hours between both groups ( P -value 0.215, 0.12, and 0.083, respectively). A significant decrease in VAS scores was observed at the 24-hour interval in the NSAID group compared with the opioid group ( P -value 0.041). No significant differences in union rates were observed between groups ( P -value 0.820). Using an NSAID-based postoperative pain protocol led to a decrease in opioid consumption without affecting pain scores or union rates. Owing to the minimal risk of short-term NSAID use, their role in the perioperative management of tibia shaft fractures is justified, especially when they reduce opioid consumption markedly. Therapeutic Level I.

The role of methadone in cardiac surgery for management of postoperative pain

BackgroundThis retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids. MethodsPatients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M). ResultsPatients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P<0.01). Both Groups M and M+O had lower total opioid administered compared with Group O for all days POD0–POD6 (all P<0.001). The median number of hours until initial postoperative opioid after surgery was 2.55 (inter-quartile range [IQR]=1.07–5.12), 6.82 (IQR=3.52–12.98), and 7.0 (IQR=3.82–12.95) for Group O, Group M+O, and Group M, respectively. The incidence of postoperative complications did not differ between groups. ConclusionsIntraoperative administration of methadone was associated with better pain control without significant side-effects after cardiac surgery.