Morphine Equivalent Dose Research Articles

Cancer pain in the emergency department: An EMR-based opioid dosing intervention and the effects on patient outcomes.

e24167 Background: Pain is a common reason for patients with cancer to seek care in the Emergency Department (ED). Many of these patients are on chronic opioids and may have developed opioid tolerance, which makes appropriate dosing challenging for emergency physicians. Therefore, we designed an electronic medical record (EMR) based best practice advisory (BPA) intervention to recommend appropriate opioid dosing in the ED, based on a patient’s prescription opioid use. Methods: We conducted a retrospective cohort study to evaluate our cancer pain intervention at two academic EDs from May 2020 to May 2022. Our novel BPA algorithm identified ED cancer patients who were taking prescription opioids with an EMR-calculated morphine equivalent daily dose (MEDD) of at least 100. If an ED provider ordered an opioid for one of these patients, the BPA would fire and recommend an opioid dose based on the patient’s individual MEDD. The ED provider would then have the option of accepting or cancelling the BPA. We compared outcomes based on whether patients received BPA-guided increased opioid dosing. We utilized the chi-squared test with an alpha of < 0.05 to assess the relationship between BPA-guided increased opioid dosing and pain scores, hospital admission rates and ED bounce-back rates (return visit within 7 days). Results: We identified 399 patients who met our inclusion criteria, representing 705 BPA alerts. Those patients that received increased opioid dosing were similar to those that did not, with respect to age, sex, race/ethnicity and ECOG score. Patients who received BPA-guided increased opioid dosing experienced a greater improvement in pain (72.5% vs 65.1%, p = 0.03) and were admitted less frequently (58.5% vs 63.9%, p = 0.04). However, among discharged patients, those that received increased opioid dosing bounced back to the ED more frequently (16.2% vs 7.7%, p < .01). Conclusions: This EMR-based BPA intervention was associated with improved pain scores and decreased admission rates among cancer patients visiting the ED. The same intervention, however, was associated with increased ED return visits within 7 days, suggesting that pain management strategies may need to be implemented or modified upon ED discharge to assure that patients’ symptoms are adequately managed at home.

Phase II study about efficacy and safety of the continuous intravenous infusion of ketamine as adjuvant to opioids in terminally ill cancer patients with refractory cancer pain.

e24139 Background: The ketamine is used to control refractory cancer pain as adjuvant to opioids. However, usefulness of ketamine has not yet been confirmed due to lack of previous studies. Additionally, most of prior studies were studied in heterogenous patients, and continuous intravenous infusion (CIVI) method was rare. The CIVI method using gradual dose titrations of ketamine is safe. So, it is suitable to terminally ill cancer patients who have available IV access but vulnerable to AEs. This phase II single-arm study investigated efficacy and safety of CIVI of Ketamine in these population. Methods: Cancer patients with expected limited survival time within several months and refractory cancer pain were enrolled. Refractory cancer pain indicates requirements of breakthrough analgesics ≥ 4 times/day or average pain score > personalized pain goal (PPG) in spite of intravenous Morphine Equivalent Daily Dose (MEDD) > 120 mg/day. The CIVI of ketamine was increased from 0.05 mg/kg/hr to 0.5 mg/kg/hr by 0.05 mg/kg/hr every 8hr when average pain score exceeded PPG or breakthrough was needed ≥ 2 times/8hr during 5 days. The primary end-point was overall pain response rate, which indicates complete response (both breakthrough ≤ 3/day and NRS ≤ PPG) plus partial response (breakthrough ≤ 3/day), without unacceptable toxicities. A total of 26 patients are needed to verify assumption of response rate of 40% with width of 0.4 for two-sided 95% CI and assuming 5% drop-out rate. This study was prematurely terminated at enrollment of 21 patients. Results: Among 21 enrolled patients between SEP 2019 and JAN 2023, 20 were analyzed except 1 due to early transfer. Most pain mechanisms were mixed type (n = 15, 75%), while some reported nociceptive pain (n = 3, 15%) or neuropathic pain (n = 2, 10%). The baseline background opioids were MEDD 186 mg/day (range, 124-592), number of breakthrough opioids were 5 (IQR, 5-7). The median PPG were 4 (range, 3-6). After application of ketamine, overall pain response rate was 45% (n = 9), complete pain response was 35% (n = 7) and partial pain response was 10% (n = 2). The other 11 were non-responders (six failed to achieve overall pain response despite of maximal dose or completing 5 days of ketamine, five patients discontinued the treatment due to AEs). AEs included confusion (n = 9, 45%), dizziness (n = 3, 15%), and hypertension (n = 2, 10%). Communication capacities were sustained in 10 patients and decreased in other 10 patients. OS were 21 days (95% CI, 18.1-23.9). Conclusions: Our study showed efficacies and safeties of gradually increasing CIVI of ketamine for terminally ill cancer patients with refractory cancer pain. The CIVI of ketamine can be a useful tool in these patients considering limited treatment options. Further studies comparing usefulness of CIVI of ketamine and usual practice with opioids escalation are needed (NCT03362073). Clinical trial information: NCT03362073 .

Long-term deprescription in chronic pain and opioid use disorder patients: Pharmacogenetic and sex differences.

More than half of patients with opioid use disorder for chronic non-cancer pain (CNCP) reduced their dose through a progressive opioid withdrawal supported by a rotation to buprenorphine and/or tramadol. The aim of this research is to analyse the long-term effectiveness of opioid deprescription taking into account the impact of sex and pharmacogenetics on the inter-individual variability. A cross-sectional study was carried out from October 2019 to June 2020 on CNCP patients who had previously undergone an opioid deprescription (n = 119 patients). Demographic, clinical (pain, relief and adverse events) and therapeutic (analgesic use) outcomes were collected. Effectiveness (< 50 mg per day of morphine equivalent daily dose without any aberrant opioid use behaviour) and safety (number of side-effects) were analysed in relation to sex differences and pharmacogenetic markers impact [OPRM1 genotype (rs1799971) and CYP2D6 phenotypes]. Long-term opioid deprescription was achieved in 49 % of the patients with an increase in pain relief and a reduction of adverse events. CYP2D6 poor metabolizers showed the lowest long-term opioid doses. Here, women showed a higher degree of opioid deprescription, but increased use of tramadol and neuromodulators, as well as an increased number of adverse events. Long-term deprescription was successful in half of the cases. Understanding sex and gender interaction plus a genetic impact could help to design more individualized strategies for opioid deprescription.

Celiac plexus radiosurgery for pain management in advanced cancer: An international phase II trial, health-related quality of life (HRQOL) outcomes.

e16293 Background: Upper abdominal / lower back pain characterizes celiac plexus involvement from pancreatic and other cancers which may impair HRQOL; its satisfactory treatment is an unmet clinical need. We hypothesized that ablative radiation delivered to the celiac plexus would decrease pain and improve HRQOL. Methods: An international single arm Phase II study included patients with an average pain level ≥ 5/11 on the brief pain inventory (BPI), ECOG 0-2, and anatomical involvement of the celiac axis. The intervention was a single fraction of 25Gy delivered to the celiac plexus. The primary endpoint was ‘complete or partial (≥2 points) pain response’ based upon the BPI ‘average pain’ 11-point scale. Changes in Health-related QOL at 3 &amp; 6 weeks compared to baseline were secondary endpoints as measured by FACT-Hep, &gt; 8 point change being the minimal clinically important difference (MCID). Evaluable patients included eligible irradiated subjects, who had stable pain levels pre-treatment, and were alive 3 weeks’ post-treatment. The sample size was 90 evaluable patients, giving 90% power to show response rate ≥ 40%. Opioid usage was assessed using intravenous morphine equivalent dose. Sensitivity HRQOL analyses imputed worsened outcomes (-9 for total FACT-Hep) for missing data. Results: Between 2018 and 2022, 149 patients were enrolled, 90/125 who received treatment were evaluable. Median age was 65.5 years (range 28-88), 65% were female, 92% had pancreatic cancer, and 86% had metastatic disease. Median Zubrod PS was 1, median number of systemic treatment lines was 1 (range 0-5), and median baseline opioid use 31 mg/d. At 3 weeks, 48 (53.3%, 95% CI 42.5-63.9) had at least a partial pain, the BPI ‘average pain’ score decreased by a mean of 2.5 points at 3 weeks (86/90 reported) and 3.2 points at 6 weeks (67/90 reported), both p&lt;0.001. Opioid usage decreased by 0.6 mg/d at 3 weeks (NS) and 16.9 mg/d at 6 weeks (p=0.005). The FACT-Hep total score increased by 7.8 points at 3 weeks (54/90 reported, NS diff. from 8) and 16.6 points at 6 weeks (45/90 reported, sig. &gt; 8, p = 0.01), showing an improvement in patients’ HRQOL. Changes in FACT-Hep were especially noted in the Physical Well Being subscale. The Trial Outcome Index (sum of physical, functional &amp; disease-specific concerns) increased markedly at 3 weeks (6.6 points, p=0.005) after treatment and even more after 6 weeks (14.5 points, p&lt;0.). Sensitivity analyses demonstrated improvements in HRQOL at 3 and 6 weeks (1.1, 3.8), but these were less than MCID. Conclusions: Celiac plexus SBRT decreases pain and opioid use amongst patients with pancreatic cancer and other tumors invading the celiac axis. The treatment appears to improve HRQOL. Clinical trial information: NCT03323489 .

Phase III, international, multicentre, double-blind, dose increment, parallel-arm, randomised controlled trial of duloxetine versus pregabalin for opioid-unresponsive neuropathic cancer pain.

TPS12146 Background: Management of neuropathic cancer pain (NCP) refractory to regular opioids remains an important challenge. The efficacy of pregabalin for NCP except chemotherapy-induced peripheral neuropathy has already been confirmed in two randomised controlled trials (RCTs) compared with placebo. Duloxetine offers the potential of analgesia in opioid refractory NCP. However, there are no RCT of duloxetine for the management of opioid-refractory NCP as a first line treatment. Both classes of drugs have the potential to reduce NCP, but there has been no head-to-head comparison for the efficacy and safety, especially given differing side effect profiles. Methods: An international, multicentre, double-blind, dose increment, parallel-arm, RCT. Eligibility criteria include: adult cancer patients experiencing NCP refractory to opioids; Brief Pain Inventory (BPI)-item 3 (worst pain) ≥4; Neuropathic Pain on the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale ≥12 despite of an adequate trial of regular opioid medication (≥60mg/day oral morphine equivalent dose). The study will recruit inpatients and outpatients in Japan and Australia. Participants will be randomised (1:1 allocation ratio) to duloxetine or pregabalin. Dose escalation is to day 14 and from day 14 to 21 is a dose de-escalation period to avoid withdrawal effects. Dose escalation schedule in each-arm is shown in Table 1. The primary endpoint is the mean difference in BPI item 3 over the previous 24 hours on day 14 between groups. Null hypothesis is there is no difference in BPI item 3 in the previous 24 hours on day 14 between both groups for patients with opioid refractory NCP. Comparison of the BPI item 3 on day 14 between duloxetine groups and pregabalin groups will be conducted using a two-sided Student’s t-test at a significance level of 5% according to the intention-to-treat principle. Point estimates and 95% CIs for the difference between two groups will be calculated. A sample size of 160 participants is required with 67 subjects enrolled to date. The DSMC last reviewed the trial in December 2022 and case accumulation expected to be completed by the end of 2024. Table 1：Dose escalation schedule in each-arm. Duloxetine Arm Stage 1 (Day 1-3): Duloxetine (30 mg) 1 capsule (morning) and Placebo 1 capsule (bedtime) Stage 2 (Day 4-7): Same as Stage 1 Stage 3 (Day 8-14): Duloxetine (30 mg) 1 capsule twice a day (morning and bedtime). Pregabalin Arm Stage 1 (Day 1-3): Pregabalin (25 mg) 1 capsule twice a day (morning and bedtime). Stage 2 (Day 4-7): Pregabalin (75 mg) 1 capsule twice a day (morning and bedtime). Stage 3 (Day 8-14): Pregabalin (75 mg) 2 capsules (150 mg) twice a day (morning and bedtime). Clinical trial information: ACTRN12620000656932 , jRCTs051190087.

Impact of CYP2D6 genotype on opioid use disorder deprescription: an observational prospective study in chronic pain with sex-differences.

Introduction: Opioid deprescription is the process of supervised tapering and safe withdrawal when a potentially inappropriate use is detected. This represents a challenge in chronic non-cancer pain (CNCP) patients who may respond differently to the procedure. Our aim was to analyze the potential impact of CYP2D6 phenotypes and sex on the clinical and safety outcomes during an opioid use disorder (OUD) tapering process. Methods: A prospective observational study was conducted on CNCP ambulatory OUD patients (cases, n = 138) who underwent a 6-month opioid dose reduction and discontinuation. Pain intensity, relief and quality of life (Visual analogue scale, VAS 0-100mm), global activity (GAF, 0-100 scores), morphine equivalent daily dose (MEDD), analgesic drugs adverse events (AEs) and opioid withdrawal syndrome (OWS, 0-96 scores) were recorded at basal and final visits. Sex differences and CYP2D6 phenotypes (poor (PM), extensive (EM) and ultrarapid (UM) metabolizers based on CYP2D6*1, *2, *3, *4, *5, *6, *10, *17, *41, 2D6*5, 2D6 × N, 2D6*4 × 2 gene variants) were analyzed. Results: Although CYP2D6-UM consumed three-times less basal MEDD [40 (20-123) mg/day, p = 0.04], they showed the highest number of AEs [7 (6-11), p = 0.02] and opioid withdrawal symptoms (46 ± 10 scores, p = 0.01) after deprescription. This was inversely correlated with their quality of life (r = -0.604, p < 0.001). Sex-differences were evidenced with a tendency to a lower analgesic tolerability in females and lower quality of life in men. Discussion: These data support the potential benefits of CYP2D6-guided opioid deprescription, in patients with CNCP when OUD is detected. Further studies are required to understand a sex/gender interaction.

0707 Spinal Cord Stimulation for Restless Legs Syndrome: Case Report and Scoping Review

Abstract Introduction Restless legs syndrome (RLS) can dramatically impair sleep quality and quality of life. Some patients have insufficient treatment response or intolerance to available pharmacological options. Exploration of novel therapeutic approaches is needed. Methods We report a case of spinal cord stimulation (SCS) providing benefit in RLS. We also performed a scoping review of SCS in RLS with comprehensive literature search of MEDLINE, EMBASE, Cochrane, and Scopus. Results A 77-year-old woman with DM2, OSA (on ASV), depression, familial RLS and iron deficiency with typical RLS symptoms for all of her adult life presented for management in 2000. In 2011 she developed intractable painful peripheral neuropathy and chronic back pain. Levodopa, pramipexole, oral/intravenous iron, gabapentin, pregabalin, tramadol, oxycodone, and methadone were ineffective or poorly tolerated. A 7-day percutaneous SCS trial resulted in RLS symptoms improvement initially by 50%. A Medtronic stimulator with lead placement at T8-T9 was implanted. 6 months later, the patient toggled between a tonic program (2.1-4.6 mA, 200 us, 50 Hz) and a sub-perception, differential target multiplexed program duty-cycled to 1:2 on:off (3.7 mA, 170 us, 300 Hz). She reported 75% improvement in RLS symptoms. Pain improved by 50%. Total daily dose of Oral Morphine Equivalents was reduced from 48.75mg/day to 37.5mg/day, with a stable once daily dose of 400 mg gabapentin at night. Uninterrupted sleep went from 2-5 hours to 6 hours. RLS worsened when the device was off. Our case corroborates the current evidence of benefit of SCS for RLS from the literature. We identified other 16 unique patients from case reports and series who had undergone SCS for RLS. Leads were most often implanted in mid or low thoracic levels. Stimulation waveforms were high frequency in 4 patients, tonic in 3 patients, burst stimulation in 1 patient, and undescribed in the others. All patients had RLS symptom reduction. Comorbid pain was reported in 14 patients, which also improved with SCS. Complication with lead erosion was reported in one case. Conclusion SCS remains a promising therapeutic approach for refractory RLS that deserves further investigation. SCS may reduce hyperexcitability seen in RLS by modulating dysfunctional spinal, subcortical, and cortical networks. Support (if any)

Dose Escalations Among Workers' Compensation Claimants Using Opioid Medications-An 8 Year Postinjury Follow up Study.

The aim of the study is to determine the morphine equivalent dose in milligrams (MED)/day escalation trend after initial utilization. A total of 25,108 lost time claims filed between 1998 and 2007 were followed for 8 years from injury date. Claims were stratified by initial MED/day at 3 months after injury into four groups (0, 1 to < 15, 15 to < 30, and ≥30 MED/day). The slopes in MED/year of opioid dose escalation were determined for each initial MED/day group. The slopes of MED/day escalation by initial MED categories were similar ( P ≥ 0.05) ranging from 5.38 to 7.76 MED annually. On average, MED/day increased in a liner pattern with a slope at 6.28 MED/year ( P < 0.01). Opioid MED/day increased in a linear pattern, regardless of initial MED/day dose.

Reducing Opioid Use for Chronic Pain With a Group-Based Intervention

Opioid use for chronic nonmalignant pain can be harmful. To test whether a multicomponent, group-based, self-management intervention reduced opioid use and improved pain-related disability compared with usual care. Multicentered, randomized clinical trial of 608 adults taking strong opioids (buprenorphine, dipipanone, morphine, diamorphine, fentanyl, hydromorphone, methadone, oxycodone, papaveretum, pentazocine, pethidine, tapentadol, and tramadol) to treat chronic nonmalignant pain. The study was conducted in 191 primary care centers in England between May 17, 2017, and January 30, 2019. Final follow-up occurred March 18, 2020. Participants were randomized 1:1 to either usual care or 3-day-long group sessions that emphasized skill-based learning and education, supplemented by 1-on-1 support delivered by a nurse and lay person for 12 months. The 2 primary outcomes were Patient-Reported Outcomes Measurement Information System Pain Interference Short Form 8a (PROMIS-PI-SF-8a) score (T-score range, 40.7-77; 77 indicates worst pain interference; minimal clinically important difference, 3.5) and the proportion of participants who discontinued opioids at 12 months, measured by self-report. Of 608 participants randomized (mean age, 61 years; 362 female [60%]; median daily morphine equivalent dose, 46 mg [IQR, 25 to 79]), 440 (72%) completed 12-month follow-up. There was no statistically significant difference in PROMIS-PI-SF-8a scores between the 2 groups at 12-month follow-up (-4.1 in the intervention and -3.17 in the usual care groups; between-group difference: mean difference, -0.52 [95% CI, -1.94 to 0.89]; P = .15). At 12 months, opioid discontinuation occurred in 65 of 225 participants (29%) in the intervention group and 15 of 208 participants (7%) in the usual care group (odds ratio, 5.55 [95% CI, 2.80 to 10.99]; absolute difference, 21.7% [95% CI, 14.8% to 28.6%]; P < .001). Serious adverse events occurred in 8% (25/305) of the participants in the intervention group and 5% (16/303) of the participants in the usual care group. The most common serious adverse events were gastrointestinal (2% in the intervention group and 0% in the usual care group) and locomotor/musculoskeletal (2% in the intervention group and 1% in the usual care group). Four people (1%) in the intervention group received additional medical care for possible or probable symptoms of opioid withdrawal (shortness of breath, hot flushes, fever and pain, small intestinal bleed, and an overdose suicide attempt). In people with chronic pain due to nonmalignant causes, compared with usual care, a group-based educational intervention that included group and individual support and skill-based learning significantly reduced patient-reported use of opioids, but had no effect on perceived pain interference with daily life activities. isrctn.org Identifier: ISRCTN49470934.

(283) Managing Patient Pain Expectations in Buried Penis Repair: An Opportunity for Quality Improvement

Abstract Introduction Buried penis repairs are complex cases often requiring collaboration between urology and plastic surgery. These surgeries are often extensive, can require split thickness skin grafting (STSG) of the penile shaft, negative pressure wound vac, and have high incidence of wound complications. There are no studies that evaluate perioperative pain in patients undergoing buried penis repair. Objective In the ongoing opioid epidemic, we aim to evaluate patient risk factors and peri-operative elements that can minimize opioid use in buried penis repair. Methods A retrospective chart review of patients who underwent buried penis repair from 7/2012 to 7/2021 was performed. Patient demographics, comorbidities and perioperative data were collected, including history of chronic pain, indications, intraoperative findings, perioperative pain control, and 30-day post-operative encounters. The state’s prescription monitoring program was used to verify use of prescription pain medications prior to surgery, at discharge, and refills, collected as Morphine Equivalent Dose (MED). Results A total of 63 patients were included in analysis. Mean age was 55.9 ± 14.4 with a mean pre-op BMI of 41.99 ± 9.17. 75% required a STSG on the penile shaft. The median discharge MED (dMED) was 150, ranging from 0 to 450 MED. 36.5% required opioid refills within 30 days of surgery. This cohort was further separated into two groups: patients who were discharged with &amp;lt; 150 MED (A) vs ≥ 150 MED (B), based on the median dMED. Three patients were excluded: two were on home opioids, one discharged on benzodiazepines. There were no differences in age, pre-op BMI, medical comorbidities (CAD, PVD, HTN, DM, psychiatric history) or history of chronic pain between the cohorts. Surgery for improvement of hygiene was more likely to have higher dMED, 40.7% (A) vs 69.7% (B), p=0.017. Other surgical indications (sexual health, voiding) showed no difference. Prior surgeries (urethral procedures, circumcision) were statistically more likely to require higher dMED, 48.1% (A) vs 72.7% (B), p=0.033. If a penile skin graft was required, there was no difference in graft size and dMED. Twenty-six patients had a hospital managed wound vac, while 19 patients had home wound vacs, but there was no difference in dMED. Although there was no standardized hospital pain regimen, patients on scheduled acetaminophen were more likely to have a lower dMED, 70.3%(A) vs 42.4% (B), p=0.021. 40.7% (A) vs 36.4% (B) of patients required opioid refills within 30 days of surgery, showing no statistical significance. Conclusions For patients who are embarking on buried penis repair, providers can pre-operatively set pain control expectations, especially for those who require repair for hygiene purposes or have had prior urologic reconstructive surgery. In the perioperative setting, this data supports the use of non-opioids, specifically scheduled acetaminophen, to minimize opioid prescribing at discharge. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific

Post-lumbar surgery prescription variation and opioid-related outcomes in a large US healthcare system: an observational study

BACKGROUND CONTEXTSpinal decompression and fusion procedures are one of the most common procedures performed in the United States (US) and remain associated with high postsurgical opioid burden. Despite guidelines emphasizing nonopioid pharmacotherapy strategies for postsurgical pain management, prescribing practices are likely variable and guideline-incongruent. PURPOSEThe purpose of this study was to characterize patient-, care-, and system-level factors associated with opioid, nonopioid pain medication, and benzodiazepine prescribing variation in the US Military Health System (MHS). STUDY DESIGN/SETTINGRetrospective study analyzing medical records from the US MHS Data Repository. PATIENT SAMPLEAdult patients (N=6,625) undergoing lumbar decompression and spinal fusion procedures from 2016 to 2021 in the MHS enrolled in TRICARE at least a year prior to their procedure and had at least one encounter beyond the 90-day postprocedure period, without recent trauma, malignancy, cauda equina syndrome, and co-occurring procedures. OUTCOME MEASURESPatient-, care-, and system-level factors influencing outcomes of discharge morphine equivalent dose (MED), 30-day opioid refill, and persistent opioid use (POU). POU was defined as dispensing of opioid prescriptions monthly for the first 3 months after surgery and then at least once between 90 and 180 days after surgery. METHODS(Generalized) linear mixed models evaluated multilevel factors associated with discharge MED, opioid refill, and POU. RESULTSThe median discharge MED was 375 mg (IQR 225, 580) and days’ supply was 7 days (IQR 4, 10); 36% received an opioid refill and 5%, overall, met criteria for POU. Discharge MED was associated with fusion procedures (+151–198 mg), multilevel procedures (+26 mg), policy release (-184 mg), opioid naïvty (-31 mg), race (Black -21 mg, another race and ethnicity -47 mg), benzodiazepine receipt (+100 mg), opioid-only medications (+86 mg), gabapentinoid receipt (-20 mg), and nonopioid pain medications receipt (-60 mg). Longer symptom duration, fusion procedures, beneficiary category, mental healthcare, nicotine dependence, benzodiazepine receipt, and opioid naivety were associated with both opioid refill and POU. Multilevel procedures, elevated comorbidity score, policy period, antidepressant receipt, and gabapentinoid receipt, and presurgical physical therapy were also associated with opioid refill. POU increased with increasing discharge MED. CONCLUSIONSSignificant variation in discharge prescribing practices require systems-level, evidence-based intervention.

Pre-operative sciatic nerve block vs postoperative surgeon-placed perineural stump catheter for prevention of phantom limb pain after below-knee amputation.

Pre-operative sciatic nerve block vs postoperative surgeon-placed perineural stump catheter for prevention of phantom limb pain after below-knee amputation.

Hysterectomy inequities between black and white patients in the US military health system: A retrospective cohort study

ObjectiveTo evaluate multicomponent aspects of hysterectomy-related care in the US Military Health System including the probability of open hysterectomy (versus vaginal or laparoscopic hysterectomy), probability of having a length of stay > 1 day, and discharge milligram morphine equivalent dose (MED). Analyses sought to identify the presence and strength of healthcare inequities between Black and white patients. MethodsIn this retrospective cohort study, records of patients (N = 11,067) ages 18–65 years enrolled in TRICARE who underwent a hysterectomy between January 2017 to January 2021 in US military treatment facilities (direct care) or civilian facilities (purchased care) were included. Graphic representations illustrated provider and facility variation. Generalized additive mixed models (GAMMs) evaluated inequities across outcomes. Sensitivity analyses included only direct care receipt and added a random effect for the facility. ResultsThere was significant variation in provider use of open versus vaginal or laparoscopic hysterectomies, as well as provider and facility discharge MED. The GAMMs indicated Black patients were more likely to receive an open hysterectomy [log(OR) −0.54, (95 %CI −0.65, −0.43), p < 0.001] and have a length of stay > 1 day [log(OR) 0.18, (95 %CI 0.07, 0.30), p = 0.002], but had similar discharge MED [-2 mg (95% CI −7 mg, 3 mg), p = 0.51], relative to white patients. Patients receiving care in purchased care, relative to direct care, were more likely to receive a vaginal or laparoscopic hysterectomy [log(OR) 0.28, (95 %CI 0.17, 0.38), p = 0.002] and received approximately 21 mg lower discharge MED (95 %CI 16–26 mg less, p < 0.001), but were more likely to have a hospital stay > 1 day [log(OR) 0.95, (95 %CI 0.83, 0.1.10), p < 0.001]. Additional gynecological conditions (e.g., uterine fibroids) and prescription receipt were associated with some, but not all outcomes. ConclusionImproving timely care receipt, especially for uterine fibroids, increasing access to vaginal and laparoscopic hysterectomies, and reducing unwarranted variation in discharge MED could improve care quality and equity in the US Military Health System.

Prevalence of preoperative opioid usage and its impact on postoperative outcomes: a retrospective cohort study.

Preoperative opioid treatment increases postoperative adverse events. This study was aimed to analyze preoperative opioid prevalence in countries with low opioid consumption. Additionally, the effect of low opioid usage on postoperative outcomes was also investigated. We conducted this single center retrospective cohort analysis in a Japanese university-affiliated hospital to investigate opioid usage and its impact on the duration of postoperative hospitalization and in-hospital mortality. Adult patients who underwent general anesthesia between 2015 and 2020 were included. We extracted the patients' characteristics, surgical information and postoperative outcomes. Subgroup analysis to address opioid dose effect was performed in high and low dose opioid subgroups. Among 20,306 inpatients, 535 (2.63%) patients used opioids preoperatively. Tramadol was the most frequently used opioid. The median morphine equivalent (MME) dose was 15mg/day. Median duration of hospitalization was 18 and 9days in the opioid and non-opioid groups, and in-hospital mortality was 2.06% and 0.42%. Multivariable regression analysis demonstrated that preoperative opioid use was associated with a longer duration of hospitalization and in-hospital mortality. Subgroup analysis demonstrated longer durations of hospitalization in both high (> 30mg/day MME) and low (≤ 30mg/day MME) dose opioid groups, while higher in-hospital mortality was seen only in the high dose opioid group. Preoperative opioid usage was one-tenth of the United States average. Despite its low prevalence and small dosage, preoperative opioid usage was associated with poor postoperative outcomes. Dedicated perioperative interventions to prevent opioid-associated adverse events should be developed even in countries with low opioid consumption.

Medical cannabis is effective for cancer-related pain: Quebec Cannabis Registry results

ObjectivesTo evaluate the safety and effectiveness of medical cannabis (MC) in reducing pain and concurrent medications in patients with cancer.MethodsThis study analysed data collected from patients with cancer who were...

The Edmonton Classification System for Cancer Pain in Patients with Bone Metastasis: a descriptive cohort study

PurposeWe describe the prevalence of the Edmonton Classification System for Cancer Pain (ECS-CP) features in patients with bone metastasis and cancer-induced bone pain (CIBP) and the relationship between ECS-CP features, pain intensity, and opioid consumption.MethodsWe assessed ECS-CP features and recoded pain mechanisms and opioid use in adult patients with bone metastasis. Validated measures were used to assess pain intensity, incident pain, psychological distress, addictive behavior, and cognition.ResultsAmong 147 eligible patients, 95.2% completed the assessment. Mean participant age was 73.2 years, the majority female (52.1%) with breast cancer occurring most commonly (25.7%). One or more ECS-CP features were present in 96.4% and CIBP in 75.7% of patients. The median average and worst pain scores were 3 and 6, respectively. Neuropathic pain was the most prevalent pain mechanism (45.0%) and was associated with breakthrough pain frequency (p=0.014). Three-quarters had incident pain, which was strongly associated with a higher average and worst pain scores (3.5 and 7, p<0.001 for both), background oral morphine equivalent daily dose (26.7mg, p=0.005), and frequency of daily breakthrough analgesia (1.7 doses/day, p=0.007). Psychological distress (n=90, 64.3%) was associated with a significantly higher average pain score (4, p=0.009) and a slightly higher worst pain score (7, p=0.054). Addictive behaviour and cognitive dysfunction were relatively uncommon (18.6% and 12.9%, respectively).ConclusionThere is a need to promote standardized assessment and classification of pain syndromes such as CIBP. The ECS-CP may allow us to consider CIBP in a systematic manner and develop personalized pain interventions appropriate to the pain profile.Trial registrationRetrospectively registered in ANZCTR ACTRN12622000853741 (16/06/2022)

Does the combination of intrathecal fentanyl and morphine improve clinical outcomes in patients undergoing lumbar fusions?

Intrathecal morphine (ITM) has been widely effective in improving postoperative outcomes in patients undergoing a multitude of surgeries, including lumbar spine fusion. A major limitation of ITM administration is the increase in the incidence of respiratory depression in a dose-dependent manner. One way to bypass this is to use a more potent opioid with a shorter half-life, such as fentanyl. This is a retrospective analysis of patients who underwent one- or two-level transforaminal lumbar interbody fusions. The patients received one of two interventions: 0.2mg intrathecal duramorph/morphine (ITM group; n=70), 0.2mg duramorph + 50 mcg fentanyl (ITM + fentanyl group; n=68) and the control group (n=102). Primary outcomes included postoperative pain (Visual Analog Scale) and opioid intake (MED - morphine equivalent dosage, mg) for postoperative days (POD) 1- 4. Secondary outcomes included opioid-related side effects. One-way analyses of variance and follow-up post-hoc Tukey's honest significant difference statistical tests were used to measure treatment effects. Significantly lower POD1 pain scores for both the ITM and ITM + fentanyl groups vs. control were detected, with no difference between the ITM vs. ITM + fentanyl groups. Similar results were found for POD1 MED intake. A multivariate regression analysis controlling for confounding variables did not attenuate the differences seen in POD1 pain scores while revealing that only the ITM + fentanyl predicted a decrease in POD1 MED intake. No differences were seen for postoperative opioid-related side effects. Our study provides support for supplementing a low dose of both intrathecal morphine and fentanyl to improve postoperative outcomes.

E051 A systematic review of audit and feedback tools to reduce opioid prescribing for chronic non-cancer pain

Abstract Background/Aims Opioid prescribing has increased considerably over the 15 years for chronic non-cancer pain in the UK, including for musculoskeletal conditions. Whilst there are national and international guidelines to reduce inappropriate opioid prescribing, these are not always adhered to in practice. Audit and feedback is a common intervention for supporting clinical behaviour change. Little is known if such tools have been used to support safer opioid prescribing to date. This systematic review aimed to describe audit and feedback tools that were designed, implemented and led to changes in opioid prescribing practices. Methods A systematic review of the literature was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework (PRISMA). Both Embase and MEDLINE were searched to identify studies that included audit and feedback tools in patients prescribed opioids with chronic non-cancer pain until the 31st of May 2021. Results Of the 539 studies imported, following removal of duplicates, 497 studies were screened. Following title and abstract review 6 full-text studies were assessed for eligibility. A total of three studies were deemed to meet inclusion criteria. Approaches found included: The Controlled Medication Advisory Board (CMAB), Systems Consultation and the Opioid Safety Initiative (OSI). CMAB involved the use of a dashboard to provide feedback to clinicians on referred patients. As a result the opioid prescribing rate per 100 patient visits decreased by 31% and the rate of co-prescription of benzodiazepines and opioids decreased by 56%. Systems Consultation involved the use of audit and feedback, academic detailing and external facilitation to reduce opioid prescribing. Systems consultation resulted in a statistically significant reduction in the morphine equivalent daily doses. The OSI used automatic electronic medical records auditing to enable clinic leaders to identify physician prescribing patterns via a dashboard. OSI enabled a 9.9% reduction in opioid prescriptions from 571,476 to 514,883. Conclusion Computerised audit and feedback tools may be effective interventions to support opioid stewardship initiative and promote safer opioid prescribing. Such approaches being used internationally could pave the way for similar initiatives in the UK and future research evaluating their impact on patient safety. Disclosure J. Feldman: None. M. Jani: Grants/research support; National Institute for Health and Care Research Advanced Fellowship (NIHR301413).

Pericapsular nerve group (PENG) block for early pain management of elderly patients with hip fracture: a single-center double-blind randomized controlled trial

BackgroundThe pericapsular nerve group block (PENG) is a novel technique that blocks the articular branches of the hip joint. This study aimed to compare its effectiveness to a sham block...

The trend of opioid prescriptions among cancer patients in a tertiary hospital: A multimethod quantitative study.

Pain is a major symptom in cancer patients. World Health Organization recommends opioids as the main analgesic agent. Few studies have examined the amount of opioid uses in cancer patients in Southeast Asia, however, none of them have examined the factors associated with the amount of opioid uses which were lower than required. To assess the trends and factors associated with opioid prescriptions for cancer patients in Songklanagarind Hospital, the largest referral center in Southern Thailand. Multi-method quantitative study. We reviewed the electronic medical records of 20,192, outpatients aged ≥18 years diagnosed with cancer between 2016 and 2020 who received opiod prescriptions. Oral morphine equivalents (OME) were calculated using the standard conversion factors and the OME trend during the study period was assessed by a generalized additive model. Factors affecting the morphine equivalent daily dose (MEDD) were assessed using multiple linear regression with a generalized estimating equation. The mean overall MEDD for all study patients was 27.8 ± 21.9 mg per day per patient. The bone and articular cartilage cancer patients had the highest MEDD. For every 5-year increase in the duration of cancer, the MEDD increased by 0.02 (95% confidence interval [CI]: 0.01 - 0.04). Patients with stage 4 cancer received a higher average MEDD of 4.04 (95% CI: 0.30-7.62) as compared to those with stage 1 cancer. Patients with bone metastasis received a average higher MEDD of 4.03 (95% CI: 0.82-7.19) compared to those without. Age was inversely associated with the MEDD. Patients aged 42-58, 59-75 and >76years old received MEDDs of 4.73 (95% CI: 2.31-7.15), 6.12 (95% CI: 3.66-8.59) and 8.59 (95% CI: 6.09-11.09) compared with those aged 18-42 years old. Brain metastasis was inversely associated with MEDD of 4.49 (95% CI: 0.61-8.37) compared to those without. Opioid use in cancer patients in this study is lower than the average global usage. Promoting opioid prescriptions for pain management through medical education can help doctors overcome opiophobia.