Guide Pain Management Research Articles

Patient-level patterns in daily prescribed opioid dosage in single level lumbar fusion are associated with postoperative opioid dosage and adverse events: a retrospective analysis of claims data

BACKGROUNDPatients undergoing lumbar spine surgery have high rates of preoperative opioid use, which is associated with inferior outcomes and higher risks for opioid dependency postoperatively. PURPOSEDetermine whether there are identifiable subgroups of patients that follow distinct patterns in pre- and postoperative opioid dosing. Examine how preoperative patterns in opioid dosing relate to postoperative opioid patterns, opioid cessation, and the risk for adverse events. STUDY DESIGN/SETTINGRetrospective analysis of an administrative claims database (MeritiveTM Marketscan® Research Databases 2007–2015). PATIENT SAMPLEThe 9,768 patients undergoing primary single level lumbar fusion. OUTCOME MEASURESPrimary: daily morphine milligram equivalent (MME) opioid dosing calculated from prescriptions dispensed for 1 year before and after surgery; secondary: 90-day all-cause readmission and complications, 90-day acute postoperative pain, 90-day and 1-year reoperation, surgical costs, length of stay, and discharge disposition. METHODSDistinct patient subgroups defined by patterns of daily MME pre- and postoperatively were identified via group-based trajectory modeling. Associations between these groups and outcomes were assessed with multivariable logistic regression with risk adjustment for patient and surgical factors. RESULTSAmong primary single level lumbar fusion patients, 59.5% filled an opioid prescription in the 3 months preceding surgery, whereas 40.5% were opioid naïve (Naïve). Five distinct subgroups of daily MME were identified among those filling opioids preoperatively:(1) Naïve to 3m (21.2% of patients): no opioids until 3 months preoperatively, escalating to 15 MME/day;(2) Low to 3m (11.4%): very low or as needed dose until 3 months preoperatively, escalating to 15 MME/day;(3) 6m Rise (6.9%): no opioids until 6 months preoperatively, escalating to >30 MME/day;(4) Medium (9.8%): increased linearly from 10 to 25 MME/day across the year before surgery;(5) High (10.0%): increased linearly from 60 to >80 MME/day across the year before surgery.These five preoperative opioid groups were related to postoperative opioids filled in a dose-response manner. The two preoperative patient groups with chronic Medium to High-dose opioid dosing were associated with increased adverse events, including all-cause readmission, reoperation, and pneumonia, whereas a low baseline group with a large, earlier preoperative rise in opioid dosing (6m Rise) had increased encounters for acute postoperative pain.Postoperatively, only 9.5% of patients did not fill an opioid prescription. Five distinct postoperative subgroups were identified based on their patterns in daily MME: Two groups ceased filling opioids within the year following surgery (33.6% of patients), and three groups declined in opioid dosage following surgery but plateaued at low (0–5 MME/day, 29.1%), medium (10–15 MME/day, 12.0%), or high (70–75 MME/day), 13.1%) doses by 1 year. Patients within the higher preoperative opioid groups were more likely to belong to the postoperative groups that were unable to cease filling opioids. CONCLUSIONSIdentification of a patient's preoperative time trend in daily opioid use may provide significant prognostic value and help guide pain management and risk reduction efforts. LEVEL OF EVIDENCEIII.

Patient and physician radiation exposure during minimally invasive lumbar decompression: A prospective assessment of X-ray exposure risks.

Minimally invasive lumbar decompression (mild®) is becoming a popular procedure for treating lumbar spinal stenosis (LSS) secondary to hypertrophic ligamentum flavum (LF). The mild® procedure is commonly performed under live fluoroscopic guidance and carries a risk of radiation exposure to the patient and healthcare. One physician performed mild® on 41 patients at the Cleveland Clinic Department of Pain Management from October 2019 to December 2021, while wearing a radiation exposure monitor (Mirion Technologies). Mean fluoroscopy time, mean exposure per case, and mean exposure per unilateral level decompressed were the primary outcomes measured. The secondary outcome was to provide a comparison of radiation exposure during similar fluoroscopically guided procedures. Mean patient fluoroscopy exposure time was 2.1 min ±0.9 (range: 1.1-5.6) fluoroscopy time per unilateral level decompressed. The mean patient radiation skin exposure from mild® was 1.1 ± 0.9 mGym2, and the mean total dose was 142.3 ± 108.6 mGy per procedure. On average, the physician was exposed to an average deep tissue exposure of 4.1 ± 3.2 mRem, 2.9 ± 2.2 mRem estimated eye exposure, and 14.7 ± 11.0 mRem shallow tissue exposure per unilateral level decompressed. An individual physician would exceed the annual exposure limit of 5 Rem after approximately 610 mild® procedures per year. This study is an attempt to quantify the radiation exposure to the physician and patient during the mild® procedure. Compared with other fluoroscopically guided pain management procedures, patient and physician radiation exposure during mild® was low.

Reliability of urine drug testing among patients on buprenorphine transdermal patch.

Urine drug testing (UDT) plays a significant role in monitoring patients on chronic opioid therapy (COT) for non-medical opioid use (NMOU). UDT, at times, can be inconsistent and misleading. We present a case where a patient on a buprenorphine patch had false negative results. A female in her 70s with metastatic breast cancer presented with uncontrolled pain from a T6 compression fracture. She had no relief with tramadol 50 mg every 6 hours as needed. Due to an allergic reaction to hydromorphone, our team prescribed a buprenorphine patch of 5 μg/h. Subsequently, she expressed excellent pain control, and the clinician confirmed the patch placement on examination. She underwent a UDT during the visit. The UDT was negative for both buprenorphine and its metabolites. The literature review showed that false negative UDT results are relatively common among patients with low-dose buprenorphine patches. The combination of a thorough physical examination, a review of the Prescription Drug Monitoring Program, and reassuring scores on screening tools placed her at low risk for NMOU. Buprenorphine has a ceiling effect on respiratory depression and a lower risk for addiction. However, when used in low doses, the drug might not have enough metabolites in the urine, leading to a false negative UDT. Such results might affect patient-physician relationships. In addition to the UDT, a thorough history, screening for NMOU, physical exam, a review of PDMP, and a good understanding of opioid metabolism are necessary to help guide pain management.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction.

The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons. A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics. Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols. Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management. Level V.

A simple method for clinical implications of pain; comprehensive geriatric assessment.

SUMMARYOBJECTIVE:The effect of chronic pain on the elderly population is enormous in terms of both human suffering and cost. This study aimed to investigate the factors associated with chronic low back pain in older adults by performing a comprehensive geriatric assessment.METHODS:This cross-sectional study included 225 elderly patients admitted to a geriatric outpatient clinic. All participants underwent a comprehensive geriatric assessment, and factors related to chronic low back pain were assessed. Participants were grouped as those with and without chronic pain.RESULTS:The mean age of the participants was 72.9±6.9 years, and 149 (66.2%) of them had chronic pain complaints. The number of chronic diseases and medications, depressive symptom scores, and sleep quality scores were higher, and quality of life (European Quality of Life-5 Dimensions index and European Quality of Life-5 Dimensions visual analog scale) and nutritional status scores were lower in the chronic pain group. The pain visual analog scale score had a statistically significant moderate negative correlation with the European Quality of Life-5 Dimensions index (r=-0.440, p=0.000) and European Quality of Life-5 Dimensions visual analog scale (r=-0.398, p=0.000) scores. The male gender was associated with a reduced risk of chronic pain, while poor sleep quality and number of comorbidities were associated with an increased risk of chronic pain (p=0.000, OR 0.20, p=0.021, OR 2.54, and p=0.010, OR 1.40, respectively).CONCLUSION:Chronic pain is common and independently associated with poor sleep quality, an increased number of diseases, and female gender. The results of our study may guide pain management in older individuals.

Analgesia in the Initial Management of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. The present systematic review and meta-analysis aims to compare the efficacy of different analgesic modalities trialled in AP. A systematic search of PubMed, MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science conducted up until June 2021, identified all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis was undertaken of the improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Across all modalities, the pooled VAS scores showed global improvement from baseline to day 2. Epidural analgesia appears to provide the greatest improvement in VAS within the first 24h but is equivalent to opiates by 48h. Within 24h, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting. There is remarkable paucity of level 1 evidence to guide pain management in AP with small datasets per study. Epidural administration appears effective within the first 24h of AP although infrequently used and featured in only a single RCT. NSAIDs are an effective opiate sparing alternative during the first 24h.

Analgesia within the Initial Management of Acute Pancreatitis: A Systematic Review and Meta-analysis of Randomised Controlled Trials

Introduction: The optimal analgesic strategy for patients with acute pancreatitis (AP) is unclear. The present systematic review and meta-analysis compares the efficacy of different analgesic modalities trialled in AP. Methods: A systematic search of PubMed, MEDLINE and EMBASE was conducted up until June 2021, identifying all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis performed for the primary outcome measure: improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. Results: Twelve RCTs including 542 patients were identified. Seven trial agents were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Pooled VAS scores improved globally across all modalities between baseline and day 2. Epidural analgesia appears to demonstrate greatest improvement in VAS within the first 24hrs, however at 48hrs it performed similarly to opiates. Within the first 24hrs, NSAIDs offered similar pain-relief to opiates. Placebo also performed comparably to other modalities within 24hrs however this effect subsequently plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting. Conclusions: There is remarkable paucity of level 1 evidence to guide pain management in AP despite its prevalence in acute takes, with relatively small datasets per study. Epidural administration may be most effective within the first 24hrs of AP. NSAIDs are an effective opiate sparing alternative during this same timeframe.

'Sufficient Pain relief ' as a Practical Benchmark in Cancer Pain Management: A Prospective Study of Serial Pain Scores, Patient-rated Pain Relief and Perceived Sufficiency of Analgesics.

Objectives:Serial pain scores are used to guide pain management but there can be variability in what constitutes ‘adequate’ pain relief for an individual patient. We aimed to evaluate how patient-rated sufficiency of pain relief corresponded to pain scores, pain relief scores, and the felt need for increasing analgesics.Material and Methods:Baseline and follow-up scores on the 11-point numerical rating scale (11-NRS) and verbal rating scale were obtained for116 patients with cancer pain. Patients used the pain relief sufficiency rating (PRSR) to rate pain relief as ‘no reduction,’ ‘some reduction, but not enough,’ ‘sufficient reduction,’ and ‘very good reduction.’ They also rated analgesics as ‘sufficient’ or ‘insufficient.’ Receiver-operating characteristic (ROC) curve analysis was used to compare PRSR responses with follow-up pain scores, patient rated percentage pain relief, and the perceived need for an increase in analgesics.Results:The 11-NRS had an area under the ROC curve of 94.2% against the PRSR. A pain score of three provided the best cutoff to identify adequate pain relief (88.2% sensitivity and 85.7% specificity). Follow-up verbal pain scores corresponded to PRSR categories (severe pain: no reduction; moderate pain: some reduction; mild pain: sufficient reduction and no pain: very good reduction). The PRSR identified 97.3% of patients who wanted analgesics increased and 85% of those who said pain medications were sufficient.Conclusion:The PRSR is a brief, simple and intuitive measure to elicit patient perceptions on the sufficiency of pain relief. Our findings suggest that it might be a useful tool in pain and symptom management.

P-P08 Towards effective analgesia in acute pancreatitis: a systematic review of randomised controlled trials

Abstract Background The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. The present systematic review and meta-analysis aims to compare the efficacy of several analgesic modalities trialled in AP. Methods A systematic search of PubMed, MEDLINE and EMBASE was conducted up until June 2021, according to PRISMA Guidelines to identify all randomised control trials (RCTs) comparing analgesic modalities in AP. The primary outcome measure was improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. Results Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), placebo, local anaesthetic, epidural, paracetamol and metamizole. A weighted single-arm effects estimate showed global improvement in VAS across all modalities from baseline to day 2. On visual inspection, epidural analgesia appears to provide the greatest improvement in pain scores within the first 24hrs, however at 48hrs it was comparable to opiates. Within the first 24hrs, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant heterogeneity in pain-relief reporting with relatively small datasets per study. Conclusions Given the incidence of AP there is remarkable paucity of level 1 evidence to guide pain management. Epidural administration is most effective analgesic modality within the first 24hrs of AP. NSAIDs are an effective opiate sparing alternative during the first 24hrs.

Serum biomarkers for chronic pancreatitis pain patterns

ObjectivesChronic pancreatitis (CP) is associated with debilitating refractory pain. Distinct subtypes of CP pain have been previously characterized based on severity (none, mild-moderate, severe) and temporal (none, intermittent, constant) nature of pain, but no mechanism-based tools are available to guide pain management. This exploratory study was designed to determine if potential pain biomarkers could be detected in patient serum and whether they associate with specific pain patterns. MethodsCytokines, chemokines, and peptides associated with nociception and pain were measured in legacy serum samples from CP patients (N = 99) enrolled in the North American Pancreatitis Studies. The unsupervised hierarchical cluster analysis was applied to cluster CP patients based on their biomarker profile. Classification and regression tree was used to assess whether these biomarkers can predict pain outcomes. ResultsThe hierarchical cluster analysis revealed a subset of patients with predominantly constant, mild-moderate pain exhibited elevated interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-2 (IL-2), tumor necrosis factor alpha (TNFα), and monocyte chemoattractant protein-1 (MCP1) whereas patients with higher interleukin-4 (IL-4), interleukin-8 (IL-8) and calcitonin gene related peptide (CGRP) were more likely to have severe pain. Interestingly, analyses of each individual biomarker revealed that patients with constant pain had reduced circulating TNFα and fractalkine. Patients with severe pain exhibited a significant reduction in TNFα as well as trends towards lower levels of IL-6 and substance P. DiscussionThe observations from this study indicate that unique pain experiences within the chronic pancreatitis population can be associated with distinct biochemical signatures. These data indicate that further hypothesis-driven analyses combining biochemical measurements and detailed pain phenotyping could be used to develop precision approaches for pain management in patients with chronic pancreatitis.

Pain management during a bromelain-based selective enzymatic debridement in paediatric and adult burn patients

BackgroundPain associated with surgical or enzymatic burn wound debridement prevents many burn centres from working outside an operating theatre, creating a burden. Alternatives for general anaesthesia to manage pain in burn patients treated with enzymatic debridements, such as regional anaesthesia, have not been studied in detail. This study explores the different possibilities for pain management during a bedside NexoBrid™ procedure. Material and methodsWe performed a single-centre retrospective study that included 82 paediatric, adolescent, and adult patients with deep dermal and full-thickness burns treated bedside with NexoBrid™ under regional or general anaesthesia. Outcome measures were pain during the NexoBrid™ procedure, the safety of the anaesthesia and the NexoBrid™ procedure, logistics of the bedside NexoBrid™ procedure, and time to wound closure. ResultsForty-three patients in the adult group (43/67, 64%) only presented with burn wounds on one upper or the one or two lower extremities. In 29 of them (29/43, 67%), a NexoBrid™ procedure was performed under regional anaesthesia, which resulted in low pain levels without any adverse events. All seven patients in the paediatric group, where only one upper or one or two lower limbs were involved (7/15, 47%), underwent a NexoBrid™ procedure performed under regional anaesthesia where no adverse events were reported. In these children, the use of regional anaesthesia was associated with a significant decrease in time to wound closure (average treatment effect on the treated = −22.5 days, p = 0.021). ConclusionThis study highlights that regional anaesthesia administered at the bedside should be the method of choice for pain management during NexoBrid™ procedures because often, it can be adequately and safely performed in all age groups. This approach will reduce the burden on operating theatres. A flow chart has been developed to guide pain management during a NexoBrid™ procedure.

PNS15 Cost-Effectiveness Analysis of Pharmacogenetic Testing in Opioid Analgesia in Pediatric Population Undergoing Surgery

For pediatric patients deemed ultra-rapid metabolizers (UMs), genetic variability in CYP2D6 increases codeine’s risk of respiratory depression and death. As the cost of pharmacogenomics (PGx) testing decreases and the sensitivity and specificity of PGx testing improves, pain management may benefit from greater PGx-testing adoption. The objective of this study is to determine the cost-effectiveness of PGx testing to guide short-term post-surgical codeine therapy in pediatric patients. We developed a TreeAge-based decision analytical model to compare opioid analgesia with and without PGx testing using a payer’s perspective. For PGx-guided opioid analgesia, we restricted the use of codeine to non-UMs only and considered alternative opioids among patients deemed UMs. We measured the effectiveness as (i) reduction in the hospital length of stay (LOS) due to opioid-induced adverse drug reactions (ADRs) related to the respiratory system, and (ii) averting respiratory depression, a severe opioid-induced ADR. Model parameters were taken from published literature. Compared to non-PGx testing, PGx testing resulted in approximately 0.0441 fewer LOS days with an incremental cost of $362, resulting in TreeAge reported incremental cost-effectiveness ratio (ICER) of $8,214. PGx testing also resulted in approximately 0.0055 fewer respiratory depression events with an incremental cost of $404 compared to non-PGx testing. The TreeAge reported ICER value was estimated at $73,177 to avert a severe respiratory depression event with PGx testing. The results were robust in probabilistic sensitivity analyses for LOS outcomes. However, for the respiratory depression outcome, 71.8% of iterations resulted in an ICER value exceeding the common $50,000 willingness to pay threshold. This analysis suggested that PGx guided opioid analgesia with codeine is a cost-effective strategy for pain management in pediatric patients. As the availability and cost of PGx testing improve, policymakers may want to reconsider the benefit of PGx guided pain management, including codeine.

Postoperative Pain After Mohs Micrographic Surgery is Well Tolerated Regardless of Psychological and Pain-Related Comorbidities.

Preoperative patient screening has been evaluated in many surgical specialties as a way to improve the overall patient experience. Current data are limited regarding patient screening for dermatologic procedures. The goal of preoperative screening is to identify patients at risk for poor outcomes and tailor the treatment plan to ensure a greater overall patient experience. To investigate the association between psychological comorbidities and acute postoperative pain in patients treated with Mohs micrographic surgery (MMS). Subjects were recruited from a single center, single provider, uniformed service MMS practice, and asked to complete preoperative and postoperative questionnaires for scheduled MMS. Outcome variables included anticipated pain, actual pain after MMS, duration of pain, and medications used for pain. Mohs micrographic surgery was well tolerated. There were no significant differences in anticipated or reported pain, or in medication use between cohorts. Significant differences in pain were noted with closure technique with complex surgical repairs generating the greatest pain across groups. Mohs micrographic surgery is well tolerated by patients, both with and without psychological comorbidities. Our results show no statistically significant differences, suggesting a limited role for preoperative screening as a tool to guide pain management after MMS.

Genomics testing and personalized medicine in the preoperative setting: Can it change outcomes in postoperative pain management?

Postoperative pain and opioid use are major challenges in perioperative medicine. Pain perception and its response to opioid use are multi-faceted and include pharmacological, psychological, and genetic components. Precision medicine is a unique approach to individualized health care in which decisions in management are based on genetics, lifestyle, and environment of each person. Genetic variations can have an impact on the perception of pain and response to treatment. This can have an effect on pain management in both acute and chronic settings. Although there is currently not enough evidence for making recommendations about genetic testing to guide pain management in the acute care setting, there are some known polymorphisms that play a role in surgical pain and opioid-related postoperative adverse outcomes. In this review, we describe the potential use of pharmacogenomics (PGx) for improving perioperative pain management. We first review a number of genotypes that have shown correlations with pain and opioid use and then describe the importance of PGx-guided analgesic protocols and implementation of screening in a preoperative evaluation clinical setting.

Pain assessment and interventions by nurses in the emergency department: A national survey.

The aim of this study was to examine the knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses. Pain is the most commonly reported symptom in patients presenting to the emergency department, with over half rating their pain as moderate-to-severe. Patients unable to communicate, such as critically ill intubated patients, are at greater risk of inadequate pain management. This cross-sectional exploratory study used survey methodology to explore knowledge, perceptions and factors influencing pain management practices among Australian emergency nurses. Australian emergency nurses were invited to complete an online survey comprising 91 items. The response rate was 450 of 1,488 (30.2%). STROBE guidelines were used in reporting this study. Variations in level of acute pain management knowledge, especially in older, cognitively impaired or mechanically ventilated patients were identified. Poor interprofessional communication, workload and staffing negatively impacted on nurses' intention to administer analgesia. For intubated patients, validated observation pain assessment instruments were rarely used, although respondents recognised the importance of pain management in critically ill patients. Emergency nurses recognise the importance of pain relief. The ability to nurse-initiate analgesia, education and training in pain management education is variable. Little education is provided on assessing and managing acute pain in elderly, cognitively impaired or mechanically ventilated patients. Use of validated pain assessment instruments to assess pain in critically ill patients is poor. While pain management is the responsibility of all healthcare professionals, in the emergency department, it is a core role of emergency nursing. This study highlights the variation in ability to nurse-initiate analgesia, level of acute pain knowledge, education and training, and use of validated pain assessment instruments to guide pain management in critically ill intubated patients.

Role of Radiology in Image Guided Pain Management

Abstract not available
 Journal of Current and Advance Medical Research 2019;6(1):1

Treatment of Low Back Pain With Opioids and Nonpharmacologic Treatment Modalities for Army Veterans.

In the Veterans Health Administration (VHA) there is growing interest in the use of nonpharmacologic treatment (NPT) for low back pain (LBP) as pain intensity and interference do not decrease with opioid use. To describe overall and facility-level variation in the extent to which specific NPT modalities are used in VHA for LBP, either alone or as adjuncts to opioid medications, and to understand associations between veterans' clinical and demographic characteristics and type of treatment. This retrospective cohort study examined use of opioids and 21 specific NPT modalities used by veterans. VHA-enrolled Iraq and Afghanistan veterans who utilized care in ("linked" to) 130 VHA facilities within 12 months after their separation from the Army between fiscal years 2008-2011, and who were diagnosed with LBP within 12 months after linkage (n=49,885). Measures included per patient: days' supply of opioids, number of visits for NPT modalities, and pain scores within one year after a LBP diagnosis. Thirty-four percent of veterans filled a prescription for opioids, 35% utilized at least 1 NPT modality, and 15% used both within the same year. Most patients with LBP receiving NPT, on average, had moderate pain (36%), followed by low pain (27%), severe pain (15%), and no pain (11%). Eleven percent had no pain scores recorded. About 65% of VHA patients with a LBP diagnosis did not receive NPT, and about 43% of NPT users also were prescribed an opioid. Understanding utilization patterns and their relationship with patient characteristics can guide pain management decisions and future study.

Patient Factors Associated With Prolonged Postoperative Opioid Use After Total Knee Arthroplasty

BackgroundPain persists in a moderate proportion of patients after total knee arthroplasty (TKA). Identifying patient factors that are associated with persistent pain may lead to improved care. PurposeThe purpose of the study was to identify preoperative factors associated with increased opioid prescriptions after TKA. MethodsA retrospective cohort study of TKAs in an integrated health-care system (January 2008-December 2011) was conducted. The number of opioid prescriptions per 90-day period after TKA (up to 1 year), was the outcome of interest. Patient risk factors that were evaluated included demographics, pain prescriptions, comorbidities, and chronic pain conditions. Multivariable Poisson regression models were employed. ResultsThe median age for 23,726 patients was 67 years. Before surgery, 60.0% used opioids. Three months after surgery, 41.2% of patients continued using opioids. Factors associated with greater opioid use included: younger age (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.82-0.84 per 10-year increase), liver disease (OR = 1.11, 95% CI 1.06-1.16), preoperative nonsteroidal anti-inflammatory drug use (OR = 1.09, 95% CI 1.07-1.10), anxiety (OR = 1.05, 95% CI 1.03-1.08), substance abuse (OR = 1.03, 95% CI 1.00-1.06), diabetes mellitus (OR = 1.03, 95% CI 1.01-1.05), preoperative opioid use (OR = 1.04, 95% CI 1.04-1.04), back pain (OR = 1.23, 95% CI 1.18-1.127), congestive heart failure (OR = 1.16, 95% CI 1.06-1.27), depression (OR = 1.14, 95% CI 1.09-1.18), fibromyalgia (OR = 1.10, 95% CI 1.02-1.18), hypertension (OR = 1.06, 95% CI 1.02-1.10), nonspecific chronic pain (OR = 1.06, 95% CI 1.02-1.10), black race (OR = 1.17, 95% CI 1.12-1.23), and chronic lung disease (OR = 1.05, 95% CI 1.01-1.10). ConclusionSeveral preoperative factors were associated with prolonged opioid use after TKA, and their identification can assist providers guide pain management. Avoidance or weaning of preoperative opioids should be considered.

Pharmacogenetics of Opioid Use and Implications for Pain Management.

Opioid analgesics are frequently prescribed to manage acute and chronic pain, but individual differences in opioid response make effective pain control in all patients an elusive goal. Furthermore, the risk of addiction following opioid consumption varies among individual patients. Although many psychosocial factors contribute to an individual's opioid response and risk for addiction, a strong genetic component has also been demonstrated. Opioids undergo substantial enzymatic modification that can generate metabolites with either increased or decreased opioid activity relative to the parent compound. To elicit their analgesic effect, parent compounds and active metabolites must be transported into the central nervous system where they bind to opioid receptors and inhibit neurotransmission. Inherited genetic variants that alter the function of proteins involved in these processes have been associated with differences in opioid response and risk for addiction. Detection of these variants can help guide opioid selection, inform dosing decisions, or encourage use of a nonopioid analgesic. Whereas some genetic variants are clearly associated with differences in opioid response and have been included in consensus clinical practice guidelines, the impact of other variants on opioid response remains unclear. Studies performed to date have generated promising results, but inconsistent findings, reimbursement challenges, and the lack of robust decision support tools have hampered widespread adoption of pharmacogenetic testing to guide pain management treatment decisions. Future work involving the simultaneous evaluation of large numbers of variants and demonstration of a clear clinical benefit provided by pharmacogenetic testing will be required to overcome these obstacles.

Advanced dementia pain management protocols

Pain management in advanced dementia is complex because of neurological deficits present in these patients, and nurses are directly responsible for providing interventions for the evaluation, management and relief of pain for people suffering from this health problem. In order to facilitate and help decision-makers, pain experts recommend the use of standardised protocols to guide pain management, but in Spain, comprehensive pain management protocols have not yet been developed for advanced dementia.This article reflects the need for an integrated management of pain in advanced dementia. From the review and analysis of the most current and relevant studies in the literature, we performed an approximation of the scales for the determination of pain in these patients, with the observational scale PAINAD being the most recommended for the hospital setting. In addition, we provide an overview for comprehensive management of pain in advanced dementia through the conceptual framework “a hierarchy of pain assessment techniques by McCaffery and Pasero” for the development and implementation of standardised protocols, including a four-phase cyclical process (evaluation, planning/performance, revaluation and recording), which can facilitate the correct management of pain in these patients.