Nonopioid Adjuncts Research Articles

Global research on sufentanil use in anesthesiology from 2003 to 2023: a bibliometric analysis.

The application of sufentanil of anesthesiology has become a popular research area. However, literature-based bibliometric analyses on sufentanil are limited. Therefore, this study aimed to review the application of sufentanil in anesthesiology, and evaluate the research status and trends in this field. We searched the SCI-Expanded, SSCI, and CPCI-S databases from the Web of Science core collection as data sources for articles published from 1 January2003, to 31 December2023, and bibliometric and VOSviewer software were used to visualize and analyze the literature in terms of authors, journals, countries, institutions, and their collaborative networks, as well as keyword networks. Our analysis included 1,473 relevant publications on the application of sufentanil in anesthesiology. The overall number of publications is on the rise; the top three countries of study were China, the US and France; the top three universities that published relevant articles were Anhui Medical University, Capital Medical University and Zhejiang University; the largest number of publications focused on Anesthesia and analgesia; At present, the studies in this field mainly focus on the application scope, mode, and advantages; adverse reactions; and combined effects of sufentanil in combination with other drugs. The adverse factors for the use of sufentanil in anesthesiology and ways to improve its safety and efficacy are hot topics of research. Future research should explore the applicability of population and dose utilization, novel drug combinations, non-opioid adjuncts, and technological innovations. An increasing number of publications indicates that researchers are showing interest in the field of sufentanil use in anesthesiology, and ongoing research is at a relatively mature level. While the international community has established a strong foundation for cooperation, the cooperation among researchers, institutions, and countries needs to be enhanced. Simultaneously, efforts must be made to explore and strengthen personnel cooperation, expand the coverage of funding support, and improve the quality of the literature.

Pudendal nerve block decreases narcotic requirements and time spent in post-anesthesia care units in patients undergoing primary inflatable penile prosthesis implantation.

Efforts to minimize narcotic usage following inflatable penile prosthesis (IPP) implantation are vital, considering the current opioid epidemic in the United States. We aimed to determine whether pudendal nerve block (PNB) utilization in a multiethnic population undergoing primary IPP implantation can decrease rates of post-operative opiate usage. A single-institution, retrospective study was conducted on patients who underwent primary IPP implantation between December 2015 and June 2022. PNB usage and intra- and post-operative outcomes were analyzed using multivariate binary logistic regression. 449 patients were included, with 373 (83.1%) in the PNB group. Median time (minutes) spent in the post-anesthesia care unit (PACU) (1499 [119-198] vs. 235 [169-322], p < 0.001) was significantly lower in the PNB group. There were no significant differences in intra-operative and PACU morphine milligram equivalents or post-operative safety outcomes between groups. However, fewer patients in the PNB group called for pain medications post-operatively (10.2% vs 19.7%, p = 0.019). Multivariate analysis revealed a significantly decreased operative time (B -6.23; 95%CI -11.28, -1.17; p = 0.016) and decreased time in recovery (B: -81.62; 95%CI: -106.49, -56.76, p < 0.001) in the PNB group. PNB decreases post-operative opioid analgesic requirements and time spent in PACU in patients undergoing a primary IPP implantation and thus may represent an attractive, non-opioid adjunct.

Children and the Opioid Crisis: We Can Make a Difference

The use of opioid-sparing and opioid-free strategies in children can provide adequate analgesia while decreasing the risk of adverse events and contributing to the ongoing battle against the opioid crisis. However, every child must be evaluated individually so that a safe and efficacious perioperative pain management plan can be created. A working knowledge of the risks and benefits of opioids, nonopioid adjuncts, and regional anesthesia along with the ethical considerations for balancing stewardship and beneficent care is essential to the success of these strategies. As perioperative practitioners caring for children, we have an obligation to consider opioid-sparing and opioid-free strategies to promote overall best outcomes. We can make a difference, one child at a time.

Effects of aromatherapy on patient satisfaction with procedural abortion at less than 10 weeks’ gestation: A randomized controlled trial

ObjectivesThis study aimed to compare satisfaction with procedural abortion prior to 10 weeks’ gestation in patients randomized to lavender essential oil aromatherapy vs placebo (jojoba oil). Study designThis randomized trial compared lavender aromatherapy vs placebo in patients undergoing procedural abortion <10 weeks’ gestation. Participants self-administered and inhaled oil during their procedures. Our primary outcome was composite mean score on the Iowa Satisfaction with Anesthesia Scale. Participants completed the State-Trait Anxiety Inventory, a visual analog scale reporting maximum procedural pain, and reported postprocedure aromatherapy acceptability. ResultsWe analyzed 112 participants randomized to aromatherapy (n = 57) vs placebo (n = 55). Baseline characteristics were similar between groups. We found no difference in overall satisfaction (mean Iowa Satisfaction with Anesthesia Scale scores aromatherapy: 0.72 ± 0.96 vs placebo: 0.46 ± 0.98, p = 0.17) or maximum procedural pain (median visual analog scale score aromatherapy: 65 [range: 4–95] vs placebo: 63 [range: 7–97], p = 0.91). Independent predictors of satisfaction included the use of oral sedation (B: 0.36; 95% CI: 0.04–0.69), state anxiety (B: −0.45; 95% CI: −0.79 to −0.10), and maximum procedural pain (B: −0.17; 95% CI: −0.25 to −0.09). The aromatherapy participants were significantly more likely to have found inhaling scented oil helpful during their procedure (71.9% vs 45.5%; p = 0.005) and would recommend it to a friend who needed a procedural abortion (86.0% vs 56.4%; p = 0.0005) compared to those in the placebo group. Additionally, patients in the aromatherapy group were significantly more likely to agree with the statement, “If I need another procedural abortion, I would want to inhale scented oil during my procedure” (87.7% vs 70.9%; p = 0.03). ConclusionsThe adjunctive use of lavender aromatherapy during first-trimester procedural abortion does not improve satisfaction with anesthesia but is highly valued by patients. ImplicationsOral opioids as an adjunct to standard analgesics during procedural abortion (ibuprofen and paracervical block) do not decrease pain, and nonopioid options are lacking. Given current limited anesthesia options, aromatherapy could serve as an affordable and acceptable nonopioid adjunct to current standard of care during procedural abortion. ClinicalTrials.gov IdentifierNCT04969900.

Adherence to Opioid Prescribing Guidelines in a Statewide Surgical Quality Improvement Collaborative

IntroductionThe opioid crisis is an ongoing crisis in the United States. Postoperative patients who receive opioid prescriptions have a 3%-7% risk of developing a chronic opioid abuse problem. This study aims to describe on-target opioid prescribing and use of multimodal pain management strategies 2 y after the implementation of a multicomponent quality improvement initiative across our statewide collaborative. MethodsFrom July 2020 to September 2021, we prospectively collected data on opioid-prescribing and multimodal strategies for 10 targeted procedures in general, gynecologic, and orthopedic surgery at three hospitals. Prescribing was on-target if a patient was prescribed ≤50 daily morphine milligram equivalents. Multimodal strategies were defined as two or more nonopioid adjuncts used within 48 h of surgery. ResultsOne thousand and eleven targeted procedures were performed with prescription data available for 993 cases. The on-target prescribing rate was 79.6% (n = 790), with general surgery 92.5% (n = 285), gynecology 84.9% (n = 331), and orthopedic surgery 59.0% (n = 174). Patients who received multimodal pain approaches were associated with interventions such as patient education, transversus abdominus plane block, and prescriptions for nonopioid analgesics at discharge. There was no evidence to support a difference in the use of multimodal pain control approaches between patients whose opioid prescribing was on-target or not (73.8% versus 77.3%, P = 0.30). At the first postoperative visit, data on continued opioid use were missing in 57.3% of patients, number of pills used was missing in 93.8%, and adequate pain control was missing in 52.8%. ConclusionsOn-target prescribing and multimodal strategies are common but vary by specialty. Additionally, postoperative pain control and opioid use are often not documented. To better match prescribing to patient needs, understanding patient-level and specialty-level opioid use is important.

Postoperative Pain Following Coblation of Sinonasal Hereditary Hemorrhagic Telangiectasias.

Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease and epistaxis is the most common symptom. This can be treated conservatively but severe cases may require operative interventions. Endoscopic endonasal coblation of HHT lesions has been used successfully but postoperative pain management has not been well described. This study aimed to assess levels of postoperative pain and opioid use among patients with HHT who underwent coblation of sinonasal lesions. This is a longitudinal, prospective cohort study of adult patients undergoing endoscopic endonasal coblation for treatment of HHT lesions with or without bevacizumab injection between November 2019 and March 2020 at a single academic university hospital. Patients were given preoperative questionnaires and contacted via telephone 48 hours after surgery. If they reported using opioids for pain control, they were called every 2 days until they no longer used these medications. Fourteen cases, including 13 unique patients, were included in this study. Opioids were ordered on discharge in 4 cases and the average morphine milligram equivalent prescribed on discharge was 41. The median pain score on postoperative day (POD) 2 was 4 of 10. Twelve patients reported using acetaminophen and 4 were using opioid pain medications. Of those using opioid pain medications, only 1 patient was using opioid pain medication by POD 4 and denied any use after POD 10. This study is the first to analyze postoperative pain management and opioid prescribing patterns in HHT patients undergoing endonasal coblation of telangiectasias. Postoperative pain was mild to moderate and most patients stopped using opioid medications by POD 4, although the majority of patients solely used acetaminophen. Future studies with increased sample size will be useful to further identify predictors of need for analgesics postoperatively and other non-opioid adjuncts for pain control.

Comparative Efficacy of Adjuvant Nonopioid Analgesia in Adult Cardiac Surgical Patients: A Network Meta-Analysis

To compare the relative efficacy of adjuvant nonopioid analgesic regimens in adult cardiac surgical patients. This frequentist, random-effects network meta-analysis (NMA) was prospectively registered on PROSPERO (CRD42021282913) and conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses for Network Meta-Analyses (PRISMA-NMA). The risk of bias (RoB) and confidence of evidence were assessed by RoB 2 and Confidence in Network Meta-Analysis, respectively. Relevant databases were searched from inception to October 9, 2021. A total of 124 (N=26,257) randomized controlled trials were included, of which 110 were analyzed. Trials enrolling adults (≥18 years of age) undergoing cardiac surgery that compared nonopioid analgesics against other nonopioid analgesics, placebo, or no additional treatment, as adjuvants to standard analgesic management, and reported at least 1 of the outcomes of interest. Outcomes of interest included resting postoperative pain scores at 24 hours. Compared with standard care and/or placebo, pain scores were reduced significantly by 10 different regimens, including acetaminophen (N=176; mean difference [MD] -0.66 points, 95% CI -1.16 to -0.15 points; high confidence), magnesium (N=323; -0.05 points, 95% CI -0.07 to -0.02 points; high confidence), gabapentin (N=96; MD -0.40 points, 95% CI -0.71 to -0.09; moderate confidence), and clonidine (N=64; MD v0.38 points, 95% CI -0.73 to v0.04 points; moderate confidence). Indomethacin, diclofenac, magnesium, and gabapentin significantly reduced 24-hour opioid consumption. Four regimens significantly decreased the intensive care unit length of stay. Hydrocortisone, dexmedetomidine, and clonidine significantly decreased the duration of mechanical ventilation. Magnesium decreased, while methylprednisolone significantly increased, the risk of myocardial infarction. Given the increasing emphasis on enhanced recovery after surgery(ERAS) protocols and the eventual goal of limiting opiate prescriptions postoperatively, the authors' data suggested far greater use of nonopioid adjuncts to minimize pain and enhance recovery following cardiac surgery.

Alternatives to remifentanil for the analgesic component of total intravenous anaesthesia: a narrative review.

Propfol-remifentanil-based total intravenous anaesthesia has dominated recent clinical practice due to its favourable pharmacokinetic profile. Interruption in remifentanil supply has presented an opportunity to diversify or even avoid the use of opioids and consider adjuncts to propofol-based total intravenous anaesthesia. Propofol, while a potent hypnotic, is not an effective analgesic. The administration of opioids, along with other adjuncts such as α-2 adrenoceptor agonists, magnesium, lidocaine, ketamine and nitrous oxide provide surgical anaesthesia and avoids large doses of propofol being required. We provide an overview of both target-control and manual infusion regimes for the alternative opioids: alfentanil, sufentanil and fentanyl. The optimal combination of hypnotic-opioid dose, titration sequence and anticipated additional postoperative analgesia required depend on the chosen combination. In addition, we include a brief discussion on the role of non-opioid adjuncts in total intravenous anaesthesia, suggested doses and expected reduction in propofol dose.

The butterfly effect: How an outpatient quality improvement project affected inpatient opioid's prescribing habits.

The aim of the study was to assess whether a quality improvement project focused on providers' education of responsible opioid prescribing, creating order sets to facilitate pre- and post-operative adjunct use, and decreasing the number of opioids prescribed following elective outpatient surgery affected opioid prescribing habits and the use of adjunct pain medication on the inpatient Emergency General Surgery (EGS) service. Inpatient EGS opioid prescribing habits following laparoscopic cholecystectomy, laparoscopic and open inguinal hernia repair, or open umbilical hernia repair during the pre- and post-Acute Care Surgery Division-Quality Improvement (QI) periods were recorded retrospectively. Demographics, type and dose of opioids, and non-opioid adjuncts prescribed were collected. Opioids were converted to oral morphine equivalents (OME). Pre- and post-QI data were compared. Post-QI discharge opioids prescribed were compared to reported use of opioids. Patients' rating of pain management is reported. One hundred twenty-two and 62 patients were included during the pre- and post- QI periods, respectively. Post-QI, opioid prescribing decreased, and adjunct prescribing increased (31.1% vs. 72.6%; p < 0.001) at discharge. Interestingly, higher 24 h pre-discharge OME was associated with a higher OME prescribed at discharge (B = 1.255 [0.377 - 2.134]; p = 0.005). Of the 47 EGS patients who followed up in clinic post-ACS QI, 89.4% rated their pain management as excellent/good, 8.5% as fair, and 2.1% as poor. Implementation of a multifaceted approach to decrease opioid prescribing in the outpatient setting organically affected opioid prescribing habits at discharge for inpatients.

A Large Database Evaluation of Infection and Nonunion Following Ankle Arthrodesis: Does Pain Regimen Matter?

Category: Ankle Arthritis; Ankle Introduction/Purpose: Multimodal therapies are critical for limiting use of opioids for postoperative pain control after orthopaedic procedures. Though NSAIDs and COX-2 inhibitors are effective non-opioid adjuncts for postoperative pain, animal models have demonstrated increased rates of nonunion or delayed union in the presence of NSAIDs. Nonunion or delayed union results in a protracted postoperative course that may warrant longer duration of surveillance or revision procedures. Retrospective studies and meta-analyses investigating NSAID use and bone healing have conflicting findings. Additionally, there are few studies investigating NSAID use and other adverse events such as postoperative infection. Improved understanding of the impact of NSAID use on union rates and infection after ankle arthrodesis will allow practitioners to optimize safe, effective pain control while limiting risk of nonunion. Methods: This large retrospective database study queried a national insurance claims database (PearlDiver Technologies) for patients undergoing ankle arthrodesis from 2015 through 2019 as identified by ICD-10 codes. Patients prescribed NSAIDs or COX-2 inhibitors within six weeks following ankle arthrodesis were identified. Patients with any operation one year prior to or following ankle arthrodesis were excluded from analysis to prevent attributing complications to another operation. Association between NSAID or COX-2 inhibitor use and infection or nonunion following ankle arthrodesis were analyzed using multivariable logistic regression analyses. To adjust for comorbid conditions, multivariable models included age at time of operation, sex, obesity, tobacco use, and diabetes. Results: Our query yielded 2,355 patients in the five-year period who underwent ankle arthrodesis. 257 (11%) patients were prescribed NSAIDs following surgery and 56 (2.4%) patients were prescribed COX-2 inhibitors. Infection risk was similar between patients not prescribed either medication (n=92, 4.5%) and those treated with NSAIDs (n=14, 5.4%; P=0.60) or COX-2 inhibitors (n=2, 3.5%; P=0.99). The nonunion rate between patients not prescribed either medication (n=232, 11%) was similar to those treated with COX-2 inhibitors (n=8, 14%; P=0.64), but increased in patients treated with NSAIDs (n=45, 18%; P=0.006). On multivariable analysis, tobacco use (OR, 1.46; 95% CI, 1.09-1.94), obesity (OR, 2.08; 95% CI, 1.57-2.76), and NSAID use (OR, 1.53; 95% CI, 1.06-2.17) were associated with increased odds of nonunion after ankle arthrodesis (all P&lt;0.02) (Table). Conclusion: Analysis of the PearlDiver database, the largest available administrative claims database, for 2,355 patients undergoing ankle arthrodesis demonstrated an 11% risk of nonunion and 4.5% risk of infection. The risk of nonunion is increased in patients prescribed NSAIDs within six weeks postoperatively (18%). After adjusting for comorbid conditions associated with nonunion, such as tobacco use and obesity, NSAID use increased risk of nonunion whereas COX-2 inhibitor use did not. Prospective investigation is necessary to better understand these relationships, however, our analysis suggests practitioners should judiciously utilize NSAIDs and consider use of COX-2 inhibitors for pain control after ankle arthrodesis surgery.

Assessment of Discharge Analgesic Prescription Patterns for Hospitalized Patients With Rib Fractures

There is a paucity of data describing opioid prescribing patterns for trauma patients. We investigated pain medication regimens prescribed at discharge for patients with traumatic rib fractures, as well as potential variables predictive of opioid prescribing. A single-center, retrospective analysis was performed of 337 adult patients presenting with ≥1 traumatic rib fractures between January and December 2019. The primary outcome was oral morphine milligram equivalents (MME) prescribed on discharge. A multivariable logistic regression analysis was performed to determine factors independently associated with above median (150) MME prescription at discharge. The majority of patients were male (68.8%) with a median age of 53y. Blunt trauma accounted for 97.3% of cases with a median Injury Severity Score(ISS) of 10. Locoregional pain procedures were utilized in 16.9% of patients. Opioids were the most common analgesic prescribed at discharge, and 74.1% of patients prescribed opioids on discharge were also prescribed a non-opioid adjunct. On multivariable analysis, daily MME prescribed during hospitalization (OR 1.01, 95% CI 1.01-1.02, P<0.01) and number of rib fractures (OR 2.26, 95% CI 1.36-3.74, P<0.01) were predictive of high MME prescribed on discharge. For patients with traumatic rib fractures, daily MME during hospitalization and number of rib fractures were predictive of high MME prescribing on discharge. Further prospective studies evaluating strategies for pain management and protocolized approaches to opioid prescribing are needed to reduce unnecessary and inappropriate opioid use in this patient population.

Decreasing opioid prescribing at discharge while maintaining adequate pain management is sustainable

Background:In 2018, using a pragmatic multimodal approach, discharge opioid prescriptions were reduced without affecting pain control management. Herein, we assessed whether this approach was sustainable and whether discharge opioid prescriptions could be further reduced.Methods:This is a single center prospective study of patients who underwent elective outpatient procedures provided by our institution‘s Acute Care Surgery Division surgeons. Adult patients who underwent elective surgeries performed by surgeons in the Division of Acute Care Surgery from November 2018 to June 2021 and agreed to participate were included. The opioid prescriptions pre-populated in the order set at discharge were reduced from 20 pills to 10 pills in May 2020. Demographics, opioid information, non-opioid adjuncts prescribed, reported use of opioids prescribed, and patients’ satisfaction were collected. Opioids were converted to oral morphine equivalents (OME).Results:A total of 178 patients were included. Elective surgeries performed mainly included inguinal hernia repair (38.8%), laparoscopic cholecystectomy (30.3%), cyst excision (13.5%), and umbilical hernia (8.4%). One hundred twenty-five and 53 patients underwent an elective operation with a surgeon in the Acute Care Surgery Division before and after the number of opioids pre-populated in the order set at discharge was reduced from 20 pills to 10 pills, respectively. Reducing the pre-populated discharge opioid prescriptions led to a significant decrease in OME prescribed (75 [75–76.5] vs. 80 [75–150], p < 0.001) without affecting patients’ satisfaction with pain management (excellent/good: 87.8% vs. 84%; p = 0.305)Conclusions:Our pragmatic multimodal approach is sustainable and allows for additional opioid prescription reduction without affecting patients’ satisfaction with pain management.

Implementing a Discharge Opioid Bundle in Adult Trauma Patients Decreases the Amount of Opioids Prescribed at Discharge.

Opioids remain the mainstay treatment of acute pain caused by trauma. The lack of evidence driven prescribing creates a challenging situation for providers. We hypothesized that the implementation of a trauma discharge opioid bundle (TDOB) would decrease the total morphine milligram equivalents (MME) prescribed at discharge while maintaining pain control. This was a pre-post study of adult trauma patients before and after implementation of a TDOB to guide the prescription of opioids and discharge prescription education in patients discharged from a level one trauma center. The pre-group and post-group, included consecutively discharged patients from September through November in 2018 and 2019. The primary outcome was the total MME prescribed at discharge. A total of 377 patients met inclusion criteria. One hundred and fifty-one patients were included in the pre-group and 226 in the post-group. The total MME prescribed at discharge (225 ± [150-300] pre vs 200 ± [100-225] post, P = < .001) and maximum MME/day (45 ± [30-45] vs 30 ± [20-45], P = .004) were significantly less in the post-group. Incidence of outpatient refills within fourteen days were similar. More non-opioid pain adjuncts were prescribed post-intervention and discharge pain education was provided more frequently. The implementation of a TDOB significantly reduced the MME prescribed at discharge without increasing the number of opioid refills.

Less Is More: A Multimodal Pain Management Strategy Is Associated With Reduced Opioid Use in Hospitalized Trauma Patients

IntroductionAdequate pain control is critical to the management and recovery of acutely injured patients. Opioids are associated with various adverse effects, and drug overdose is the leading cause of injury-related death in the United States. We hypothesized that a multimodal pain management protocol would reduce opioid use while still optimizing pain control. MethodsThe study included the preanalysis (August 2017-September 2018) and postanalysis (October 2018-August 2019) of a multimodal pain management strategy implemented in hospitalized adult patients admitted to the trauma service at a single American College of Surgeons-verified level-1 trauma center. Patients less than 18 y of age, pregnant patients, or imprisoned patients were excluded. The primary endpoint was opioid prescription on discharge (morphine milligram equivalent [MME]). The secondary endpoints included inpatient MMEs, nonopioid adjunct use, and pain scores. Subgroup analysis evaluating opioid use based on Injury Severity Score groups (mild, moderate, or severe) and by the Abbreviated Injury Scale body region was performed. ResultsThere were 1755 patients in the PRE group and 1723 patients in the POST group. MMEs prescribed on discharge decreased from median 15 (interquartile range: 37.5) to 1.2 (interquartile range: 22.5) (P < 0.001). More patients in the POST group were discharged opioid-free (44% versus 37%, P < 0.001). There was a significant increase in the use of all nonopioid pain medications. Pain scores did not change. Subgroup analysis revealed a significant decrease in discharge MMEs in mild and moderate Injury Severity Score groups and in all injured body regions except the chest. ConclusionsThe implementation of a multimodal pain management protocol in trauma patients targeting scheduled nonopioid medications and patient education is feasible and is associated with reduced opioid amount prescribed on discharge, without compromising pain control.

The divided dose approach to perioperative buprenorphine management in patients with opioid use disorder

There is limited evidence and no clear consensus suggesting best practices for perioperative buprenorphine management in patients with opioid use disorder. As such, we aimed to develop a standardized perioperative management approach with the goals of (1) optimizing perioperative analgesia, (2) minimizing relapse risk, (3) setting expectations for patients and clinicians, (4) achieving prescribing consistency and mitigating risk among clinicians not familiar with perioperative buprenorphine management, and (5) maintaining continuity throughout care transitions. An interprofessional expert focus group convened to develop a consensus algorithm based upon buprenorphine's unique pharmacologic features and published perioperative management recommendations. The resulting consensus algorithm continues the patient's home buprenorphine dose in order to minimize relapse risk, but utilizes a divided dose approach starting the day of surgery if moderate to severe post-operative pain is expected. This strategy leverages the analgesic effects of buprenorphine while allowing for additional opioid binding to optimize analgesia. A patient-centered multimodal perioperative approach including local and/or regional anesthetics and nonopioid adjuncts is employed. Post-operative care is optimized by preoperative planning, including standardized patient assessment, perioperative communication with the buprenorphine prescriber, and education for patients and clinicians. Overall, integrating an understanding of pharmacology and clinical impact through the use of a readily adaptable algorithm such as the divided dose approach is key to optimizing patient care in this high-risk population.

Standardizing Discharge Opioid Prescriptions in Kidney Transplant Patients Decreases Opioid Usage

BackgroundKidney transplant recipients are frequently prescribed excess opioids at discharge relative to their inpatient requirements. Recipients who fill prescriptions after transplant have an increased risk of death and graft loss. This study examined the impact of standardized prescriptions on discharge amount and number of outpatient refills. Materials and MethodsA historical cohort (Group 1) was compared to a cohort without patient-controlled analgesia (Group 2) and a cohort in which providers prescribed no opioids to patients who required none on the day prior to discharge, and 10 pills to those who required opioids on the day prior (Group 3). Demographics, oral morphine equivalents (OMEs) prescribed on the day prior to and at discharge, and outpatient refills were collected. Results270 recipients were included. There was a nonsignificant trend towards lower OMEs on the day prior to discharge in Groups 2 and 3. Nonopioid adjunct use increased (P < 0.001). Discharge OMEs significantly decreased (mean 87.2 in Group 1, 62.8 in Group 2, 26.6 in Group 3, P< 0.001). The number of patients discharged without opioids increased (23.8% of Group 1, 37.5% of Group 2, 60.6% of Group 3, P < 0.001). Group 3, Asian descent, and lower OMEs on the day prior were factors significantly associated with decreased discharge OMEs on multivariable linear regression. Twelve percent of Group 2 and 2% of Group 3 patients received an outpatient refill (P = 0.02). ConclusionsA protocol targeting discharge opioids significantly reduced the amount of opioids prescribed in kidney transplant recipients; most patients subsequently received no opioids at discharge.

65 Pain Management Practices in the Elderly Patient with Burn Injury

Abstract Introduction Opioids are key to pain management in burns but have increased side effects like falls and delirium in the elderly. However, comorbidities prevalent in this population (e.g., chronic kidney disease) limit use of non-opioid adjuncts, making pain control for these patients a difficult balance. Little data exists regarding pain control practices in elderly burn patients. We aim to retrospectively characterize pain management strategies (including opioids and non-opioid adjuncts) in this patient population. Methods This is a retrospective cohort of patients age &amp;gt;65 with burns &amp;lt; 20% total body surface area (TBSA) admitted to the burn stepdown unit from 2014 to 2019. The primary outcome was to quantify opioid use inpatient and at discharge in morphine milligram equivalents (MME). Secondary outcomes included percent of patients receiving opioids and adjunct analgesics at these timepoints. Mean MME inpatient vs. at discharge were compared using paired t-test. Percent of patients receiving opioids and non-opioid adjuncts were compared using McNemar’s test. Results One hundred elderly patients (mean age 73.9, SD 6.7) with mean TBSA of 5.6% (SD 4.5) were included. Fifty-two percent required autografting; the remainder received porcine or non-operative therapy. Mean daily inpatient MME was 18.0 (SD 20.8) and mean discharge MME was 28.0 (SD 20.5) (p=.001), equivalent to 12mg and 18.5mg of oral oxycodone. Inpatient, 72% of patients received opioids vs. 83% at discharge (p=.041). Acetaminophen was the most commonly prescribed non-opioid adjunct inpatient and at discharge; other adjuncts like non-steroidal anti-inflammatories (NSAIDs) and gabanoids were infrequently used. Conclusions Elderly burn patients are discharged with more opioids than utilized while inpatient. Aside from acetaminophen, non-opioid adjuncts used commonly in younger patients such as NSAIDs and gabanoid medications are under-utilized, presumably due to concern for comorbidities.

880: Assessment of Patient Race on Opioid and Non-Opioid Adjunct Therapy Administration in the ICU

880: Assessment of Patient Race on Opioid and Non-Opioid Adjunct Therapy Administration in the ICU

Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures.

IntroductionPain management is the pillar of caring for patients with traumatic rib fractures. Intravenous lidocaine (IVL) is a well-established non-opioid analgesic for post-operative pain, yet its efficacy has yet to be investigated in trauma patients. We hypothesized that IVL is associated with decreased inpatient opioid requirements among patients with rib fractures.MethodsWe retrospectively evaluated adult patients presenting to our Level 1 trauma center with isolated chest wall injuries. After 1:1 propensity score matching patients who received vs did not receive IVL, we compared the two groups’ average daily opioid use, opioid use in the last 24 hours of admission, and pain scores during admissions hours 24–48. We performed multivariable linear regression for these outcomes (with sensitivity analysis for the opioid use outcomes), adjusting for age as a moderating factor and controlling for hospital length of stay and injury severity.ResultsWe identified 534 patients, among whom 226 received IVL. Those who received IVL were older and had more serious injury. Compared to propensity-score matched patients who did not receive IVL, patients who received IVL had similar average daily opioid use and pain scores, but 40% lower opioid use during the last 24 hours of admission (p = 0.002). Multivariable regression–with and without sensitivity analysis–did not show an effect of IVL on any outcomes.ConclusionIVL was crudely associated with decreased opioid requirements in the last 24 hours of admission, the time period associated with opioid use at 90 days post-discharge. However, we did not observe beneficial effects of IVL on multivariable adjusted analyses; we are conducting a randomized control trial to further evaluate IVL’s opioid-sparing effects for patients with rib fractures.

Perioperative nonopioid analgesia reduces postoperative opioid consumption in knee arthroscopy: a systematic review and meta-analysis

The opioid epidemic has prompted an emphasis on investigating opioid-sparing alternatives for pain management following knee arthroscopy. This review evaluated the effects of perioperative nonopioid adjunct analgesia on postoperative opioid consumption and pain control in patients undergoing knee arthroscopy. A systematic review and meta-analysis was performed using the following databases: PubMed, Embase, Web of Science, MEDLINE, and SCOPUS. Prospective comparative studies assessing the efficacy of various perioperative nonopioid analgesic strategies in patients undergoing knee arthroscopy were included. Twenty-five studies (n = 2408) were included. Pre-emptive nonopioid pain medications demonstrated a reduction in cumulative postoperative oral morphine equivalent (OME) consumption by 11.8mg (95% CI - 18.3, - 5.4, p ≤ 0.0001) and VAS pain scores by 1.5 (95% CI - 2.3, - 0.7, p < 0.001) at 24h compared to placebo. Postoperative nonopioid pain medications significantly reduced cumulative postoperative OME consumption by 9.7mg (95% CI - 14.4, - 5.1, p < 0.001) and VAS pain scores by 1.0 (95% CI - 1.354, - 0.633, p < 0.001) at 24h compared to placebo. Saphenous nerve blocks significantly reduced cumulative postoperative OME consumption by 6.5mg (95% CI - 10.3, - 2.6, p = 0.01) and VAS pain scores by 0.8 (- 1.4, - 0.3, p = 0.03) at 24h compared to placebo. Both preoperative patient education and postoperative cryotherapy reduced postoperative opioid consumption. Perioperative nonopioid pharmacotherapy, saphenous nerve blocks, and cryotherapy for patients undergoing knee arthroscopy significantly reduce opioid consumption and pain scores when compared to placebo at 24h postoperatively. These interventions should be considered in efforts to reduce opioid consumption in patients undergoing knee arthroscopy. More research is needed to determine which interventions can reduce pain outside of the immediate postoperative period and the potential synergistic effects of combining interventions. II.