Narcotic Medication Research Articles

8747 Excision of Endometriosis in a Postmenopausal Patient

<h3>Study Objective</h3> We seek to demonstrate endometriosis excision in a postmenopausal patient status post hysterectomy and explore the important clinical features of postmenopausal endometriosis. <h3>Design</h3> Case study. <h3>Setting</h3> Urban academic tertiary care center. <h3>Patients or Participants</h3> One postmenopausal female with history of biopsy proven endometriosis experiencing persistent pelvic pain and deep dyspareunia following prior total laparoscopic hysterectomy and endometriosis excision procedures. <h3>Interventions</h3> Exam under anesthesia, bilateral salpingo-oophorectomy, lysis of adhesions, excision of endometriosis, partial peritonectomy, and cystoscopy. <h3>Measurements and Main Results</h3> Intra-op findings included abundant filmy adhesions and focal hemorrhagic lesions, which appeared consistent with endometriosis. Pathology showed fibrous serosal adhesions and associated hemosiderin laden macrophages compatible with clinical impression of endometriosis, though classical findings of endometrial glands and stroma were absent. The patient reported near complete resolution of her prior symptoms following the surgery, without use of narcotic medication, and overall satisfaction with the procedure. <h3>Conclusion</h3> Endometriosis is an estrogen-mediated chronic inflammatory condition that is benign but has a significant impact on the quality of life of many people. Though symptoms are typically seen in premenopausal individuals, cases of postmenopausal endometriosis have also been shown and are estimated to account for roughly 1-5% of all cases. It is hypothesized that extra-ovarian estrogen production from adipose tissue or endometriosis implants may contribute to or drive these processes, but the precise mechanism and etiology is not well understood. Surgical management is particularly important for postmenopausal patients, especially those with endometriomas, given the increased association with malignancy. Here we present a case of a patient with postmenopausal endometriosis status post TLH who experienced significant symptom improvement following surgical treatment with bilateral salpingo-oophorectomy, partial peritonectomy, lysis of adhesions and excision of endometriosis lesions. More research is needed to fully understand the etiology, impact, and appropriate treatment options for postmenopausal endometriosis.

자동차보험 약관상 ‘마약 약물운전’ 조항의 해석과 적용

In case of narcotic drugs/medication driving in the first party property damage insurance, it is excluded from the scope of compensation. Also the bodily injury liability insurance and property damage liability insurance of the standardized clause of automobile insurance requires the insured to pay a large deductible to the insurer. In other words, exemption of part of insured money, not full exemption of liability, is provided in narcotic drugs/medication driving. The meaning of narcotic drugs and medication in automobile insurance policy refers to narcotics, marijuana, psychotropic drugs, and others prescribed by Ordinance of the Ministry of the Interior and Safety as prescribed in Article 45 of the Road Traffic Act. And the meaning of narcotic drugs/medication driving refers to the act of driving in a state that makes it impracticable to drive a motor vehicle, etc. normally due to the impact of the influence of drugs referring to narcotics, marijuana, psychotropic drugs, Korean Supreme Court of Justice emphasizes the circumstance of breach of law caused by drunk driving at the time of occurrence of accident in interpretation of exclusion provision of drunk driving in first party property damage insurance. Therefore, it cannot be interpreted that it only applies to the case there is causal relation between drunk driving and insured accident. This position of Korean Supreme Court of Justice can be interpreted that an act of drunk driving is considered as a sort of reasons for exclusions of risk which is excluded from the category of covered risk by the insurer from the beginning. However, the narcotic drugs/medication driving in automobile insurance policy, which is more likely to be socially criticized than drunk driving, stipulate a reason for exemption from the cause. In other words, there is causal relation between drunk driving and insured accident. The meaning of narcotic drugs and medication and interpret act of narcotic drugs/medication driving in current automobile insurance clauses should be revised because there is a problem. First, in the scope of psychotropic substances stipulated as immunity drugs in automobile insurance policy, drugs prescribed by doctors should be excluded. Next, it is necessary to revise the same form as the exclusion clause of drunk driving and unlicensed driving in automobile insurance policy.

Intra-operative Methadone Decreases Post-operative Pain and Opioid Use in DIEP Flap Breast Patients: A New ERAS Protocol

BACKGROUND: Post-operative pain relief is a significant problem for many patients, increasing the risk of surgical complications and chronic post-operative pain. Patients undergoing surgery can achieve better analgesia with just one dose of methadone (long acting μ-opioid) then with multiple doses of a short acting opioid, however this has never been evaluated in the plastic surgery literature. This purpose of this study is to evaluate the effectiveness of methadone for pain control following DIEP flap breast reconstruction in the setting of a newly instituted ERAS protocol. METHODS: This is a prospective study of an ERAS protocol for all patients undergoing DIEP flap breast reconstruction at a single institution, which centered around the standardization of a single weight based intra-operative dose of methadone. Patients who were operated on after institution of the ERAS protocol were compared to those immediately prior to protocol implementation. Charts were reviewed for patient demographics, intra-operative analgesics, and postoperative medication, both during hospitalization and after discharge. RESULTS: 83 women who underwent DIEP flap Breast reconstruction were identified, 54 patients in the ERAS cohort and 29 in our non-ERAS cohort. The two cohorts had comparable age, weight, BMI, and other medical co-morbidities (p>0.05). The ERAS cohort had significant reduction in opioid usage overall. During the first 12 hours following surgery, the morphine milligram equivalents (MME) was 11.18 versus 27.28 (p<0.001) in the ERAS versus the non-ERAS group, 24 hours following surgery it was 38.69 vs 77.40 MME (p<0.001), and in total during hospital admission it was 79.98 vs 146.7 MME,(p=0.002). The ERAS cohort also had a significant reduction in their overall daily patient rated pain score (P<0.05) and significantly lower heart rate throughout admission. Importantly, those in the ERAS cohort were less likely to be tachycardic throughout admission, defined as a heart rate greater than 100 bpm for at least 12 consecutive hours. There was no difference in length of stay (p>0.05) between the two cohorts. On average during the first week after discharge, patients in the ERAS cohort required 13.9 MME of narcotic pain medications per day. 25% of patients did not require any narcotics at home and after 1 week, more then 75% of patients did not require any narcotics at home. CONCLUSION: In conclusion, after instituting our ERAS protocol with a single dose of intra-operative methadone, post-operative opioid analgesic usage and pain was significantly reduced. Methadone has the potential to be used for patients undergoing plastic surgery procedures, both inpatient and ambulatory, to decrease post-operative pain, opioid use, and increase overall patient comfort and satisfaction. Further work is ongoing to study the impact of our ERAS protocol on DIEP flap patients’ post-operative course.

Perioperative Outcomes of Immersive Virtual Reality as Adjunct Anesthesia in Primary Total Hip and Knee Arthroplasty.

BackgroundImmersive virtual reality (IVR) is utilized as an adjunct to anesthesia to distract patients from their intraoperative environment, thereby potentially reducing sedative and narcotic medication usage. This study evaluated intraoperative and acute postoperative results of patients undergoing primary total hip (THA) and total knee arthroplasty (TKA) with and without IVR.MethodsUtilizing IVR as an adjunct to spinal anesthesia, 18 primary THAs (n = 8) and TKAs (n = 10) were performed. These cases were 1:2 matched based on procedure type, age, sex, and body mass index to those performed without IVR. Intraoperative and postanesthesia care unit sedative/narcotic usage, vital signs, and pain scores were compared. Acute perioperative outcomes, including 24-hour oral morphine equivalent (OME), first ambulation distance, length of stay, and 30-day complications, were also analyzed. Pearson Chi-square and Wilcoxon-Mann-Whitney tests evaluated categorical and continuous variables, respectively.ResultsWhen compared to non-IVR primary THAs and TKAs, those performed with IVR utilized significantly less intraoperative sedation (48 mg vs 708 mg of propofol; P < .001) and trended toward less narcotic usage (13 mcg vs 39 mcg of fentanyl; P = .07). In the postanesthesia care unit, IVR and non-IVR patients showed no significant differences (P > .3) in vital signs, pain scores, or OME received. Additionally, similar (P > .3) postoperative outcomes were noted in both cohorts’ 24-hour OME use, distance at first ambulation, length of stay, and 30-day complications.ConclusionsThe use of spinal anesthesia with the IVR adjunct to perform primary THAs and TKAs appears to be well-tolerated and associated with less intraoperative sedative medication usage than spinal anesthesia alone.

Elimination of Postoperative Narcotics in Infant Robotic Pyeloplasty Using Caudal Anesthesia and a Non-Narcotic Pain Pathway.

Introduction: Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for postoperative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics after infant robotic pyeloplasty. Methods: We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes, and unscheduled health care encounters within 30 postoperative days. Results: Sixty-three percent (15/24) of patients were male and average age was 12.1 months (range 4-34 months). Fifty-eight percent (9/15) underwent surgery on the left, and 16.7% (4/24) of patients received a single postoperative dose of narcotics in the postanesthesia care unit. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related unscheduled visits or phone calls after discharge. Conclusions: This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Postprocedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.

A Prospective Evaluation of Opioid Utilization Following Ankle Fracture Surgery

Category: Trauma; Ankle Introduction/Purpose: There has been significant scrutiny of physicians' opioid prescribing patterns for both operative and non- operative patients. Orthopaedic surgeons are the third highest group of opioid prescribers among physicians in the United States. The wide scope of orthopaedic procedures lends to the variability and difficulty in setting forth prescribing guidelines. Recent orthopedic literature has highlighted that orthopaedic surgeons are prescribing excess narcotic medication than is needed in common orthopaedic procedures. Ankle fractures make up about 9% of all fractures, which correlates to about 400,000 per year. The purpose of this study was to assess the amount of post-operative pain medication being prescribed and how much of that medication was being consumed in patients who underwent an open reduction internal fixation (ORIF) of an ankle fracture. Methods: We identified all patients that underwent a unilateral ORIF of a closed ankle fracture. We prospectively collected data on patients at the time of surgery. Patients were identified and enrolled in the study prior to their surgical procedure, where they were instructed to bring their pain medication bottle with them to their first post-operative visit. Patients were asked about the quantity of opioids consumed. At the twelve-week post-op, the American Orthopedic Foot and Ankle Score (AOFAS) was completed by the patient. We recorded the number, dosage, and formulation of opioid medication prescribed up to 90 days after surgery using the Pennsylvania Drug Monitoring Program (PDMP) website. Using opioid equianalgesic charts, we converted dosages of opioid to a morphine milligram equivalent (MEq) to standardize prescription amounts across all patients. Descriptive statistics were calculated and reported. Categorical data were compared using chi-square tests and quantitative data were compared using independent sample t-tests. Results: 75 patients were included in our study, 45 of which were female. The mean age of the patient was 46.7 years old with a range from 17-77 years old. On average, 400MEq were prescribed to the patient after surgery. Patients consumed an average of 258 MEq within the 2 weeks following surgery, which accounted for about 65% of the initial prescription. Thirty (13.3%) patients consumed their entire first prescription. Patients who consumed the full opioid prescription were 8.7 times more likely (95% CI 2.6, 29.3, X2(1)=14.1, p&lt;0.001) to have other scripts filled in the PDMP. After adjusting for inequal variances, an independent samples t-test found that subjects that did not consume the full prescription also had statistically significantly higher functionality scores (82 vs. 70) than patients that consumed the full prescribed amount (p=0.001). Conclusion: We found the average patient consumes the equivalent of 34 pills of 5mg oxycodone after undergoing an open reduction internal fixation of an ankle fracture. Our providers over prescribed, on average, by 21 total pills. 9.3% of patients were still requiring narcotic pain medication ninety days post-operatively. Those patients who did not consume their first narcotic prescription were found to have statistically better functional outcome scores compared to those who did. Further studies should continue to assess patient characteristics, surgeon techniques, and prescribing habits to further improve post-operative pain control in patients undergoing open reduction internal fixation of ankle fractures.

Opiate Free Multimodal Pain Pathway in Elective Foot and Ankle Surgery: A Prospective Study

Category: Bunion; Other Introduction/Purpose: Orthopedic surgeons frequently prescribe and overprescribe narcotic pain medications during the postoperative period, despite our increased understanding of the opioid crisis. In an effort to minimize narcotic analgesia and its potential side effects, opiate free multimodal pain pathways have been developed with promising results. However, there is a lack of published literature looking at opiate free multimodal pain protocols for elective outpatient foot and ankle surgeries. At our institution we have been implementing a novel opiate free multimodal post-operative pain protocol for elective outpatient foot and ankle surgeries. The purpose of this study was to explore the efficacy, feasibility, outcomes and satisfaction of an opioid-free, multimodal postoperative pathway in patients undergoing elective outpatient foot and ankle surgery. Methods: This study was approved by our IRB and was a prospective study. Data was collected from December 1st, 2020 through February 9th, 2022 for patients who underwent a primary elective outpatient foot and ankle surgery including bunion correction surgery with or without a lesser toe procedure(s). These patients completed a comprehensive opioid-free, multimodal pain management protocol and a follow up with one of two fellowship trained orthopedic foot and ankle surgeons. The multimodal treatment protocol included oral Lyrica, Tylenol, Toradol and flexeril to begin POD#0. Mobic was given to POD #4 once Toradol was completed. All data was collected in a prospective manner. At POD#1, #3, and #8, patients were contacted to collect VAS scores, complications, ED and Urgent care visits, and pain medication needs. At two week follow up these were again collected in addition to overall satisfaction rates. Results: 33 patients enrolled with a mean age of 55 (19-81) years old. The average follow up was 11.5 weeks. On POD#1, #3, #8, and at 2 week follow up our patients’ average VAS pain score was a 4.0, 2.5, 1.6, and 1.4 out of 10, respectively. 18% of patients required narcotics within the first 2 weeks, but by 2 weeks no patients were taking narcotics. No patients visited an ED or urgent care during the first 2 weeks post operatively. Common side effects were drowsiness/tiredness and constipation. Only 4 reported nausea or GI upset at 2 week follow up. Overall, 91% were satisfied with their pain control, 78% would follow the same protocol again, and 82% would recommend this pain management regimen to others. Conclusion: An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing elective outpatient foot and ankle surgery with a very low risk of requiring rescue opioids, having significant side effects, and/or needing an ED or urgent care evaluation within the first 2 week post operative period.

Comparison of skin graft donor site management using oxidised regenerated cellulose (ORC)/collagen/silver-ORC with absorptive silicone adhesive border and transparent film dressing vs semi-occlusive dressings.

Split-thickness skin grafts (STSG) are widely used in wound reconstruction. However, donor site wounds are created as a result. Traditionally, moist wound healing and transparent film dressings have been used to promote donor site wound healing. This retrospective study evaluated the use of oxidised regenerated cellulose (ORC)/collagen/silver-ORC dressing (ORC/C/Ag-ORC) with an absorptive silicone adhesive border dressing and transparent film dressing (treatment) compared with petrolatum-based gauze dressing (control) over donor site wounds. Patients underwent an STSG procedure between January and December 2020. Donor sites received treatment (n=10) or control (n=10) dressings. Dressing changes occurred as necessary. Time to epithelialisation, narcotic pain medication requirements, and the number of office/hospital visits were examined. Twenty patients were managed (9 males, 11 females, average age: 49.7± 13.9y). Patient comorbidities included hypertension, diabetes, and hyperlipidemia. Wound types included traumatic and cancer excision. Time to epithelialisation was significantly reduced in the treatment group (11.1± 1.4d vs 18 ± 2.4d, P< 0.0001). The number of office visits for dressing changes was significantly lower in the treatment group (0.1± 0.3 vs 2± 0.7, P< 0.0001). No patients in the treatment group required a hospital visit, compared with 3 patients in the control group. One patient in the treatment group required narcotic pain medication, compared with 5 in the control group. In this patient population, the use of ORC/C/Ag-ORC, an absorptive silicone adhesive border dressing, and transparent film dressing resulted in a shorter time to epithelialisation and less analgesic requirement compared with petrolatum-based gauze dressing use.

Self-reported pain during the initial postoperative period following open lumbar spine fusion surgery does not correlate with the number of levels fused: A prospective trial of 40 patients.

Current spine postoperative pain control protocols consider the expected pain following spine fusion surgery to correlate with surgical extent, that is, the greater the number of operated vertebrae, the greater the postoperative pain. Due to this assumption, Enhanced Recovery After Surgery (ERAS) protocols are principally applied to minimally invasive and percutaneous spine surgery and less to open extensive spine fusion operations. The aim of this study was to determine whether postoperative pain does in fact correlate with the surgical extent, potentially opening the door to non-narcotic postoperative pain protocols for this patient subset. Forty consecutive patients, undergoing open posterior spine surgery, were evaluated for postoperative pain during the first 72 after surgery. All patients were then divided into two groups according to the number of spine levels fused, and the correlation between the number of fusion levels and self-reported pain was analyzed statistically. Self-reported pain levels were not found to correlate with the extent of the spine operation. As "bigger operation" does not necessarily equate with "bigger pain," adequate postoperative pain control after extensive spine fusion surgery might be achieved without the routine use of narcotic medication, as practiced after minimally invasive and percutaneous surgery. Additional prospective randomized trials are needed to further substantiate this conclusion.

Does the Use of a Visual Cognitive Aid Improve Patient Compliance With a Postoperative Analgesic Regimen? A Randomized Controlled Trial

The use of scheduled non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen in the postoperative setting has been shown to reduce the need for prescription narcotic pain medications. Our objective is to determine if the implementation of a visual cognitive aid will improve patient compliance with a scheduled NSAID and acetaminophen regimen, thereby decreasing the use of narcotic pain medications. We conducted a single-blind randomized controlled trial in patients receiving outpatient oral surgery procedures from a single office.

203. Epidural pain catheter improves postoperative pain control following lumbar fusion compared to patient-controlled analgesia (PCA)

<h3>BACKGROUND CONTEXT</h3> Postoperative pain control for patients in the hospital after lumbar spinal fusion can be quite challenging. Reliance on opioids postoperatively can predispose patients to tolerance and abuse. Multimodal pain control regimens have become the standard of postoperative care, though protocols tend to vary by surgeon and institution. The mainstay of pain control following lumbar spinal fusion surgery involves narcotic pain medication administered by patient controlled intravenous analgesia (PCA), which is typically supplemented by oral pain medications. One potential alternative to PCA is patient-controlled analgesia via epidural catheter. Surgeon-placed epidural catheters under direct visualization have previously been described for their simplicity, efficacy and time efficiency. <h3>PURPOSE</h3> After experiencing clinical success with the use of epidural catheters placed via the loss of resistance technique one- to three- levels above the proximal lumbar fusion level in postoperative care regimens,the senior author (TFA) embarked upon this prospective, randomized trial to assess the relative utility and complication rate of the epidural catheter method of pain management when compared to standard PCA narcotic administration for pain control after one- or two-level circumferential lumbar fusion surgery. <h3>STUDY DESIGN/SETTING</h3> The surgeries in the trial were performed by three surgeons in a university spinal surgery practice. Patients who enrolled agreed to be randomized to either the epidural catheter (EC) or the commonly practiced PCA arm of the study. A power analysis demonstrated that a sample size of 50 patients, using a level of significance of 0.05, would have a power of 0.97 to detect a 2-point difference in pain scores. <h3>PATIENT SAMPLE</h3> Fifty patients from the University spinal surgery practice were recruited to enter the study. Candidates for the study were patients undergoing one- or two-level instrumented lumbar fusion. Patients were randomized over a 10-month period into either the epidural (EA) or IV analgesia (PCA) groups, 27 to EA and 23 to PCA. <h3>OUTCOME MEASURES</h3> Preoperative pain scores, as well as daily postoperative pain scores were recorded. <h3>METHODS</h3> If randomized to the EC arm, an epidural catheter was placed by the surgeon just prior to wound closure, 1-3 levels above the most proximal level of the fusion. A 17-gauge Tuohy epidural needle was used with a loss-of-resistance syringe to locate the epidural space under fluoroscopy if deemed appropriate by the surgeon, and then the catheter was inserted through it. A bolus of 5cc of 0.25% bupivacaine was typically given at the time of catheter placement. Postoperatively, a continuous infusion was begun of 0.125% bupivacaine at 6 cc/hr combined with hydromorphone at 0.2 mg/hr. A patient controlled epidural demand dose of 25mcg of fentanyl with a 10-minute lockout period was also started. If randomized to the PCA group, patients were placed on a patient-controlled analgesia pump administering intravenous hydromorphone with a demand dose of 0.2-0.4 mg with a 10-15-minute lockout <h3>RESULTS</h3> Postoperative pain scores were statistically lower in the EC group on Days 1, 2 and 3: 2.13 vs 4.92 (day 1); 2.71 vs 4.52 (day 2); 3.13 vs 4.52 (day 3). Postoperative complications were similar between the EC and PCA groups. The incidence of nausea/vomiting were 56% and 74% (p=0.43) in EC and PCA groups, respectively, while postoperative symptomatic hypotension was seen in 8% of EC patients and 12% of PCA patients (p=0.67). <h3>CONCLUSIONS</h3> In this prospective, randomized study comparing the use of EC to PCA narcotic for pain control after one- and two-level lumbar fusions, a significant improvement in pain control was noted in the EC group with differences in minor side effects that did not reach statistical significance. Epidural anesthesia for postoperative pain control should be considered for patients undergoing lumbar fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

To block or not to block? That is the question (114)

Objectives: Quadratus Lumborum (QL) blocks have gained popularity due to their more favorable safety profile compared to neuraxial techniques (e.g., epidural) in dealing with postoperative pain. They have been studied in the gynecologic population undergoing laparoscopic surgery, where pain scores were found to decrease as patients progressed through their recovery process. Yet, very little data exists studying their use in open surgery for gynecologic indications. Therefore, we aimed to determine the effect of QL blocks on postoperative opioid consumption in patients undergoing laparotomy. Methods: A retrospective study of gynecologic oncology patients undergoing surgery via laparotomy from 2018 to 2020 was performed. Demographics, postoperative pain scores, frequency, and duration of narcotic use, amount of narcotic use using Morphine Milligram Equivalents (MME), length of hospital stay, and re-admission rates for pain management were compared. Primary outcome measures include postoperative pain scores and the amount of narcotic use in MME. Results: Thirty-eight patients who met the inclusion criteria with complete data were identified as receiving QL blocks, whereas 32 patients did not receive a block during this time frame. Eighty-six percent of the blocks were placed preoperatively. Approximately 25% of patients reported their pain score on arrival to the floor as 0 out of 10. The mean pain score for patients with and without QL blocks on arrival to the floor were 2.9/10 and 3.7/10, respectively (p=0.57). Patients who received QL blocks used a mean of 18.4 MME on postoperative day 1 compared to 31.1 MME in those without blocks (p=0.008). This trend continued throughout their hospital course as the mean total MME used on hospital days 1-3 in the QL group was 49.11 compared to 80.24 in the non-QL group (p=0.009). Conclusions: Our study suggests that the use of regional QL blocks decreases the amount of narcotic pain medication (MME) used in the immediate postoperative period in patients undergoing laparotomy for gynecologic oncology indications. This is an important finding which may help decrease overall postoperative narcotic requirements given the current opioid epidemic. Future studies will focus on the impact of QL blocks on narcotic need after discharge in this patient population. Objectives: Quadratus Lumborum (QL) blocks have gained popularity due to their more favorable safety profile compared to neuraxial techniques (e.g., epidural) in dealing with postoperative pain. They have been studied in the gynecologic population undergoing laparoscopic surgery, where pain scores were found to decrease as patients progressed through their recovery process. Yet, very little data exists studying their use in open surgery for gynecologic indications. Therefore, we aimed to determine the effect of QL blocks on postoperative opioid consumption in patients undergoing laparotomy. Methods: A retrospective study of gynecologic oncology patients undergoing surgery via laparotomy from 2018 to 2020 was performed. Demographics, postoperative pain scores, frequency, and duration of narcotic use, amount of narcotic use using Morphine Milligram Equivalents (MME), length of hospital stay, and re-admission rates for pain management were compared. Primary outcome measures include postoperative pain scores and the amount of narcotic use in MME. Results: Thirty-eight patients who met the inclusion criteria with complete data were identified as receiving QL blocks, whereas 32 patients did not receive a block during this time frame. Eighty-six percent of the blocks were placed preoperatively. Approximately 25% of patients reported their pain score on arrival to the floor as 0 out of 10. The mean pain score for patients with and without QL blocks on arrival to the floor were 2.9/10 and 3.7/10, respectively (p=0.57). Patients who received QL blocks used a mean of 18.4 MME on postoperative day 1 compared to 31.1 MME in those without blocks (p=0.008). This trend continued throughout their hospital course as the mean total MME used on hospital days 1-3 in the QL group was 49.11 compared to 80.24 in the non-QL group (p=0.009). Conclusions: Our study suggests that the use of regional QL blocks decreases the amount of narcotic pain medication (MME) used in the immediate postoperative period in patients undergoing laparotomy for gynecologic oncology indications. This is an important finding which may help decrease overall postoperative narcotic requirements given the current opioid epidemic. Future studies will focus on the impact of QL blocks on narcotic need after discharge in this patient population.

A prospective randomized study evaluating the necessity of narcotics following ureteroscopy for urinary stone disease.

To evaluate the efficacy of non-narcotic analgesics and preoperative counseling in managing postoperative pain and narcotic use following ureteroscopic laser lithotripsy (URS). Adult patients at a single academic center undergoing URS for nephrourolithiasis were recruited. After informed consent, subjects were randomized into three groups: NARC-15 tablets oxycodone-acetaminophen 5/325mg (A-OXY), 2. NSAID-15 tablets ibuprofen (IBU) 600mg, 3. CNSL-15 tablets A-OXY, 15 tablets IBU, and preoperative counseling from the surgeon to avoid narcotic if possible. Patients who did not receive an intraoperative stent were excluded. At the time of stent removal subjects completed the Universal Stent Symptom Questionnaire (USSQ), and a pill count was performed. USSQ pain indices were the primary study endpoint. Of 115 patients enrolled, 104 met the primary endpoint and were included in the analysis. No significant differences were noted in patient demographic, clinical, or operative characteristics. No differences were noted in median USSQ pain indices. The CNSL group used a significantly lower median number of A-OXY pills compared to the NARC group (2.4 vs. 5.4, p = 0.001) and less IBU compared to the NSAID group (3.1 vs. 5.9, p = 0.008). No differences in median total pill count, office calls, medication requests, nor ED visits were noted. Our data suggest that patients can achieve equivalent postoperative analgesic satisfaction with non-narcotics compared to opiates following URS. Further, counseling patients on postoperative pain before surgery can reduce the total number of postoperative narcotic and non-narcotic medications taken. We suggest surgeons strongly consider omission of narcotic prescriptions following non-complicated URS.

Prevalence of Comorbid Psychiatric Conditions and Chronic Pain in Patients Seeking Peripheral Nerve Surgery.

Background:In peripheral nerve surgery, the presence of psychiatric diagnoses and medications may affect outcomes and perioperative neuropathic pain management. The purpose of this study was to determine the prevalence of psychiatric diagnoses and chronic pain in patients referred to a peripheral nerve surgery clinic.Methods:This is a retrospective review of patients seen at a peripheral nerve clinic from July 1, 2017 to June 30, 2021. Medical records were reviewed for demographics; peripheral nerve diagnosis; psychiatric diagnoses; psychotropic prescriptions; use of nonneuroleptic/nonnarcotic, neuroleptic, and narcotic medications; and peripheral nerve surgical candidacy and outcome.Results:Six hundred twenty-two patients were included in this study. The most common reasons for referral were 24.8% lower extremity neuroma, 23.2% lower extremity compressive neuropathy, and 14.0% upper extremity compressive neuropathy. Of the included patients‚ 37.1% had a psychiatric diagnosis, and 36.3% were taking a psychotropic medication. The percentage of patients taking chronic nonneuroleptic/nonnarcotic pain medications was 34.3%‚ with 42.8% taking neuroleptic, and 24.9% narcotic medications. Patients with a psychiatric diagnosis were more likely to be taking neuroleptic (48.9% versus 38.9%, P < 0.001) and narcotic pain medications (27.3% versus 17.4%, P = 0.004) and less likely to have a positive surgical outcome (65.7% versus 83.0%, P = 0.001).Conclusions:Patients referred to a peripheral nerve surgery clinic frequently have psychiatric diagnoses and take chronic psychotropic and chronic pain medications. Knowledge of this will best help the peripheral nerve surgeon evaluate a patient for surgery, optimize perioperative care, and safely and effectively manage expectations.

Operative fixation of rib fracture nonunions.

Rib fractures are common injuries in trauma patients that often heal without intervention. Infrequently, symptomatic rib fracture nonunions are a complication after rib fractures. There is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe the efficacy of rib fracture nonunion operative fixation with particular focus on surgical technique, healing rates, and complications. Patients aged ≥ 18years with symptomatic rib fracture nonunions treated with open reduction and internal fixation (ORIF) with locking plates at a single urban level 1 trauma center were retrospectively reviewed. Pertinent demographic, clinical, radiographic, and surgical data were collected and analyzed. A total of 18 patients met inclusion criteria. The mean time from injury to undergoing ORIF for rib fracture nonunion was just under a year and the number of ribs plated was 2.95 ± 1.16 (1-5ribs) with bone grafting used in six cases. All patients (100%) showed evidence of healing at an average of 2.65 ± 1.50months (2-8months). All patients reported a decrease in pain. No narcotic pain medication was used at an average of 3.88 ± 3.76weeks (0-10weeks) post-operatively. Intraoperative and postoperative complications were found in 4 (22.2%) patients. This study concluded that operative fixation of symptomatic rib fracture nonunion demonstrated favorable outcomes with reduction in preoperative pain levels, decreased use of narcotic pain medication, minimal complications, and a high rate of fracture union. This described method provides symptomatic relief, reduction in pain, and promotes bony healing of the fracture nonunion without development of major complications. We suggest that operative fixation should be considered as the primary method of treatment of symptomatic rib nonunions.

Patients with preoperative opioid use and lower resilience scores are more likely to report inadequate pain control after total shoulder arthroplasty

BackgroundThe United States is in a prescriptive opioid crisis, and physicians have a responsibility to their patients and the healthcare system to mitigate irresponsible prescriptive practices. A patient’s preoperative opioid status and brief resilience score (BRS) may be used to individualize analgesic protocols and reduce opioid overprescription. The purpose of this study is to evaluate the relationship between preoperative resilience scores and patient-reported pain control after total shoulder arthroplasty (TSA). This study also examines reported pain control in patients with or without preoperative narcotic use 30 days before their procedure. MethodsPatients undergoing elective primary anatomic total shoulder arthroplasty (aTSA) or primary reverse total shoulder arthroplasty (rTSA) were asked to complete the BRS survey before their procedure and postoperative narcotic pain medication surveys at 1, 4, and 12 weeks after their operation. The patients were then stratified into 2 cohorts based on preoperative opioid usage status. Two-sample equal-variance t-tests were used to test for differences between resilience score group means and adequate pain control after TSA. The differences between preoperative opioid and no preoperative opioid usage cohorts, and perceived pain control and the number of oxycodone pills taken were analyzed for direction and statistical significance using t-tests for continuous variables and chi-squared tests for categorical variables. ResultsThe study cohort consisted of 218 patients, of whom 74 had preoperative opioid use (group O). Patients who reported inadequate pain control after TSA had consistently lower resilience scores at baseline. The BRS group means ± standard deviations after TSA for the adequate vs. inadequate pain control groups respectively were 3.84 vs. 3.48 (P = .010) at week 1, 3.83 vs. 3.53 (P = .055) at week 4, and 3.84 vs. 3.36 (P = .002) at week 12. Of the patients in group O (n = 74), a consistently smaller proportion of patients reported adequate pain control after TSA. Pain control rates among group O vs. nonusers/opioid-naïve patients (group N) respectively were 81.1% vs. 89.6% (P = .080) at week 1, 83.8% vs. 92.4% (P = .055) at week 4, and 82.4% vs. 93.0% (P = .016) at week 12. ConclusionA patient’s resilience score and preoperative opioid consumption are associated with postoperative pain control. Physicians may be able to use these 2 preoperative measures to better individualize postoperative narcotic prescriptive practices and reduce the number of unused opioids.

Poster 108: Narcotic Use Following Knee Arthroscopy in Adolescent Patients: A Prospective Evaluation

Poster 108: Narcotic Use Following Knee Arthroscopy in Adolescent Patients: A Prospective Evaluation

Paper 04: The effect of prescribing patterns on utilization of opioid medication in ACL reconstruction: A randomized, prospective trial

Objectives:During the 21st century, opioid medication prescription and consumption has increased, which has led to an increase in opioid abuse, dependence, and fatal overdoses. Health care providers, particularly surgeons, have recently focused on decreasing the amount of opioids prescribed, as overprescribing is a known cause contributing to the opioid epidemic. Patients undergoing anterior cruciate ligament reconstruction (ACLR) would especially benefit for the identification of an ideal opioid prescription amount for post-op pain, as the average age of patients undergoing ACLR is 29.8 years old, which falls within the age group that experienced the largest increase in opioid related deaths between 2001 and 2016. It is unknown if prescribing patterns change patient behavior related to opioid consumption. The purpose of this randomized, prospective trial was to evaluate the effects of different quantities of prescribed opioid tablets on opioid utilization by patients, post-operative pain, and patient satisfaction following ACL reconstruction.Methods:This study was a prospective, randomized trial enrolling patients undergoing primary ACLR following ACL tear. Patients were randomly assigned to one of 3 prescription groups pre-operatively: 15 tablets, 25 tablets, or 35 tablets of oxycodone-5mg. Standard of care nerve blocks were utilized in all patients in addition to general anesthesia for the surgical procedure. Patients were instructed to take acetaminophen and NSAIDs as needed with the opioid medication to be used for “breakthrough” pain. Exclusion criteria included concomitant procedure other than meniscectomy or meniscal repair, ACL revision, history of chronic pre-operative opioid use, history of substance abuse, pregnancy, or workman’s compensation claims. Patients in all 3 groups were asked to complete pain and medication logs 2 times a day for the first 14 days post-operatively, along with an opioid medication satisfaction survey at 2 weeks, and IKDC questionnaires before surgery and up to 6 months post-operatively. Demographics and complication information were gathered from the medical record. Requests for prescription refills were recorded as well. Analysis assessed for statistical differences in post-op pain and medication usage. All usage of narcotics was verified with the state database monitoring system for narcotic pain medication.Results:One hundred thirty patients were included in the analysis (41 who received 15 oxycodone tablets, 40 who received 25 oxycodone tablets, and 49 who received 35 oxycodone tablets). There were no significant differences between the two groups in mean age at surgery (33.6 vs. 31.6 vs 33.3; P=0.328), BMI (27.7 vs 26.1 vs 25.7; P=0.525), or sex ratio (24M/17F, 20M/19F, 25M/24F; P=0.735). There were also no significant preoperative differences in subjective pain and function, as measured by IKDC scores (46.8 vs 48.7 vs 46.5; P=0.794).There were no significant differences in mean total morphine milligram equivalents (MME) consumed between the three groups (72.3 in the 15 tablet group, 61.9 in the 25 tablet group, 78.1 in the 35 tablet group; P>0.05). There was a significant difference between those who received 15 tablets and those who received 25 and 35 tablets when asked if they thought they were prescribed too few/too many narcotics, with a greater percentage of the 15 tablet group reporting that they felt they received too few at 20.6%, (P=0.05) as depicted in Figure 1. Despite this difference, there was no significant difference between the three groups on subjective morning or afternoon pain for the first 14 days after surgery, total opioid pills consumed, patient satisfaction on ability of the narcotic to treat their condition, patient satisfaction on amount of pain relief they experienced since surgery, or patient satisfaction regarding the amount of narcotics initially prescribed after surgery. Finally, there was no difference between the three groups on postoperative function at 2 weeks, 6 weeks, 3 months, and 6 months, as measured by IKDC scores (Figure 2).Conclusions:Despite a significantly larger portion of the group who received 15 oxycodone tablets reporting that they felt they received too few opioid tablets, there was no difference between those who received 15, 25, or 35 oxycodone-5mg tablets in reported pain levels, opioid consumption, or any satisfaction metrics. In addition, there was no difference between the three groups in pain and function as reported in the IKDC surveys. Given these results, giving lower quantities of opioid medication appears to be as effective in appropriately controlling post-operative pain as higher quantities, and may help to limit amount of opioids prescribed and possible diversion of unused prescription opioid medication.

Prospective Randomized Controlled Clinical Trial Comparing Hyperosmolar Saline to Standard Isotonic Irrigation Fluid for Arthroscopic Knee Surgery: Initial Clinical Outcomes.

Numerous in vitro studies suggest higher osmolarity irrigation fluids potentiate a chondroprotective environment, and a recent clinical study using hyperosmolar saline for shoulder arthroscopy reported potential clinical advantages. This prospective randomized double-blind controlled clinical trial was designed to assess initial clinical outcomes associated with use of a hyperosmolar irrigation solution in patients undergoing arthroscopic knee surgery. With institutional review board approval and informed consent, patients scheduled for arthroscopic knee surgery were randomized to surgery with either isotonic lactated Ringer's (273 mOsm/L) or hyperosmolar saline (593 mOsm/L) irrigation solution. Outcomes included perioperative blood pressure, knee girth, visual analogue scale (VAS) pain scores, and narcotic pain medication consumption. Forty-six patients underwent arthroscopic knee surgery with isotonic (n = 23) or hyperosmolar (n = 23) irrigation fluids. There were 11 males and 12 females (mean age = 44.0 years) in the isotonic cohort and 8 males and 15 females (mean age = 40.2 years) in the hyperosmolar cohort. There were no significant differences with respect to surgical duration (pump time) or amount of irrigation fluid used between the two cohorts. There were no significant differences with respect to change in knee girth, blood pressure, or VAS pain scores. However, patients treated with hyperosmolar saline consumed less narcotic medication on postoperative day 3 (4.0 ± 7.6 vs. 15.5 ± 17.4 mg, p = 0.01). The results of this randomized clinical trial suggest that a hyperosmolar irrigation solution is safe and relatively inexpensive for use in patients undergoing arthroscopic knee surgery and contributes to a reduction in initial postoperative narcotic pain medication consumption. A hyperosmolar saline irrigation fluid was not associated with any detrimental effects on the execution of the surgical procedure, postoperative pain, or periarticular fluid extravasation. Taken together with previous basic science, translational, and clinical studies, hyperosmolar saline irrigation fluid is promising alternative to traditional isotonic irrigation fluids for knee arthroscopy. This study is a prospective trial and reflects level of evidence I.

Surgeon's Impact on Opioid Epidemic Following Uncomplicated Laparoscopic Appendectomy and Cholecystectomy.

The opioid crisis in the United States remains a major issue that is directly linked to the prescribing practices of physicians. There is a lack of consistency in post-operative prescribing of narcotic medications. We have designed a retrospective study to evaluate factors that contribute to the prescription of opioids following common laparoscopic procedures. In this study, we analyzed peri-operative medications and pain requirements and how they relate to the frequency in which narcotics are prescribed at Saint Joseph’s University Medical Center (SJUMC), a level two trauma center and teaching hospital. We also studied how the frequency of narcotic prescriptions is related to patient demographics and surgeon practices. We propose that standardizing pain medication protocols will be an effective way to decrease overall narcotic use as well as prescriptions for common laparoscopic procedures.