Need For Opioid Medication Research Articles

(011) Using Pre-Operative Low Intensity Vestibular Shockwave Therapy Reduces Opioid Use Post-Vestibulectomy

Abstract Introduction Surgeons performing complete vestibulectomy for neuro-proliferative vestibulodynia need to consider two competing post-operative interests: accomplishing acute pain relief in the early postoperative period; reducing risks of persistent post-operative opioid use. Data support that measures to decrease overall post-operative opioid use will decrease future opioid-related adverse events including opioid abuse and addiction. Sexual medicine providers are thus motivated to identify strategies such as pre-operative low intensity shockwave therapy (LISWT) to decrease opioid use in these vestibulectomy patients. To date, only one study has been published assessing the effect of pre-operative LISWT on surgical outcome. Dumfarth at al reported in a prospective randomized study that pre-operative LISWT significantly improved lower extremity wound healing compared to controls in patients undergoing vein harvesting for coronary artery bypass graft surgery. While Dumfarth et al did not directly assess post-operative pain, pre-operative LISWT was associated with statistically significantly increased satisfactory healing, reduced disturbance of healing and reduced minor skin infections, all consistent with less post-operative pain. It was hypothesized that pre-operative LISWT improved wound healing via enhanced blood supply and angiogenesis through expression of vascular endothelial growth factor (VEGF) and nitric oxide synthesis, and via anti-inflammatory action downregulating necrosis factor B activation thereby lowering inflammatory cytokines. Objectives We wished to see if pre-operative LISWT would reduce opioid use in women undergoing complete vestibulectomy. The objective of this study was to compare the use of opioids following vestibulectomy when LISWT with Urogold 100™ MTS was applied just prior to surgery versus no shockwave. LISWT is a non-invasive, non-pharmacologic, non-surgical treatment strategy with low morbidity that is FDA-cleared for pain amelioration in the US as non-significant risk in humans, Urogold 100™MTS provides unfocused electrohydraulic shockwaves with a unique parabolic reflector. Methods Patients scheduled for surgery were required to present to the hospital 4 days before surgery for a COVID-19 test. On that day and each subsequent day until surgery, based on the patient’s availability, the patient presented to the office for approximately 2400 shocks to the vestibule. This is a descriptive study of the patients’ post-operative experiences with pain. Results To date 4 women have undergone LISWT just prior to surgery. At the time of surgery Exparel was delivered to the site, allowing them 24-36 hours of anesthesia to the area so they could travel home easily. Patients were prescribed Percocet to be take every 4 hours as needed. Post-op patients routinely use this opioid 4-6 times a day for multiple days, causing constipation among the many side effects. The women who underwent LISWT immediately prior to surgery have experienced decreased levels of pain post-operatively such that they are using ½ tab of Percocet at bedtime or twice a day, thus decreasing opioid use with all of its potential side effects. Conclusions Performing LISWT using Urogold 100™MTS may reduce the need for opioid medications after total vestibulectomy with vaginal advancement flap as it may mediate pain after the surgical procedure. Disclosure No.

Eight-Kilogramme Giant Mesenteric Cyst of Mullerian Origin: Case Report and Review of Literature

Mesenteric cysts are a rare occurrence in clinical practice, and even fewer are found to be of Mullerian origin. Diagnosis of mesenteric cysts is typically based on clinical assessment and radiological imaging. Surgical excision remains the primary treatment option. We report a case of a middle-aged lady presenting with a giant mesenteric cyst weighing 8-kilogrammes that was managed with laparotomy. Current literature of this rare clinical entity was also reviewed, including differential diagnoses of cystic lesions within the abdomen and role of imaging in guiding pre-operative diagnosis and management strategies. The giant mesenteric cyst was successfully excised en bloc without spillage via a laparotomy. Analgesia optimisation was achieved with a continuous local anaesthetic infusion. Pre-operative radiology can assist in diagnosis of the mesenteric cyst and guide management. Should an open surgical approach be selected, analgesia can be optimised with a continuous local anaesthetic infusion which decreases need for opioid medications.

Effectiveness of Bariatric Surgery Targeting Opioid Prescriptions (BSTOP) protocol on postoperative pain control.

BackgroundSurgical pain management is a critical component in the success of bariatric procedures. With the opioid epidemic, there have been increased efforts to decrease opioid use. In 2019, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program developed the BSTOP protocol, a multimodal perioperative pain management regimen to minimize opioid use. The objective of this study is to evaluate the effectiveness of the BSTOP protocol on patients’ need for opioid medications during their perioperative care.MethodsThis is a single-institution prospective cohort study on patients who underwent bariatric surgery from 10/2019 to 5/2021. Data was collected on morphine equivalent dose of opioids during different stages of inpatient and outpatient care. BSTOP was implemented on 7/2020. Primary outcomes were total inpatient and outpatient opioid use as well as hospital length of hospital stay (LOS). Gabapentin was removed from the protocol between 10/20/2020 and 12/31/2020 due to side effects; it was re-implemented on 1/1/2021 due to observed spikes in opioid use during its absence.Results1264 patients who had bariatric surgery between 10/2019 and 5/2021 were included in the study, with 409 patients before (pre-BSTOP) and 855 patients after BSTOP implementation. There was a 36% reduction in total inpatient opiate use and a 57% reduction in total outpatient opiate use. LOS also significantly decreased, from 1.53 to 1.28 days. 179 patients received BSTOP without gabapentin. These patients used more opioids in the post-anesthesia care unit and on the inpatient floors compared to pre-BSTOP and BSTOP with gabapentin patients. With total inpatient and outpatient opioid use, patients on BSTOP without gabapentin used fewer opioids than those pre-BSTOP. However, those on BSTOP without gabapentin used more opioids than those with gabapentin.ConclusionThe BSTOP protocol significantly reduced inpatient and outpatient opioid use as well as LOS. Gabapentin is a crucial component of the BSTOP protocol.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-022-09646-4.

Using Text Messaging to Decrease Opioid Use After Hip and Knee Replacement

The development of persistent opioid use disorder after surgery is a preventable complication. The need for opioid medications after total joint replacement surgery is necessary for a favorable recovery and optimal functional outcomes. Traditionally patients get a single postoperative phone call after discharge from the hospital. This phone call does not provide adequate support to patients about postoperative pain medication tapering and cessation. The purpose of this study was to evaluate if sending interval text messages to joint replacement patients after discharge would help them discontinue opioid medications sooner. One hundred and thirty-seven patients (69 in the control group and 68 in the experimental group) participated in a quasi-experimental after only study to compare the effectiveness of text messaging on opioid use in patients undergoing total knee and total hip arthroplasty. There were no significant differences in the demographic characteristics of the two groups. The z test for the Difference of Two Proportions was used to evaluate the outcomes of the study. The results found that patients that received the text messages in the experimental group stopped using opioid medications sooner than those patients in the control group at the 30-day and 60-day postoperative interval. The was no significant difference found at 90 days after surgery between the two groups. Utilization of text messaging platforms can improve the tapering and cessation of opioid medications in the early postoperative period in patients undergoing total hip and total knee arthroplasty. This project can be used as support for clinicians considering engaging patients through technology to improve postoperative outcomes.

Neonatal Abstinence Syndrome: An Integrative Review of Neonatal Acupuncture to Inform a Protocol for Adjunctive Treatment.

The current opioid epidemic in the United States has given rise to a growing incidence of neonatal abstinence syndrome (NAS). Treatments for this condition optimize nonpharmacologic therapies in an effort to improve withdrawal symptoms and reduce or eliminate the need for opioid medications, thereby reducing hospital length of stay and improving healthy neonatal outcomes. The purpose of this review was to evaluate the current evidence for neonatal acupuncture treatments and identify essential characteristics that must be included in a treatment protocol for NAS. An integrative review was conducted under the guidance of the Whittemore and Knafl methodology and near-term infant conceptual framework. An evaluation of the quality and levels of evidence was also included. A total of 10 studies were identified in this review. Four of these studies were randomized controlled trials, and utilized acupuncture in the neonatal population to evaluate impact on pain, NAS, and weight gain. This review provided the essential elements for the development of a complementary acupuncture treatment protocol for the management of NAS. Future research should include the identified essential characteristics in high-quality, blinded, randomized controlled trials to assess the treatment effect of acupuncture on neonates experiencing withdrawal symptoms.

Interspinous process decompression is associated with a reduction in opioid analgesia in patients with lumbar spinal stenosis.

BackgroundLumbar spinal stenosis (LSS) causes significant pain and functional impairment, and medical management has increasingly included the prescription of opioid-based analgesics. Interspinous process decompression (IPD) provides a minimally-invasive treatment option for LSS.MethodsThis study estimated the type, dosage, and duration of opioid medications through 5 years of follow-up after IPD with the Superion Indirect Decompression System (Vertiflex Inc., Carlsbad, CA USA). Data were obtained from the Superion-treatment arm of a randomized controlled noninferiority trial. The prevalence of subjects using opiates was determined at baseline through 60 months. Primary analysis included all 190 patients randomized to receive the Superion device. In a subgroup of 98 subjects, we determined opioid-medication prevalence among subjects with a history of opioid use.ResultsAt baseline, almost 50% (94 of 190) of subjects were using opioid medication. Thereafter, there was a sharp decrease in opioid-medication prevalence from 25.2% (41 of 163) at 12 months to 13.3% (20 of 150) at 24 months to 7.5% (8 of 107) at 60 months. Between baseline and 5 years, there was an 85% decrease in the proportion of subjects using opioids. A similar pattern was also observed among subjects with a history of opiates prior to entering the trial.ConclusionStand-alone IPD is associated with a marked decrease in the need for opioid medications to manage symptoms related to LSS. In light of the current opiate epidemic, such alternatives as IPD may provide effective pain relief in patients with LSS without the need for opioid therapy.

The Risk of Prolonged Opioid Use Is Low After Hand Surgery Among Opioid, Benzodiazepine, and Sedative/Hypnotic-Naïve Patients

Receipt of Intellectual Property Rights: Dimension Orthotics, LLC (Rivlin) Contracted Research: Miami Device Solutions (Rivlin) Ownership Interest: Wright Medical Inc., Matador, LLC (Beredjiklian), Dimension Orthotics, LLC (Beredjiklian and Rivlin) The prescription of opioids in the United States has dramatically increased since the 1990s. Several states have developed online Prescription Drug Monitoring Programs (PDMPs) aimed at preventing the overuse and overprescribing of controlled substances. We sought to determine the proportion of prolonged opioid use in patients undergoing outpatient hand surgery. We hypothesized that preoperative exposure to opioids, benzodiazepines, and sedative/hypnotics would be directly related to increased opioid use after surgery. Consecutive patients undergoing upper-extremity surgery at one institution were enrolled. The Pennsylvania PDMP Web site was used to document all prescriptions of controlled substances filled 6 months prior to and after the procedure. Patients were grouped into exposed or not-exposed cohorts dependent upon their exposure 6 months prior to surgery. 290 patients were included in the study. Opioid-naïve (ON) patients filled fewer opioid prescriptions than their opioid-exposed (OE) counterparts (P < .001). The likelihood of filling a second opioid prescription was 23.2 times greater in the OE than the ON group (P < .001). Compared to the ON group, patients in the OE group were 7.0 times more likely to fill a benzodiazepine prescription and 6.4 times more likely to fill a sedative/hypnotic prescription (P < .001). Benzodiazepine- and sedative/hypnotic-exposed patients were significantly more likely to fill a controlled substance prescription than their naïve counterparts (P < .001). Patients in the OE group evidenced significantly prolonged opioid use compared to those in the ON group (P < .0001). Surgery was not associated with a change in “use status” of opioids, or sedative/hypnotics in the postoperative compared to the preoperative period. (P = .6). •Patients without exposure to opioid, benzodiazepine or sedative/hypnotic medications are highly unlikely to develop a prolonged need for opioid medication.•Having outpatient hand surgery and having an opioid prescribed does not appear to change the patterns of controlled substances used.•States’ PDMP Web sites may be an important tool for prescribers in the management of this difficult problem.

Decreased Risk of Delirium With Use of Regional Analgesia in Geriatric Trauma Patients With Multiple Rib Fractures.

The aim of this study was to examine the risk of delirium in geriatric trauma patients with rib fractures treated with systemic opioids compared with those treated with regional analgesia (RA). Delirium is a modifiable complication associated with increased morbidity and mortality. RA may reduce the need for opioid medications, which are associated with delirium in older adults. Cohort study of patients ≥65 years admitted to a regional trauma center from 2011 to 2016. Inclusion factors were ≥ 3 rib fractures, blunt trauma mechanism, and admission to intensive care unit (ICU). Exclusion criteria included head AIS ≥3, spine AIS ≥3, dementia, and death within 24 hours. The primary outcome was delirium positive ICU days, defined using the CAM-ICU assessment. Delirium incident rate ratios (IRRs) and 95% confidence intervals (95% CIs) were estimated using generalized linear mixed models with Poisson distribution and robust standard errors. Of the 144 patients included in the study, 27 (19%) received Acute Pain Service consultation and RA and 117 (81%) received opioid-based systemic analgesia. Patients with RA had more severe chest injury than those without. The risk of delirium decreased by 24% per day per patient with use of RA (IRR 0.76, 95% CI 0.61 to 0.96). Individual opioid use, as measured in daily morphine equivalents (MEDs), was significantly reduced after initiation of RA (mean difference -7.62, 95% CI -14.4 to -0.81). Although use of RA techniques in geriatric trauma patients with multiple rib fractures was associated with higher MED, opioid use decreased after RA initiation and Acute Pain Service consultation, and the risk of delirium was lower.

A Prospective Randomized Study Evaluating the Effect of Perioperative NSAIDs on Opioid Consumption and Pain Management After Ankle Fracture Surgery

Category: Trauma Introduction/Purpose: Currently there is an epidemic in the United States regarding opioid abuse. This has resulted in strict government prescribing regulations throughout the country and increasing efforts by orthopaedic surgeons to better manage postoperative narcotic analgesia. Non-steroidal anti-inflammatory drugs (NSAIDs) can serve as a powerful adjunct in managing postoperative pain and in turn minimize the need for opioid medications. It has recently been shown that ketorolac can be used after open reduction and internal fixation (ORIF) of ankle fractures without interfering with bone healing. Therefore, we set out to evaluate whether including ketorolac in the postoperative drug regimen reduces opioid consumption and pain after ORIF of ankle fractures. Methods: 128 patients undergoing ORIF of an ankle fracture were prospectively randomized to treatment with or without ketorolac. Patients also had the option to simultaneously undergo regional anesthesia. Patients assigned to the treatment group were given 30 mg of IV ketorolac intraoperatively; prescribed 20 tablets of ketorolac 10 mg PO Q6 H and 30 tablets of Oxycodone/Acetaminophen 5/325 Q4-6 H PRN. Patients assigned to the control group were given 30 tablets of oxycodone/acetaminophen 5/325 Q4-6 H PRN only. A survey was distributed via Research Electronic Data Capture (REDCap) on postoperative days 1-7. Patients were asked to report their daily opioid consumption, pain level using the Visual Analog Scale (VAS), satisfaction with pain management, and side effects. Intention-to-treat analysis was performed. Normality of data was tested using the Shapiro-Wilk test. Differences between the control and treatment groups were tested using Mann-Whitney U or Student’s t-tests. Results: 105/128 (82%) patients with mean BMI of 29.3 completed all study requirements. 54 received ketorolac with opioid medication and 51 received opioids alone. 43 men (41%) and 62 women (59%) participated with mean age of 48 years. Patients receiving ketorolac required less oxycodone/acetaminophen (p&lt;0.013) and reported less pain (p&lt;0.048) during postoperative days 1 and 2 compared to control patients(Figure 1). While opioid consumption did not significantly differ after day 2, patients treated with ketorolac maintained less pain (days 1-4, p&lt;0.028); better sleep (days 1-5, p&lt;0.037); lower frequency of pain (days 1-3; p&lt;0.017); and greater satisfaction with pain management (days 1-3, p&lt;0.047). Hypersensitivity was significantly less on day 1 (p=0.036) and paresthesias on day 3 (p=0.011). Surprisingly, there was no difference in nausea/constipation between groups (p&gt;0.139). Conclusion: The addition of ketorolac to the postoperative drug regimen significantly reduced pain, while decreasing the use of opioid medication following ORIF of ankle fractures early in the postoperative period. Better pain management during postoperative days 1 and 2 is particularly important because patients on average consume the most opioids during this time. With the assurance that ketorolac does not interfere with bone healing, this NSAID is a valuable tool for helping patients manage postoperative pain with less narcotic analgesia.

Patient Satisfaction With Nonopioid Pain Management Following Knee Arthroscopic Partial Meniscectomy and/or Chondroplasty.

The purpose of this study was to determine the efficacy of nonopioid pain management following arthroscopic partial meniscectomy and/or chondroplasty and to assess patients' attitudes regarding their need for opioid pain medication following these procedures. Patients who underwent a knee arthroscopy procedure for either partial meniscectomy and/or chondroplasty from July 2016 to January 2017 by a single surgeon at a single institution were included. Medical records were reviewed, and demographics were recorded. Two weeks postoperatively, patients self-reported opioid and nonopioid medication use. Patients were also questioned regarding their perceived need for opioid medication, whether they felt their pain was adequately controlled, and how their pain compared with their preoperative expectations. Thirty-four patients (17 male, 17 female), with a mean age at the time of surgery of 47.79 years (range, 19-68 years), were included. Eighty-two percent (n=28) of the patients reported using nonopioid analgesics for pain control, whereas 18% (n=6) reported using opioids. Of those not using opioids, 96.4% (n=27) reported not feeling the need for opioid medications. Three of 6 patients requiring opioids were unable to take nonsteroidal anti-inflammatory drugs. All 6 patients who took opioids felt that they needed them for adequate pain control. This study provides initial encouragement that it is largely possible to remove opioids from the postoperative pain regimen of knee arthroscopy patients and maintain adequate pain control and patient satisfaction. [Orthopedics. 2018; 41(4):209-214.].

Spinal or general anaesthesia for lower‐limb amputation in peripheral artery disease – a retrospective cohort study

The present study aimed to determine which method of anaesthesia (spinal anaesthesia or general anaesthesia) is better in reducing post-operative analgesic requirements in patients undergoing major limb amputation for lower-limb ischaemia. Another aim was to find out if anaesthesiologists use neuraxial anaesthesia in high-risk patients despite abnormal coagulation profile or use of anticoagulation. The study was a retrospective cohort study. All patients undergone above-the-knee amputation or below-the-knee amputation due to peripheral artery disease between 1996 and 2010 were reviewed to evaluate post-operative opioid consumption and complications. A total of 434 amputations in 323 patients were included in the study. The number of surgical complications, the need for surgical revision and the number of intensive care unit admissions were significantly higher in the general anaesthesia group. The need for post-operative opioid medication was significantly lower in patients with above-the-knee amputation and spinal anaesthesia. The use of post-operative epidural analgesia did not reduce analgesic requirements. In the present study, there were patients who received neuraxial anaesthesia despite abnormal coagulation profile or uninterrupted warfarin or clopidogrel. There were no reported cases of spinal or epidural haematoma. Patients with spinal anaesthesia had a lower rate of surgical complications, re-operations and intensive care unit admissions. Patients with above-the-knee amputation and spinal anaesthesia had a lesser need for opioid medication in the post-operative period than patients with general anaesthesia. Anaesthesiologists performed neuraxial anaesthesia and/or analgesia in high-risk patients despite abnormal coagulation profile or ongoing anticoagulation, but no adverse outcomes were reported.

Peri-operative pain and its consequences

Recent advances in the management of peri-operative pain principally concern the recognition of the risk of developing pain chronicity. The best identified risk factors for pain chronicity are the presence of pain pre-operatively, pre-operative opioid use, and the intensity of post-operative pain. Ideal management of peri-operative pain in 2015 aims to optimize post-operative pain management, to detect the risk of pain chronicity begins pre-operatively with early detection of risk factors for chronicity. In terms of treatment, the systematic and generous use of morphine has shown its limitations, particularly due to reduced efficacy for movement-related pain. Meanwhile, opioid side effects can be very debilitating for the patient, leading to delay in post-operative rehabilitation, a dose-dependent hyperalgesic effect resulting in both acute and chronic pain, immune modulation that may have a deleterious impact on infectious complications or cancer [1], and, finally, some question of possible neurotoxicity. Therefore, modern analgesia depends on both intra-operative and post-operative morphine sparing. The goal at the present time is to obtain optimal analgesia that allows rapid rehabilitation without sequelae or chronicity through the use of drugs and/or techniques to avoid the need for opioid medications.

Critical appraisal of extended-release hydrocodone for chronic pain: patient considerations.

Opioid analgesics are currently the most effective pharmacologic option for the management of both acute and chronic forms of moderate-to-severe pain. Although the “as-needed” use of immediate-release formulations is considered optimum for treating acute, painful episodes of limited duration, the scheduled dosing of extended-release formulations with immediate-release supplementation for breakthrough pain is regarded to be most effective for managing chronic conditions requiring around-the-clock treatment. The recent introduction of extended-release formulations of the opioid analgesic hydrocodone potentially broadened the possibility of providing pain relief for individuals for whom current formulations are either ineffective or not tolerated. However, reaction to the approval of the new formulations has fueled controversy over the general safety and need for opioid medications, in light of their potential for misuse, abuse, diversion, and addiction. Here, we discuss how the approval of extended-release formulations of hydrocodone and the emotionally charged controversy over their release may affect physician prescribing and the care available to patients in need of chronic opioid therapy for the management of pain.

Hypnosis Delivered Through Immersive Virtual Reality for Burn Pain: A Clinical Case Series

This study is the first to use virtual-reality technology on a series of clinical patients to make hypnotic analgesia less effortful for patients and to increase the efficiency of hypnosis by eliminating the need for the presence of a trained clinician. This technologically based hypnotic induction was used to deliver hypnotic analgesia to burn-injury patients undergoing painful wound-care procedures. Pre- and postprocedure measures were collected on 13 patients with burn injuries across 3 days. In an uncontrolled series of cases, there was a decrease in reported pain and anxiety, and the need for opioid medication was cut in half. The results support additional research on the utility and efficacy of hypnotic analgesia provided by virtual reality hypnosis. The technology involved in virtual reality hypnosis was primarily developed through Hunter Hoffman, Ph.D. This project was supported by funding from NIH grants R01 GM42725-09A1 and 1 R21 HD40954-01 as well as the Paul Allen and Scandinavian Design Foundations.