History Of Chronic Pain Research Articles

Mother-reported pain experience between ages 7 and 10: A prospective study in a population-based birth cohort.

Trajectory studies suggest considerable stability of persistent or recurrent pain in adolescence. This points to the first decade of life as an important aetiologic window for shaping future pain, where the potential for prevention may be optimised. We aimed to quantify changes in mother-reported pain experience in children between ages 7 and 10 and describe clusters of different pain experiences defined by complementary pain features. We conducted a prospective study using data from 4036 Generation XXI birth cohort participants recruited in 2005-06. Pain history was reported by mothers at ages 7 and 10 using the Luebeck pain screening questionnaire. We tracked changes in six pain features over time using relative risks (RRs) and their 95% confidence intervals (95% CIs). Clusters were obtained using the k-medoids algorithm. The risk of severe pain at age 10 increased with increasing severity at age 7, with RRs ranging from 2.18 (95% CI 1.90, 2.50) for multisite to 4.43 (95% CI 3.19, 6.15) for high frequency pain at age 7. A majority of children (59.4%) had transient or no pain but two clusters included children with stable recurrent pain (n=404, 10.2% of the sample). One of those (n=177) was characterised by higher probabilities of multisite pain (74.6% and 66.7% at ages 7 and 10, respectively), with psychosocial triggers/contexts (59.3% and 61.0%) and daily-living restrictions (72.2% and 84.6%). Most children in that cluster (58.3%) also self-reported recent pain at age 10 and had more frequent family history of chronic pain (60.5%). All pain features assessed tracked with a positive gradient between ages 7 and 10, arguing for the significance of the first decade of life in the escalation of the pain experience. Multisite pain and psychosocial attributions appeared to be early markers of more adverse pain experiences.

Characteristics and circumstances of death related to buprenorphine toxicity in Australia

BackgroundBuprenorphine is a semi-synthetic opioid used in the treatment of opioid dependence and chronic pain. The current study aimed to determine the characteristics and circumstances of all recorded cases of buprenorphine-related toxicity death in Australia; determine toxicology and organ pathology; and compare these profiles to cases of death due to buprenorphine-related traumatic injury. MethodsAll cases of buprenorphine-related drug toxicity death were retrieved from the National Coronial Information System (2000–2019), as were all cases of buprenorphine-related traumatic injury. Information was collected on cause of death, case characteristics, toxicology and major organ pathology. ResultsA total of 314 cases of drug toxicity and 55 of traumatic injury were identified. Toxicity cases were significantly older (40.5 v 36.1 years), more likely to have a history of chronic pain (OR 2.95), less likely to have a history of injecting drug use (OR 0.09), but more likely to have injected buprenorphine proximal to death (OR 4.90). There were no group differences in buprenorphine or norbuprenorphine toxicology. Toxicity cases were more likely to have hypnosedatives (OR 2.08) and other opioids (OR 4.69) present, but less likely to have psychostimulants (OR 0.26) and THC (OR 0.45). Toxicity cases were more likely to be obese (OR 4.05), have pre-existing cardiovascular disease (OR 4.02) and heavier hearts (412.1 v 355.2 g). ConclusionsBuprenorphine-related toxicity death cases differed from trauma deaths in their characteristics, toxicology and disease. Fatal buprenorphine toxicity is associated with older age, concurrent use of depressants and cardiovascular disease.

Gender, Race, Insurance, and Pain: The Influence of Patient Sociodemographics on Postoperative Prescribing Patterns Among Hand Surgeons

PURPOSE: Social and demographic factors may influence patient treatment by physicians. This study analyzes the influence of patient sociodemographics on prescription practices among hand surgeons. METHODS: We performed a retrospective analysis of all hand surgeries at a single level 1 academic medical center from January 2016 to September 2018. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and then classified by age, race, gender, type of insurance, and history of substance use or chronic pain. Multivariate linear regression was used to compare MME among groups. RESULTS: Overall, patients with a history of substance abuse were prescribed 31.2 MME more than those without (P < 0.0001), and patients with a history of chronic pain were prescribed 36.7 more than those without (P < 0.0001). After adjusting for these variables and the type of procedure performed, women were prescribed 11.2 MME less than men (P = 0.0048) and Hispanics were prescribed 16.6 MME more than Caucasians (P = 0.0091) overall. Both Hispanic and black patients were also prescribed more than Caucasians following carpal tunnel release (19.0 and 20.0 MME, respectively; P < 0.001). Patients with private insurance were prescribed 24.5 MME more than those with Medicare (P < 0.0001) but 25.0 MME less than Medicaid (P < 0.0001). There were no differences across age groups. CONCLUSIONS: Numerous sociodemographic factors influenced postoperative opioid prescription among hand surgeons. Among other factors, the role of implicit biases and insurance reimbursement may be important considerations in order to avoid the over- or undertreatment of pain in certain patient populations.

Reliability and Validity Evidence of the STarT-Lower Extremity Screening Tool for Patients With Lower Extremity Fracture: A Prospective Study

ObjectivesTo determine whether a modified version of the STarT Back Screening Tool in its current structure has adequate properties for use in patients with lower extremity fracture. DesignSingle-center, prospective study. SettingLevel I trauma center. ParticipantsPatients with lower extremity fracture without a history of chronic pain (N=114), with 93% follow-up. InterventionsNot applicable. Main Outcome MeasuresSix weeks after surgical fixation, individuals completed the Subgroups for Targeted Treatment of Lower Extremity Screening Tool (STarT-LE). A subsample completed the STarT-LE again 1 week later. The following questionnaires were completed at 6 weeks and 6 months: Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Brief Pain Inventory pain intensity subscale, and PROMIS Depression and Pain Interference computer adaptive testing modules. Reliability was evaluated using intraclass correlation coefficients (ICC) and Cronbach’s alpha (α). Convergent validity evidence was measured concurrently using the Spearman ρ correlation between the 6-week STarT-LE and established questionnaires. Predictive validity evidence was evaluated by area under the curve analysis (AUC) using the 6-week STarT-LE total and psychosocial scores and 6-month criterion physical and psychosocial reference standards. ResultsThe STarT-LE has good test-retest reliability (ICC, 0.85; 95% confidence interval, 0.78-0.91) and acceptable internal consistency (α=0.74). The convergent validity evidence was fair to moderate (ρ, 0.53-0.68; P<.001) and the predictive validity evidence was acceptable to excellent (AUC, 0.73-0.84). ConclusionsThe STarT-LE has adequate properties for use in patients with lower extremity fracture. Future larger scale studies are needed to validate risk cutoffs.

S3439 Not All That Bleeds Is of Gastrointestinal Origin: Hemorrhagic Anemia From the Nasopharynx

INTRODUCTION: There is a vast differential diagnosis as to the underlying etiology for acute blood loss anemia, and gastrointestinal hemorrhage is often the culprit. When signs and symptoms are unclear and initial routine endoscopy is unremarkable, capsule endoscopy can be a beneficial test to better ascertain the location of the bleed. While capsule endoscopy is often utilized to identify occult gastrointestinal bleeding, it can also pinpoint alternative etiologies to blood loss. This case highlights the importance of maintaining a broad differential when approaching acute blood loss anemia. CASE DESCRIPTION/METHODS: A 62-year-old female with a history of chronic pain on daily non-steroidal anti-inflammatory medication presented to the emergency room with weakness and malaise. Initial hemoglobin was 3.4 g/dL, down-trending to 2.8 g/dL with concern for acute blood loss. Further studies revealed iron deficiency anemia with an iron level less than 15 and a ferritin of 12.6; occult blood testing was negative. Esophagogastroduodenoscopy demonstrated a hiatal hernia, Schatzki’s ring, and poor dentition with loose teeth, but no active bleed was identified. Colonoscopy showed mild sigmoid diverticulosis and distal colitis, however no bleeding was located to account for the patient’s profound anemia. Capsule endoscopy revealed an active bleed from the mouth (Figure A) with bright red blood in the esophagus and stomach along with dark blood in the small intestine without active bleed. These findings suggested acute blood loss from hemorrhagic gingivitis versus traumatized gingiva around the teeth. Computed tomography of the neck with contrast identified an ulcerated malignancy occluding the nasopharyngeal airway. Positron emission tomography confirmed the large nasopharyngeal mass without distant metastatic disease (Figure B), and subsequent biopsy revealed a non-keratinizing squamous cell carcinoma secondary to human papillomavirus sixteen (Figure C). Though deemed a poor surgical candidate, the patient underwent chemoradiation and was eventually discharged to a skilled nursing facility and continues to do well several months later. DISCUSSION: This case reveals the importance of maintaining a broad differential diagnosis as to the underlying etiology for acute blood loss anemia, especially when initial suspected gastrointestinal hemorrhage workup is unremarkable. Capsule endoscopy is a useful tool in the evaluation of anemia when upper and lower endoscopy do not reveal the underlying etiology for anemia.Figure 1.: Capsule endoscopy identifying the underlying mass accounting for the hemorrhage.Figure 2.: Positron emission tomography highlighting the nasopharyngeal mass.Figure 3.: H&E of the non-keratinizing squamous cell carcinoma at 200 magnification.

S2722 Abernethy Malformation Causing Recurrent Hepatic Encephalopathy

INTRODUCTION: Hepatic encephalopathy (HE) is a spectrum of neuropsychiatric abnormalities in patients with underlying liver dysfunction such as acute liver failure (type A) or cirrhosis (type C). Less commonly, it involves patients with acquired or congenital portosystemic shunt (PSS) in the absence of hepatocellular disease (type B). CASE DESCRIPTION/METHODS: A 70-year-old female with a past medical history of chronic pain, CHF, lymphedema and prior recurrent encephalopathy, presented with altered mental status and seizure-like activity. Vital signs were stable and laboratory studies including CBC, BMP and LFTs were normal except for an ammonia level of 272 umol/L. She denied any prior history of liver disease and was previously informed that the hyperammonemia was secondary to her use of narcotics for chronic pain. CT chest and abdomen was obtained which revealed normal appearing liver, prominent azygos vein and side-to-side porto-azygos shunt (Figures 1 and 2). A liver US indicated normal echotexture with patent vasculature. Liver biopsy showed normal portal triads with mild steatosis and minimal sinusoidal dilatation. She was treated with lactulose until resolution of HE and was eventually discharged. Given the absence of liver disease, the PSS likely represent a congenital malformation that has been perpetuating the HE. DISCUSSION: In the presence of a PSS, underlying liver disease should be excluded to ensure the etiology of the shunt is not a result of portal hypertension. Congenital PSS were first described in 1793 by J. Abernethy and are classified as type 1 which involves an end-to-side porto-caval shunt with absence of the portal vein (PV), and type 2 which consists in a side-to-side shunt with an intact PV. Congenital PSS may also be associated with other abnormalities including biliary atresia, polysplenia, in addition to cardiac, skeletal and renal malformations. HE, which occurs as a complication of the shunt bypassing the hepatic conversion of ammonia to urea, is the most common neurologic complication. In addition, acquired cardiopulmonary complications are also common due to volume overload. Patients with symptomatic congenital PSS should be considered for PSS closure, whether endovascular or surgical. In patients with type 2 shunt, obliteration of the PSS can reverse HE from hyperammonemia and potentially resolve heart failure and hepatopulmonary syndrome but rarely causes regression of pulmonary hypertension. Acute portal hypertension as well as thrombosis have been reported after closure.Figure 1.: Prominent Azygos vein on coronal view.Figure 2.: Side to side portal to azygos vein shunt.

ELIMINATING PATIENT CONTROLLED ANALGESIA REDUCES OPIOID USE IN RENAL TRANSPLANT RECIPIENTS

Introduction: Six percent of opioid-naïve patients develop opioid dependence post-operatively. Renal transplant recipients who fill opioid prescriptions for more than 90 days post-operatively are at increased risk for graft failure and death. We implemented a protocol in our renal transplant recipients that eliminated opioid patient-controlled analgesia (PCA) and included a multi-modal non-opioid regimen. The purpose of this study was to examine the impact of PCA elimination on opioid requirements at discharge in renal transplant recipients. Materials and Methods: We reviewed adult renal transplant recipients for the three months prior to, and following, implementation of the protocol. Patients with an intra-abdominal transplant, a simultaneous pancreas-renal transplant, or a history of chronic pain were excluded. The number of opioid pills prescribed on the day prior to discharge were categorized as A) 0, B) 1-3, and C) 4. Discharge opioid prescriptions were then evaluated based on a recent recommendation that group A receive 0 pills, group B 15 pills, and group C 30 pills, to satisfy the outpatient pain needs of 85% of patients. Pre- and post- metrics were compared using independent t-tests and Chi squared tests. Results and Discussion: 150 recipients were included (79 pre-intervention, 71 post; 51% male).PCA use decreased significantly (95.8% vs. 19%, p<0.001). PCAs were associated with increased OMEs prescribed at discharge (84.3 vs. 68.5, p=0.14). Post-intervention, gabapentin, topical lidocaine, and acetaminophen increased significantly (7% to 73%, 6% to 68%, 72% to 94%, respectively).Of patients requiring no opioids on the day prior to discharge, 51.5% of pre- and 35.5% of post- were prescribed excess opioids at discharge.Of patients prescribed 1-3 pills on the day prior to discharge, 24.2% of pre- and 25.8% of post patients were prescribed excessive opioids at discharge.Conclusion: A multidisciplinary approach to developing an opioid-reducing protocol significantly decreased the use of PCAs and increased the use of non-opioid adjunct medications in renal transplant recipients. Eliminating PCAs trended towards a decreased amount of opioids prescribed at discharge. Excess opioids at discharge remains a problem. While we implemented a systems-based intervention to eliminate inpatient PCA prescription, we failed to adequately communicate the ultimate goal of decreasing opioids prescribed at discharge. Changing prescriber behavior requires specific interventions targeting all the metrics of interest. Following this study, we sought to protocolize both inpatient and discharge opioid prescribing wherein all patients, regardless of how many opioids received while inpatient, receive 10 opioid pills at discharge. After a three-month pilot, we plan to analyze the number of refills needed to evaluate whether this opioid-sparing approach at discharge leads to sufficient pain control in the short post-operative term. Transplant surgery nursing staff, pharmacists, and clinical providers.

T regulatory cells and TGF-β1: Predictors of the host response in mesh complications

Polypropylene mesh is frequently used in urogynecology procedures; however, pain and mesh exposure into the vagina occur in ~10% of cases. Mesh-induced pain, which occurs with or without exposure, persists after removal in 50% of cases. Chronic pain history predicts poor response to mesh removal but only a fraction have this diagnosis. We hypothesize that mesh induced pain is correlated with fibrosis and failure to improve with a heightened inflammatory and fibrotic host response. Women undergoing mesh removal were offered participation in a mesh biorepository. Standardized questionnaires including visual analog scale (VAS) pelvic pain scores were completed at enrollment and 6 months after removal. Responders were considered those with ≥13 mm VAS improvement. 30 mesh-tissue explants were randomly selected for analysis. Samples were labeled for CD8, CD4 (Th) and FoxP3 (Tregs). Peri-fiber collagen deposition (fibrosis) was measured using a customized semi-quantitative assay. Concentrations of TGF-b1, bFGF, MCP-1, PDGF-BB, and IGFBP-1 in tissue were determined by immunoassay and compared to vaginal control biopsies with pathway analysis. VAS pain scores were correlated with degree of histologic fibrosis. Responders had more Tregs (7.8 vs 0.3 per mm2, p = 0.036) and patients were 1.6 times as likely to be a responder for every additional Treg/mm2 (p = 0.05). Pro-fibrotic TGF-β1 was doubled in nonresponders (p = 0.032). On pathway analysis, decreased bFGF and increased PDGF-BB provide a possible mechanism for upregulation of TGF-β1. In conclusion, fibrosis is a plausible mechanism of pain complications and the adaptive immune response likely contributes to mitigation/prevention of complications and recovery in affected patients. Statement of SignificancePolypropylene mesh improves anatomical outcomes in urogynecologic procedures, but is associated with complications, including pain and exposure through the vaginal epithelium. Mesh-induced pain is difficult to treat, and it is unclear why only half of women experience pain improvement after mesh removal. In this study, patient pain correlated with the presence of fibrosis and women with more T regulatory cells and lower TGF-β1 were more likely to have pain improvement following mesh removal. These findings implicate fibrosis as a mechanism of pain complications and suggest that the adaptive immune response may be responsible for prevention of complication and recovery. This improved understanding of how mesh can lead to pain moves us closer to the ultimate goal of preventing mesh complications.

Patient and procedural risk factors for increased postoperative pain after cesarean delivery under neuraxial anesthesia: a retrospective study

BackgroundThere is significant interindividual variability in pain experienced after cesarean delivery. The goal of this study was to identify risk factors for increased postoperative pain in women undergoing cesarean delivery under neuraxial anesthesia with neuraxial morphine. MethodsA retrospective chart review was conducted (June 1, 2013 to August 25, 2015). Patients were categorized into three groups, according to the weighted area-under-the-curve (AUC) of pain scores within 48 h of surgery, as mild (weighted AUC 0–3), moderate (4–6) or severe (7–10) pain. We evaluated potential factors that could influence variability in pain, including patient demographics, comorbidities, obstetric history, and surgical details. ResultsA total of 1899 patients were included in the analysis. Pain was mild in 896 patients, moderate in 895, and severe in 108 patients. In the multivariable analysis, the following factors were associated with increased pain severity: history of chronic pain (OR 4.12, 95% CI 1.15 to 14.75]), current tobacco use (2.52, 1.17 to 5.44), pre-existing anxiety (1.93, 1.21 to 3.07), receipt of intra-operative intravenous ketamine or fentanyl (1.56, 1.21 to 2.01), and repeat cesarean delivery (1.54, 1.18 to 2.02). Being of non-Black race and having private health insurance were associated with lower pain severity (OR 0.44, 95% CI 0.31 to 0.62 and 0.51, 0.39 to 0.68, respectively). The overall accuracy of the model was 56%. ConclusionsCertain patient and procedural factors were associated with higher levels of reported postoperative pain. Patients with those factors may require a more targeted analgesic strategy for post-cesarean delivery pain control.

Can Prescription Drug Use Disorder Predict Suicidality in US Adults With Chronic Pain? A Pilot Study Based on Collaborative Psychiatric Epidemiological Surveys.

Individuals with chronic pain are at higher risk for suicide than other populations, and their potential for prescription drug use disorder (PDUD) enormously exists. This study aimed to estimate the prevalence and correlates of suicidality and to determine its relation to PDUD, among US adults with a history of chronic pain. Data were obtained from the Collaborative Psychiatric Epidemiology Surveys (2001-2003). This analysis was limited to respondents who had a history of chronic pain (N = 5301). Logistic regression was used to determine the association between suicidality and prescription drug use disorder among those populations. Among study respondents, there was a strong positive association between PDUD and suicidal ideation and attempts (P value < 0.001, = 0.006, respectively). Adjusted logistic regression analysis showed those with PDUD had 1.5 times greater likelihood of suicidal ideation (95% CI 1.2-1.8). Among respondents with a history of chronic pain and PDUD, Non-Hispanic Whites, female gender, lifetime mood and/or anxiety, and substance use disorders were associated with increased suicide risk (P value = 0.020, = 0.011, < 0.001, < 0.001, respectively). There is a robust relationship between PDUD and suicidality in US adults with a history of chronic pain. Ethnicity, gender, and comorbid mood, anxiety or substance use disorders can predict suicidality among individuals with both chronic pain and PDUD. Longitudinal studies need to investigate the causal relationship between PDUD and suicidality among those populations.

Tu1085 POST-OPERATIVE CROHN'S DISEASE PATIENTS UNDERGOING COLONOSCOPY REQUIRE SIGNIFICANTLY MORE ANALGESIA & SEDATION COMPARED TO A NON-IBD POST-OPERATIVE POPULATION

Rates of surgical intervention in Crohn’s disease have declined. However, a significant proportion of patients still require surgical resection and have been shown to have higher post-op pain scores and analgesia requirements. The aim of this study was to assess sedation requirements and comfort scores of post-operative Crohn’s disease patients at endoscopy. Patients with a previous intestinal resection undergoing colonoscopy 2014-2017 were identified via an electronic reporting system. Data regarding patient & disease characteristics, sedation requirements, Gloucester comfort scores and endoscopy reports were collected.Crohn’s disease patients with prior intestinal resection were compared to a non-IBD population post-intestinal resection. 212 patients were included. n=66 Crohn’s disease, n=2 UC and n=144 non-IBD patients underwent colonoscopy. Patient characteristics described in Table 1. 10.8% of patients had a documented history of chronic pain, hysterectomy or other relevant conditions that may affect comfort scores. 53% of patients with Crohn’s disease were on active treatment for IBD at the time of endoscopy. The median dose of midazolam administered was 3mg (IQR 2.12-4mg); median fentanyl dose was 50mcg. (IQR 50-75mcg).Significantly more midazolam was used in 2014 compared to procedures performed in 2016-17. (median 4mg vs 3mg; p=0.014). The median dose of Midazolam given was significantly higher in patients with Crohn’s disease (3mg IQR 3-5mg vs 3mg IQR 2-4; p=0.009).The median dose of fentanyl required was significantly higher in post-operative Crohn’s disease patients. (75mcg IQR 50-100mcg vs 50mcg ; p=0.001). The median comfort score in the Crohn’s disease patients was higher (indicating more discomfort) when compared to the non-IBD cohort. (median score 2 & 1 respectively) There was no significant difference in the proportion of patients with chronic pain etc or with multiple intestinal resections. (p=0.5 and p=0.41). There was a statistically significant difference in comfort scores with only n=25 Crohn’s disease patients (37.9%) having comfort score 1 when compared to n=79 non-IBD patients (55%) (p=0.04). Post-op Crohn’s disease patients with significant active endoscopic disease required significantly higher doses of midazolam compared to those patients with quiescent disease.(4mg IQR 3-5mg vs 3mg IQR 2.5-4mg;p=0.038) There was a trend towards significance in fentanyl dose. (75mcg IQR 50-100mcg vs 50mcg IQR 50-100mcg;p=0.06) Patients with Crohn’s disease undergoing colonoscopy in the post-operative setting have significantly higher analgesia requirements. Comfort scores are significantly worse when compared to non-IBD patients who have had similar intestinal resections. Endoscopists should use techniques e.g. CO2 insufflation, in addition to medication to ensure comfort amongst patients with Crohn’s disease.

Prevalence of postmastectomy pain syndrome and associated risk factors: A large single-institution cohort study.

Postmastectomy pain syndrome (PMPS) is a frequent complication of breast surgery, and is considered a chronic neuropathic pain in the side of surgery which persists more than 3 months. We conducted a retrospective analysis of the largest reported cohort to investigate the prevalence of PMPS and to analyze its associated risk factors as well as the influence on quality of life (QoL). Two thousand thirty-three surgically-treated female patients diagnosed between 2012 and 2017 with early-stage breast cancer were asked to complete a questionnaire survey about their current chronic neuropathic pain problems and quality of life. Multivariate logistic regression analyses were applied to determine the associated risk factors of PMPS. Results have shown that 1983 (97.5%) patients responded and completed a questionnaire survey. Among them, PMPS was found in 28.2% of patients. In univariate analysis, age≤35 years, tumor staging, history of chronic pain, total mastectomy, and axillary lymph node dissection (ALND) were significantly correlated with PMPS (P < .05). Multivariate analysis showed that age≤35 years, history of chronic pain, total mastectomy, and ALND were the independent risk factors of PMPS. QoL outcomes have shown that the global QoL score, physical function score, role function score, and social function score in the PMPS group were reduced in the PMPS group (P < .05), while the difference in emotional function score and cognitive function score showed no statistical significance (P > .05). Besides, patients with PMPS have worse body image, sexual enjoyment, and more breast symptoms. In conclusion, PMPS is linked with a high incidence among breast cancer patients, and has a considerable negative influence on the quality of life. In addition, age, total mastectomy, ALND, and history of chronic pain are the independent risk factors of PMPS.

Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in NCAA Division I Athletes: Experience at a Single Institution.

Background:The rate of return to sport after surgical treatment of femoroacetabular impingement (FAI) syndrome (FAIS) has been studied in high-level athletes. However, few studies examining this rate have focused exclusively on National Collegiate Athletic Association (NCAA) Division I athletes.Purpose:To evaluate the return-to-sport rate after hip arthroscopy for FAIS and to examine the influence of sport type on the clinical presentation of FAIS in collegiate athletes.Study Design:Case series; Level of evidence, 4.Methods:Included in this study were NCAA Division I student-athletes who underwent hip arthroscopy for FAIS at our institution between 2010 and 2017. Exclusion criteria were history of previous hip pathology, pediatric hip disease, radiographic evidence of osteoarthritis (Tönnis grade >0), prior lower extremity procedure, history of chronic pain, osteoporosis, or history of systemic inflammatory disease. Athletes were categorized into 6 subgroups based on the type of sport (cutting, contact, endurance, impingement, asymmetric/overhead, and flexibility) by using a previously reported classification system. Patient characteristics and preoperative, intraoperative, and return-to-sport variables were compared among sport types.Results:A total of 49 hip arthroscopies for FAIS were performed in 39 collegiate athletes (10 females, 29 males; mean age, 19.5 ± 1.3 years). A total of 1 (2.6%) cutting athlete, 15 (38.5%) contact athletes, 8 (20.5%) impingement athletes, 6 (15.4%) asymmetric/overhead athletes, and 9 (23.1%) endurance athletes were included in the study. There were no differences among sports groups with respect to the FAI type. Endurance athletes had lower rates of femoral osteochondroplasty (45.5%) and labral debridement (0.0%) (P < .0001). Contact sport athletes had higher rates of labral debridement (50.0%; P < .0001). Patients were evaluated for return to sport at an average of 1.96 ± 0.94 years. Overall, the return-to-sport rate was 89.7%. There were no differences in return-to-sport rates based on the sport type except for endurance athletes, who returned at a lower rate (66.6%; P < .001). No differences in return-to-sport rate (P = .411), duration after return (P = .265), or highest attempted level of sport resumed (P = .625) were found between patients who underwent labral repair versus debridement.Conclusion:Collegiate-level athletes who underwent hip arthroscopy for FAIS returned to sport at high and predictable rates, with endurance athletes possibly returning to sport at lower rates than all other sport types. Surgical procedures may be influenced by sport type, but the rate of return to sport between athletes who underwent labral debridement versus labral repair was similar.

Protective and Risk Factors for Phantom Limb Pain and Residual Limb Pain Severity.

The exact mechanisms underlying the development and maintenance of phantom limb pain (PLP) are still unclear. This study aimed to identify the factors affecting pain intensity in patients with chronic, lower limb, traumatic PLP. This is a cross-sectional analysis of patients with PLP. We assessed amputation-related and pain-related clinical and demographic variables. We used univariate and multivariate models to evaluate the associated factors modulating PLP and residual limb pain (RLP) intensity. We included 71 unilateral traumatic lower limb amputees. Results showed that (1) amputation-related perceptions were experienced by a large majority of the patients with chronic PLP (sensations: 90.1%, n=64; residual pain: 81.7%, n=58); (2) PLP intensity has 2 significant protective factors (phantom limb movement and having effective treatment for PLP previously) and 2 significant risk factors (phantom limb sensation intensity and age); and (3) on the other hand, for RLP, risk factors are different: presence of pain before amputation and level of amputation (in addition to the same protective factors). These results suggest different neurobiological mechanisms to explain PLP and RLP intensity. While PLP risk factors seem to be related to maladaptive plasticity, since phantom sensation and older age are associated with more pain, RLP risk factors seem to have components leading to neuropathic pain, such as the amount of neural lesion and previous history of chronic pain. Interestingly, the phantom movement appears to be protective for both phenomena.

Is Naloxone use in Southeast Alabama Rising? Evaluation of Naloxone Administration in an Emergency Department Setting

BackgroundFatalities caused by drug‐overdose have increased greatly in recent years across the US and is now the leading cause of injury‐related death in the United States. Drug related deaths with cointoxicants are being seen far too often and the increase in prevalence of opioid overdoses with possible concomitant medication use is a public health concern that needs to be addressed. Naloxone (Narcan ®) is an opioid antagonist approved in November 2015 by the FDA to help combat the effects of opioid overdose. Awareness of naloxone’s availability over the counter and education on opioid related overdoses for communities in the United States has been shown to improve opioid overdose deaths. In this study, we document naloxone administration in the Southeast Health Emergency Department to help identify high risk sub‐populations in this region that present with signs of potential opioid overdose and the connection between overdoses for opioids or a cointoxicant.Study DesignA retrospective study was conducted evaluating the administration of naloxone in individuals arriving in the emergency department at Southeast Health from August 01, 2011 to August 31, 2018. Patient cases were collected based on time, route, and dose of naloxone given, and data was then selected based on ICD 10 codes and documented positive reaction to naloxone. Patients who were not between ages 18–89 or were incarcerated or pregnant prior to their hospital were excluded from this study. Further data was collected on patients’ socioeconomic status, medical history, and the course of their encounter.ResultsOf the 721 charts reviewed, 261 were deemed true overdoses and 51 were possible overdoses. While there were more overdoses in individuals with a history of chronic pain or mental illness, this was not statistically significant. The data showed most patients who overdosed were taking both opioids and benzodiazepines.ConclusionsIt is apparent that disabled/retired females over 65 with Medicare or Medicaid were the most likely to be a true opioid overdose.Due to the patient’s mental status upon arrival, not all charts had complete histories or medication records. There were no clear documentation standards, so this varied from by provider and year, making it difficult to determine if there was a true overdose. Data was also dependent on patient honesty, relying on them to admit a history of abuse or what substances they had taken. The number of cases of overdose is likely under reported. Southeast Health is not the only hospital in the area. Emergency responders or home naloxone may have been administered decreasing the number of emergency consults. When considering patients insurance status, only the primary insurance listed was recorded. A patient could have also had a Medicaid plan indicating low income, but this was not noted.Age DistributionFigure 1Naloxone and Past Medical HistoryFigure 2

MP43-20 IMPACT OF SPECIFIC ANALGESIC INSTRUCTIONS FOR URETERAL STONE PATIENTS DISCHARGED FROM THE EMERGENCY DEPARTMENT

INTRODUCTION AND OBJECTIVE: While non-opioid analgesics are critical for pain management during a trial of ureteral stone passage, the deliberate instructed use of these adjuncts has not been well described. We aim to describe documented patient discharge instructions for specific analgesic use and assess its relation to unplanned healthcare utilization after discharge from the Emergency Department (ED). METHODS: A single-institution retrospective review of consecutive adults with ureteral calculi disease presenting to the ED from 1/1/2018-12/31/2018 was performed, excluding those requiring urologic intervention or hospital admission. A specific pain regimen was defined as instructions for acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) usage documented in the After Visit Summary. Telephone calls and ED return visits for stone related symptoms within 30-days were evaluated using univariable and multivariable logistic regression analysis, controlling for age, gender, psychiatric history, and stone size at ED discharge. RESULTS: A total of 155 patients (44 ± 17 years; 54% female) were included. The average ureteral stone size was 3.9 ± 2.0 mm (30% proximal; 7% mid; 63% distal). A history of chronic pain or psychiatric diagnosis was present in 28% and 20% of patients, respectively. Majority of patients were given an opioid prescription on discharge (84%). Specific analgesic instructions were given for NSAIDs (63%), acetaminophen (42%), both NSAIDs and acetaminophen (28%), or none at all (21%). Patients instructed on NSAID use were less likely to call for pain related symptoms (OR 0.3, CI 0.1-0.6), although no difference was observed for return rate to the ED. The rate of telephone calls and ED return visits did not differ with instructed acetaminophen use, both acetaminophen and NSAIDs, or none (figure). On multivariable analysis, instructed NSAID use demonstrated a lower likelihood of patient telephone calls related to symptoms (p<0.01). CONCLUSIONS: A considerable number of patients presenting to the ED for symptomatic urolithiasis did not receive advised pain regimens. When receiving specific NSAID use instructions, patients had a lower likelihood of calling for stone pain. Further studies evaluating standardized pain regimens may impact unplanned healthcare resource utilization.Source of Funding: n/a

A randomized controlled noninferiority trial of reduced vs routine opioid prescription after prolapse repair

Given the accelerating opioid crisis in the United States and evidence that patients use fewer opioid tablets than prescribed, surgeons may choose to decrease prescribed quantities. The effect this may have on patient satisfaction with pain control after hospital discharge is unknown. The primary objective of this study was to compare patient satisfaction with postoperative pain control between patients receiving a routine or reduced quantity opioid prescription after prolapse repair. Secondary objectives included a comparison of opioid-related side-effects, the number of opioid tablets used, and the number of excess tablets prescribed between these groups. This was a single-center, unmasked, 2-arm, randomized controlled noninferiority trial of women who underwent a prolapse repair with a planned overnight hospitalization. Patients were assigned randomly to 1 of 2 study arms: routine (28 tablets of oxycodone 5 mg) or reduced (5 tablets) prescription of opioid tablets. Patients were eligible if they were at least 18 years of age and undergoing a prolapse repair with an anticipated overnight hospital stay. Exclusion criteria included a history of chronic pain, preoperative opioid use, intolerance to study medication, or a score of ≥30 on the Pain Catastrophizing Scale. In addition to their opioid prescription, all patients received multimodal pain medications at discharge. Patients were asked to complete 6 weeks of diaries to record pain and medication use. The primary outcome (patient satisfaction) was collected as part of a postoperative survey completed at patients' routine postoperative visit 6 weeks after surgery. The sample size for noninferiority was calculated at 59 patients per group for a total of 118 patients. One hundred eighteen patients were assigned randomly; the primary outcome was available for 116. The majority of patients were white, postmenopausal, and nonsmokers; the mean age was 62±10.4 years. The most common surgery was a hysterectomy with native tissue repair (n=71; 60%). One hundred ten patients (93%) were satisfied with postoperative pain control. Statistical analysis constructed for noninferiority showed that the difference between the groups was <15% (93% vs 93%; P=.005). Subjects in the reduced arm reported requiring an additional opioid prescription more frequently than in the routine arm (15% vs 2%; P=.01). Patients in the routine arm used more opioid tablets than the reduced arm (median, 3 [interquartile range, 0-14] vs 1 [interquartile range, 0-3]), but overall opioid utilization was low. As such, patients in the routine arm had significantly more unused opioid tablets (median, 26 [interquartile range, 15-28] vs 4 [interquartile range, 2-5]). Patient satisfaction with pain control was noninferior in patients who received a reduced quantity of opioid tablets after prolapse repair compared with those who received a routine prescription. A large quantity of excess opioid tablets was seen in both groups. Surgeons should consider prescribing 5-10 opioid tablets after prolapse repair surgery and consider applying these findings to postoperative prescribing after other gynecologic procedures.

A prospective observational study of pediatric opioid prescribing at postoperative discharge: how much is actually used?

Research describing opioid misuse in children after surgery currently describes single specialties, short follow-up, and heterogeneous data not conducive to comparative discussion. Our primary objective was to quantify opioids prescribed to pediatric surgical patients on discharge from hospital. Secondary objectives were quantifying opioids remaining unused at four-week follow-up, and family attitudes to safe storage and disposal. We conducted a prospective observational study under counterfactual consent with telephone follow-up at four weeks of children who had undergone a surgical procedure and filled an opioid prescription at The Hospital for Sick Children, Toronto, ON, Canada. Exclusion criteria included opioid use within the previous six months, history of chronic pain, or discharge to a rehabilitation facility. Pre- and post-discharge prescribing, dispensing, and consumption data were collected prospectively in addition to parental reports of home opioid use. Opioid-dosing was converted to oral morphine milligram equivalents (MME). There were 8,672 MMEs prescribed to 110 patients. Twenty-one patients were lost to follow-up, accounting for 1,416 MME. Of the remaining 7,256 MME, 67% went unused. At follow-up, 78% of unused opioid remained in the home. Most opioids were stored in an easily accessible location in the home. These findings confirm overprescribing of opioids to pediatric surgical patients. Families tend not to return opioids that exceed post-discharge analgesic requirements at home and many of the reported disposal methods are unsafe. We recommend future studies focus on optimizing opioid prescriptions to meet, but not excessively surpass, home pain management requirements, and to encourage safe opioid disposal/return methods. www.clinicaltrials.gov (NCT03562013); registered 7 June, 2018.

Patient Perception and Duration of Pain after Microdirect Laryngoscopy.

Postoperative pain is an important part of the patient's surgical experience. The objective was to evaluate patient perception and duration of pain after microdirect laryngoscopy (MDL). Case series with planned data collection. Tertiary care, academic center. Adult patients undergoing MDL were administered the short-form McGill Pain Questionnaire (SF-MPQ) before surgery and on postoperative days (PODs) 1, 3, and 7. Demographic and clinical data were collected. In total, 130 patients (mean age 52.6 years, 84 male) participated in the study. About 46.2% required analgesia on POD 1, but only 23.1% required opioids. Overall, mild levels of pain were reported on the SF-MPQ: sensory score, affective score, total score, present pain intensity (PPI), and visual analog scale (VAS). Patients reported a significant increase in pain on POD 1, with decreases in pain on PODs 3 and 7. Pain score returned to preoperative values for total score and affective score on POD 7 but remained significantly elevated for PPI, VAS, and sensory score. None of the following factors were associated with increased pain: age, sex, body mass index, Mallampati score, Cormack score, laryngoscope used, type of MDL, time under anesthesia, employment status, intubation, Voice Handicap Index 10, and chronic pain history. Although mild levels of pain were reported after MDL, the pain persisted for up to 7 days. No demographic or clinical factors were found to be associated with increased pain. This study was one of the few prospective studies evaluating pain after MDL.

Patterns of opioid use in dialysis access procedures

BackgroundOverprescription of opioids after surgical procedures is recognized as an important contributor to opioid misuse. Dialysis access procedures are commonly performed outpatient operations with few data or guidelines to inform prescription pain management practices. We sought to characterize opioid pain medication use after dialysis access surgery to promote a conservative approach to postoperative opioid prescriptions. MethodsWe performed a retrospective review of patients who underwent surgical dialysis access procedures from August 2018 through January 2019. Patient-reported opioid use information was captured in a brief questionnaire administered during routine follow-up appointments or phone calls and recorded in the electronic medical record. The procedure, type of intraoperative anesthesia or analgesia, postoperative prescription provided, and patient factors (including age, sex, dialysis type, history of chronic pain, and preoperative opioid or benzodiazepine use) were recorded. All procedures were classified by type (arteriovenous fistula or graft with a short incision [AVF-S], arteriovenous fistula or graft with a long incision [AVF-L], or peritoneal dialysis [PD] catheter), and descriptive statistics were performed using R (R Foundation for Statistical Computing, Vienna, Austria). ResultsEighty-six patients underwent dialysis access procedures in the study time frame, of whom 63 were administered the pain questionnaire and 58 quantified opioid use; 85% of patients received a prescription, but 31% took no opioids and 71% used opioids for ≤2 days. Interquartile ranges (25th-75th percentile) of prescription and consumption quantities for patients who underwent AVF-L procedures were 10 to 28 pills and 2.5 to 20 pills; for patients who underwent AVF-S, quantities were 4.0 to 8.4 pills and 0 to 4.3 pills; and PD quantities were 10 pills and 3.3 to 9 pills. Thirty-one patients (53%) reported receiving more pain medication than they used, which resulted in a median of 8 excess pills per patient with an unused pill interquartile range of 0 to 22 pills for AVF-L procedures, 0 to 4.2 pills for AVF-S procedures, and 1.3 to 6.7 pills for PD procedures. Patients who were prescribed oxycodone or had a repeated operation had significantly increased opioid use. ConclusionsThis investigation of opioid use after surgical dialysis access procedures suggests that most patients use relatively few opioid pills after surgery, which translates into overprescription and leftover medication for >50% of patients. A conservative approach to postoperative prescription guidelines using lower prescription quantities would encourage opioid-related risk reduction while providing adequate postoperative analgesia. Recommended quantities for postoperative prescriptions were generated using the 80th percentile consumed and were 0 to 6 pills for brachiobasilic or brachiocephalic fistulas, 0 to 5 pills for basilic vein transposition, 0 to 5 pills for radiocephalic AVF, 0 to 15 pills for upper arm grafts, and 0 to 10 pills for PD catheter placement.