Use Of Nonopioid Analgesics Research Articles

Prevalence and Mortality Incidence of Poisoning Cases in Serdang Hospital

In Malaysia, there were more than 35,000 poisoning cases enquiries were reported to the poison centre since its establishment from the year 1995 to 2014. The objective of our study is to determine the prevalence of poisoning cases and antidote used in Serdang Hospital. All poisoning cases admitted to the Serdang Hospital between January 2007 to December 2016 were evaluated retrospectively by using consecutive sampling. Data were obtained from Electronic Hospital Information System (eHIS) by using data collection form. Descriptive statistic was used to analyse the data. 903 patients were included in our study. The prevalence of poisoning cases during the study period is 0.22%. The fatality rate was 1.8% (n=16). More detailed data reveals that young adults aged between 18 to 29 years old, 44.2% (n=399) has the preponderance of poisoning cases, and females, 59.7% (n=539) admission dominated over males. Most poisoning cases were intentional, 74.5% (n=673) and related to the use of non-opioid analgesics, 35.7% (n=322). In summary, these trends of poisonings provides a foundation to recognise areas for training and education on self-injury prevention among healthcare providers and public society.

Opioid prescribing practices in a pediatric burn tertiary care facility: Is it time to change?

Opioids are the mainstay therapy in burned adults. Little data in the pediatric burn population exists that elucidates opioid prescribing practices. The primary purpose of this report is to quantify opioid and non-opioid analgesic use in pediatric burn patients admitted to a tertiary referral burn center. A retrospective audit of hospital charts and discharge records for patients <18 years old from March 2016 to March 2017 was performed. Opioid amounts were converted to either oral morphine miligram equivalents (MME) or oral MME per day and subsequently adjusted for age in kilograms (kg). Of the 226 patients, 223 (98.7%) were administered an opioid during admission. The median total opioid amount administered during admission was 0.4 (IQR: 0.3–0.6) mg oral MME per kilogram per day. Anecdotally, doses above 1 mg/kg/day are considered high risk for opioid tolerance. The median total opioid amount prescribed upon discharge was high at 3.9 (IQR: 2.3, 5.6) mg of oral MME per kilogram. Hydrocodone (96.0%) was the most common opioid administered, followed by morphine (88.1%). The most commonly prescribed discharge opioid was hydrocodone (95.4%). Non-opoioid analgesia during admission was used in 112 patients (49.6%). This study provides novel insight into the opioid practices at a tertiary burn center for pediatric patients, with our analysis showcasing high usage of opioids during admission and discharge for burn analgesia. It emphasizes the need to expand beyond opioids for burn analgesia and the importance of promoting non-opioid, multimodal analgesia in the pediatric burn population.

Trends in Prescription Analgesic Use Among Adults With Musculoskeletal Conditions in the United States, 1999-2016

Monitoring trends in prescription analgesic use among adults with musculoskeletal conditions provides insight into how changing prescribing practices, guidelines, and policy measures may affect those who need pain management. To evaluate trends in prescription opioid use and nonopioid analgesic use among adults with functional limitations attributable to musculoskeletal conditions. This repeated cross-sectional study uses data from the National Health and Nutrition Examination Study from 1999 to 2016. Data were analyzed from January to July 2019. The participants were adults aged 30 to 79 years who reported functional limitations due to back or neck problems and/or arthritis or rheumatism. Any use of a prescription opioid or exclusive use of a prescription nonopioid analgesic. In this population of 7256 adults with 1 or more functional limitations attributable to a musculoskeletal condition (4226 women [59.9%]; 3508 [74.4%] non-Hispanic white individuals; median [interquartile range] age, 63 [53-70] years), opioid use and exclusive nonopioid analgesic use exhibited approximately reciprocal patterns of change from 1999 to 2016. Opioid use increased significantly (difference in prevalence for 2015-2016 vs 1999-2000, 7.2%; 95% CI, 1.3% to 13%; P for trend = .002), and exclusive use of nonopioid analgesics decreased significantly (difference in prevalence for 2015-2016 vs 1999-2000, -13%; 95% CI, -19% to -7.5%; P for trend < .001) during this period. The increase in any opioid use was driven by long-term rather than short-term use. A crossover in the prevalence of opioid use and exclusive use of nonopioid analgesics occurred between 2003 and 2006, after which opioid use was more prevalent. Between 2013 and 2016, decreases in opioid use were observed among men (difference in prevalence for 2015-2016 vs 2013-2014, -11%; 95% CI, -21% to 1.8%) and participants with less than a high school education (difference, -15%; 95% CI, -24% to -6.1%). During this same period, exclusive nonopioid analgesic use also decreased markedly across the population (difference, -5.3%; 95% CI, -9.1% to -1.5%). The substitution of opioids for nonopioid analgesics between 2003 and 2006 may have occurred as evidence emerged on the cardiovascular risks associated with nonopioid analgesics. Reductions in opioid use between 2013 and 2016 were most substantial among those with low socioeconomic status, who may encounter barriers in accessing alternatives. Despite those decreases, opioid use remained more prevalent in 2015 to 2016 than in 1999 to 2000, suggesting a potentially long tail for the opioid epidemic.

The intraoperative use of non-opioid adjuvant analgesic agents: a survey of anaesthetists in Australia and New Zealand

BackgroundOpioids have long been the mainstay of drugs used for intra-operative analgesia. Due to their well-known short and long term side effects, the use of non-opioid analgesics has often been encouraged to decrease the dose of opioid required and minimise these side effects. The trends in using non-opioid adjuvants among Australian Anaesthetists have not been examined before. This study has attempted to determine the use of non-opioid analgesics as part of an opioid sparing practice among anaesthetists across Australia and New Zealand.MethodsA survey was distributed to 985 anaesthetists in Australia and New Zealand. The questions focused on frequency of use of different adjuvants and any reasons for not using individual agents. The agents surveyed were paracetamol, dexamethasone, non-steroidal anti-inflammatory agents (NSAIDs), tramadol, ketamine, anticonvulsants, intravenous lidocaine, systemic alpha 2 agonists, magnesium sulphate, and beta blockers. Descriptive statistics were used and data are expressed as a percentage of response for each drug.ResultsThe response rate was 33.4%. Paracetamol was the most frequently used; with 72% of the respondents describing frequent usage (defined as usage above 70% of the time); followed by parecoxib (42% reported frequent usage) and dexamethasone (35% reported frequent usage). Other adjuvants were used much less commonly, with anaesthetists reporting their frequent usage at less than 10%. The majority of respondents suggested that they would never consider dexmedetomidine, magnesium, esmolol, pregabalin or gabapentin. Perceived disincentives for the use of analgesic adjuvants varied. The main concerns were side effects, lack of evidence for benefit, and anaesthetists’ experience. The latter two were the major factors for magnesium, dexmedetomidine and esmolol.ConclusionThe uptake of tramadol, lidocaine and magnesium amongst respondents from anaesthetists in Australia and New Zealand was poor. Gabapentin, pregabalin, dexmedetomidine and esmolol use was relatively rare. Most anaesthetists need substantial evidence before introducing a non-opioid adjuvant into their routine practice. Future trials should focus on assessing the opioid sparing benefits and relative risk of using individual non-opioid adjuvants in the perioperative period for specific procedures and patient populations.

Postoperative Pain and Opioid Use Following Surgical Treatment of Ankle Fractures

Category:Ankle, Bunion, TraumaIntroduction/Purpose:Chronic opioid abuse is one of the greatest public health challenges in the United States. The most common first exposure to opioids comes from acute care prescriptions, such as those after surgery. Moreover, opioids are often prescribed excessively, with current estimates suggesting ˜75% of the pills prescribed are unused. Ankle fractures are the most common operatively treated fracture in orthopaedic surgery, and management of acute pain following surgery is challenging. The optimal perioperative pain regimen is still a point of controversy, as there is limited data available regarding appropriate amount of opioid to prescribe. This study evaluates opioid prescribing techniques of multiple foot and ankle surgeons, and associated patient outcomes. We aim to help surgeons improve their pain management practices and to limit opioid overprescription.Methods:Chart review and phone survey were performed on forty two adult patients within three to six months of ankle fracture fixation at our institution. These patients were offered to voluntarily participate in a standardized questionnaire regarding pain scores, opioid use, non-opioid analgesic use, pain management satisfaction, and patient prescription education.Results:57% of patients reported that they were given “more” or ”much more” opioid medication than needed, 38% stated that they were given the “right amount”, and 5% reported that they were given ”less” or “much less” than needed. 40.0% were on opioids prior to operation. 53.5% did not require refill of discharge opioid prescriptions, 30.2% of patients did not fill any posteroperative opioid prescription. 16.3% of patients filled their discharge prescription and at least one additionall refill (mean refill = 2.22). Mean number of reported opioid pills taken after surgery was 17.4. Mean satisfaction with overall pain management at phone follow up was 8.6/10.Conclusion:While postoperative pain and management vary substantially, a majority of patients feel that they are given more opioid medication than necessary following ankle fracture repair, and a majority of opioid prescriptions are not completely used. Going forward, it is likely that a majority of patients could experience the same beneficial results with less prescription opioid pain medication, which would reduce overpresciption and potential misuse.

Multimodal analgesia for craniotomy.

To explore the data for and against the use of the various components of multimodal analgesia in cranial neurosurgery. Postcraniotomy pain is a challenging clinical problem in that analgesia must be accomplished without affecting neurologic function (i.e. 'losing the neurologic exam'). The traditional approach with low-dose opioids is often insufficient and can cause well recognized side effects. Newer multimodal analgesic approaches have proven beneficial in a variety of other surgical patient populations. The combined use of multiple nonopioid analgesics offers the promise of improved pain control and reduced opioid administration, while preserving the clinical neurologic exam. Specifically, acetaminophen and gabapentinoids should be considered for craniotomy patients, both preoperatively and postoperatively. The gabapentinoids have the added benefit of reduced nausea. Scalp blocks have moderate quality evidence supporting their use over incisional infiltration alone, with analgesia that extends into the postoperative period. Intraoperative dexmedetomidine reduces postoperative opioid requirements with the added benefit of reduced postcraniotomy hypertension. Methocarbamol, NSAIDs [both nonspecific cyclooxygenase (COX) 1 and 2 inhibitors and specific COX-2 inhibitors], ketamine, and intravenous lidocaine require further data regarding safety and efficacy in craniotomy patients. Opioids are the mainstay for treating acute postcraniotomy pain but should be minimized. The evidence to support a multimodal approach is growing; neuroanesthesiologists and neurosurgeons should seek to incorporate multimodal analgesia into the perioperative care of craniotomy patients. Preoperative and postoperative gabapentin and acetaminophen, intraoperative dexmedetomidine, and scalp blocks over incisional infiltration have the most data for benefit, with good safety profiles. Further research is needed to define the safety, efficacy, and dosing parameters for NSAIDs including COX-2 inhibitors, methocarbamol, ketamine, and intravenous lidocaine in cranial neurosurgery.

Extension for Community Healthcare Outcomes-Palliative Care in Africa Program: Improving Access to Quality Palliative Care.

PURPOSEThere is limited access to quality palliative care (PC) for patients with advanced cancer in sub-Saharan Africa. Our aim was to describe the development of the Project Extension for Community Healthcare Outcomes-Palliative Care in Africa (ECHO-PACA) program and describe a preliminary evaluation of attitudes and knowledge of participants regarding the ability of the program to deliver quality PC.METHODSAn interdisciplinary team at the MD Anderson Cancer Center, guided by experts in PC in sub-Saharan Africa, adapted a standardized curriculum based on PC needs in the region. Participants were then recruited, and monthly telementoring sessions were held for 16 months. The monthly telementoring sessions consisted of case presentations, discussions, and didactic lectures. Program participants came from 14 clinics and teaching hospitals in Ghana, Kenya, Nigeria, South Africa, and Zambia. Participants were surveyed at the beginning, midpoint, and end of the 16-month program to evaluate changes in attitudes and knowledge of PC.RESULTSThe median number of participants per session was 30. Thirty-three (83%) of 40 initial participants completed the feedback survey. Health care providers’ self-reported confidence in providing PC increased with participation in the Project ECHO-PACA clinic. There was significant improvement in the participants’ attitudes and knowledge, especially in titrating opioids for pain control (P = .042), appropriate use of non-opioid analgesics (P = .012), and identifying and addressing communication issues related to end-of-life care (P = .014).CONCLUSIONProject ECHO-PACA was a successful approach for disseminating knowledge about PC. The participants were adherent to ECHO PACA clinics and the completion of feedback surveys. Future studies should evaluate the impact of Project ECHO-PACA on changes in provider practice as well as patient outcomes.

The Effect of Decreased Opioid Prescribing After Routine Vaginal Delivery on Post Discharge Patient Encounters [37P

INTRODUCTION: In line with nationwide commitment to decrease opioid prescribing, our department instituted new guidelines to no longer routinely provide opioids at discharge following vaginal delivery. The purpose of this study was to measure the effect of this change on discharge opioid prescriptions and postpartum encounters. METHODS: This was a retrospective cohort study of patients who underwent vaginal delivery during two time periods: November 2016 to January 2017 before the guideline and November 2017 to January 2018 after its implementation. IRB approval was obtained. Exclusion criteria included substance use disorder history, age under 18 and having a contraindication for nonopioid analgesic use. The number of patients who were provided discharge opioid prescriptions or had an outpatient encounter related to pain within six weeks postpartum were compared using Student t-tests. RESULTS: A total of 1,188 patients delivered during the study periods, of those 810 met inclusion criteria. 405 patients delivered prior to the guideline and 405 after its implementation. The proportion of patients prescribed opioids decreased from 79.8% (n=323) to 7.2% (n=29) after the guideline (p<0.001). The number of patients who had a post-discharge outpatient encounter (either in the Emergency Department, clinic or via phone call) related to pain did not change (4% before and 6.7% after the guideline; p = 0.085). The majority of encounters were related to dysuria and pain around repaired lacerations. CONCLUSION: Substantially limiting opioid prescribing after vaginal delivery does not appear to increase the burden of outpatient patient encounters after discharge.

Analgesic use among the Brazilian population: Results from the National Survey on Access, Use and Promotion of Rational Use of Medicines (PNAUM).

PurposeTo estimate the prevalence of use of analgesics in Brazil; and to characterize this use, according to sociodemographic and health-related characteristics.MethodsA cross-sectional population-based study (National Survey on Access, Use and Promotion of Rational Use of Medicines, PNAUM) was conducted between September 2013 and February 2014. A total of 41,433 people of all ages in Brazilian urban households were interviewed. Occasional use (within the last 15 days) and continuous use of non-opioid analgesics, opioid analgesics and non-steroidal anti-inflammatory drugs were investigated, regardless of whether this use occurred through prescription or self-medication. The main outcome was the use of at least one analgesic.ResultsThe majority of the individuals were female (52.8%), aged between 20 and 59 years (57.2%), with 1 to 8 years of schooling (45.6%). The overall prevalence of analgesic use was 22.8% [95% CI: 21.4–24.2]. The use of analgesics was significantly higher among women, adults and elderly (20 years or more), highly educated individuals and respondents who referred: diagnosis of one or more chronic diseases, using three or more medications, possession of health insurance and with one or more emergency care admittances or hospitalizations within the last year. Non-opioid analgesics were the agents most used (18.5% of the sample), followed by non-steroidal anti-inflammatory drugs (6.9%) and opioid analgesics (0.5%). The most commonly used drugs were metamizole (37.8% of all analgesics), paracetamol (25.3%) and diclofenac (10.7%). These drugs were used mainly to manage occasional health conditions, particularly pain.ConclusionOne in five Brazilians used some analgesic, especially non-opioid analgesics, to manage acute health problems such as painful conditions.

Antidepressant Use Among People Prescribed Opioids for Chronic Noncancer Pain.

Although depression and chronic pain often coexist, few studies have examined antidepressant use among people with pain. This study examines the prevalence and characteristics associated with antidepressant use among people prescribed opioids for chronic noncancer pain (CNCP). Baseline data from a prospective cohort study. Australian community. A total of 1166 people prescribed opioids for CNCP. Baseline data collection consisted of a self-completed seven-day medication diary and telephone interview to collect information on sociodemographic characteristics and mental/physical health using validated questionnaires. Logistic regression was used to examine characteristics associated with antidepressant use, reporting adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Of the 1166 participants, 668 (57.3%) were female, and the median (interquartile range) age was 59 (49-68) years. About half the cohort (N = 637, 54.6%) used antidepressants. Of these, 329 (51.7%) reported moderate to severe depression. Amitriptyline was the most commonly used antidepressant (17.3%). Factors independently associated with antidepressant use were being female (AOR = 1.47, 95% CI = 1.13-1.92), more years lived in pain (AOR = 1.01, 95% CI = 1.00-1.02), and use of nonopioid analgesics (AOR = 1.34, 95% CI = 1.01-1.78), benzodiazepines and related drugs (AOR = 1.84, 95% CI = 1.36-2.49), antiepileptics (AOR = 1.86, 95% CI = 1.38-2.51), and antipsychotics (AOR = 2.15, 95% CI = 1.22-3.77). Antidepressant use is common among people with CNCP prescribed opioids. Those using antidepressants were more likely to use other psychotropic medicines concurrently, highlighting that they are a high-risk population requiring comprehensive assessment to optimize outcomes and reduce potential harms from polypharmacy.

Sedation and Analgesia During Pediatric Burn Dressing Change: A Survey of American Burn Association Centers.

Sedation practices for pediatric burn patients during dressing changes vary between institutions and providers. To better understand the current trends in pediatric sedation practice, a survey was conducted among the members of the American Burn Association (ABA). Questions asked about nonoperating room sedation and analgesia practices for burn patients (ages 0-17) having dressing changes in the intensive care unit, inpatient unit, and outpatient clinics. ABA members providing sedation for pediatric patients undergoing burn dressing changes are diverse. Physician respondents included surgeons, critical care intensivists, and anesthesiologists. Others included physician assistants, nurse anesthetists, nurse practitioners, and sedation credentialed nurses. Opioids for pain control were prescribed by 100% of respondents, but use of adjuvant nonopioid analgesics was utilized <50% of the time. Benzodiazepines and ketamine were prescribed more than twice as often as other sedatives. Many noted that up to 50% of children did not have adequately controlled anxiety and pain with initial sedation plans, and escalation of care was needed to complete dressing changes. Self-reported adverse events were infrequent. In outpatient settings, benzodiazepines, ketamine, oral opioids, and topical lidocaine were used frequently, as were nonpharmacologic methods of distraction and comfort. Sedation in pediatric burn patients is challenging. Responses highlighted areas for improvement regarding pain control during dressing changes and increasing use of multimodal analgesia. Commonly used medications including opioids, benzodiazepine, and ketamine are well established in the treatment of burn patients, as are nonpharmacologic methods. A collaborative effort among institutions is needed to formulate practice guidelines for sedation during burn dressing changes.

An Observational Study on the Use of Intravenous Non-Opioid Analgesics and Antipyretics in Poor-Grade Subarachnoid Hemorrhage: Effects on Hemodynamics and Systemic and Brain Temperature.

Intravenous nonsteroidal anti-inflammatory drugs and nonopioid analgesics are used to achieve normothermia or relieve pain in patients with aneurysmal subarachnoid hemorrhage (aSAH). We investigated the effects of paracetamol (1 g), diclofenac (75 mg) and metamizole (1 g) on systemic and cerebral hemodynamics and temperature during febrile and nonfebrile episodes after aSAH. Prospectively collected data from 77 consecutive poor-grade aSAH patients with invasive neuromonitoring were included. The burden and occurrence of hypotension (mean arterial pressure <70 mmHg), brain tissue hypoxia (PbtO2 < 20 mmHg), high intracranial pressure (>22 mmHg), low cerebral perfusion pressure (CPP <70 mmHg), and cerebral autoregulation pressure (pressure reactivity index [PRx]) during baseline (1 hour before) and 6 hours after medication were analyzed in febrile (core temperature; Tcore ≥ 38.3°C) and nonfebrile episodes. Nine hundred eighty-nine infusions (278 paracetamol, 542 diclofenac, and 169 metamizole) were administered resulting in significant reduction of core and brain temperature during febrile (49%) and nonfebrile (51%) episodes (p < 0.001). In febrile cases, temperature decreased for >1 hour below 37.5°C in 36% of interventions and ≤37°C in 11%. Hemodynamic side effects with hypotension and low CPP occurred in both febrile and nonfebrile episodes (p < 0.001) prompting increased vasopressor support in 31% of cases, even more pronounced during the vasospasm period (4-12 days postictus) (OR 5.4, 95% CI 1.8-16). The magnitude of PbtO2-decrease is directly correlated with the decrease in Tcore (p = 0.002) and higher baseline PbtO2 (p < 0.001). PRx decreased in febrile and nonfebrile episodes (p < 0.001), indicating improvement of cerebrovascular autoregulation. Antipyretics were insufficient to achieve sustained normothermia in poor-grade aSAH patients. Hemodynamic side effects were common even when given as analgesic drugs. Further studies are needed to weigh hemodynamic side effects to benefits (inter alia improved cerebral autoregulation).

Opioid Prescribing and Consumption Patterns following Outpatient Plastic Surgery Procedures.

Opioid overprescribing is a nationwide problem contributing to the current epidemic. This study evaluated opioid consumption, physician prescribing, and patient satisfaction with pain control following outpatient plastic surgery procedures. Patients completed a questionnaire during their first postoperative visit. The authors queried about procedure type, quantity of opioids prescribed and consumed, days to opioid cessation, prescription refills, pain scores, use of nonopioid analgesics, and satisfaction with pain control. One hundred seventy patients were included. On average, 26 tablets were prescribed and 13 were consumed. Eighty percent of patients stopped opioids by postoperative day 5. Patients rated their worst pain at 6.1 and follow-up pain at 1.9. Approximately 50 percent of patients consumed nonopioid analgesics. Ninety-six percent of patients were satisfied with their pain control. Similar findings were observed across procedure subcategories. The number of pills prescribed was not correlated with satisfaction but was predictive of worst pain level (p = 0.014). Reduction mammaplasty and abdominoplasty patients consumed the most opioids at 17 and 18.6 pills, respectively; however, first-stage alloplastic breast reconstruction had the largest percentage of patients consuming opioids at the time of follow-up (25 percent) and requiring refills (7 percent). Patients who underwent revision of their reconstructed breast reported the earliest opioid cessation, rated their pain the lowest, and were prescribed the most excess tablets. Plastic surgeons are prescribing almost double the amount of opioids consumed by patients after outpatient plastic surgery procedures. The results of this study may help guide prescribing practices.

Minimally Invasive Versus Open Transforaminal Lumbar Interbody Fusion Surgery: An Analysis of Opioids, Nonopioid Analgesics, and Perioperative Characteristics.

Study Design:Retrospective study of consecutive patients at a single institution.Objective: Examine the effect of minimally invasive surgery (MIS) versus open transforaminal lumbar interbody fusion (TLIF) surgery on long-term postoperative narcotic consumption.Objective:Examine the effect of minimally invasive versus open TLIF on short-term postoperative narcotic consumption.Methods:Differences between MIS and open TLIF, including inpatient opioid and nonopioid analgesic use, discharge opioid use, and postdischarge duration of narcotic usage were compared using appropriate statistical methods.Results:A total of 172 patients (109 open; 63 MIS) underwent primary TLIF. There was no difference in baseline characteristics. The MIS TLIF cohort had a significantly shorter operative time (223 vs 251 min, P = .006) and length of stay (2.7 vs 3.7 days, P < .001) as well as less estimated blood loss (184 vs 648 mL, P < .001). MIS TLIF had significantly less total inpatient opioid usage (167 vs 255 morphine milligram equivalent [MME], P = .006) and inpatient oxycodone usage (71 vs 105 mg, P = .049). Open TLIF cases required more ongoing opiate usage at 3-month follow-up (36% open vs 21% MIS, P = .041). A subanalysis found that patients who underwent an open TLIF with a history of preoperative opioid use are significantly more likely to remain on opioids at 6-week follow-up (87% vs 65%, P = .027), 3-month follow-up (63% vs 31%, P = .008), and 6-month follow-up (50% vs 21%, P = .018) compared with MIS TLIF.Conclusion:Patients undergoing MIS TLIF required less inpatient opioids and had a decreased incidence of opioid dependence at 3-month follow-up. Patients with preoperative opioid use undergoing MIS TLIF are less likely to require long-term opioids.

Postoperative Pain Management of Non-"Opioid-Naive" Patients Undergoing Hand and Upper-Extremity Surgery.

Background: Patients with prior opioid use are often difficult to manage postoperatively. We examined potential strategies for managing these patients: (1) prescribing a different opioid; and (2) encouraging the use of nonopioid analgesics over opioids. Methods: A pain control program was implemented at an outpatient hand and upper-extremity center. Patients were recruited before (n = 305) and after (n = 225) implementation. Seventy of them were taking opioids prior to surgery. Information about pain control satisfaction and opioid use was collected. The Fisher exact test was used to compare categorical variables with small expected frequencies. Wilcoxon rank sum test was used to compare nonnormally distributed continuous variables. Results: Opioid users used 28.8 ± 25.6 opioid pills; nonopioid users used 14.5 ± 21.5 pills. Furthermore, 41.4% of opioid users sought more pills after surgery compared with 14.0% among nonopioid users. The pain control program was more effective in reducing opioid consumption and waste and increasing nonopioid consumption for nonopioid users than for opioid users. Prior opioid users who were prescribed a different opioid after surgery used 24.6 ± 22.0 opioid pills. Patients prescribed the same opioid used 37.9 ± 30.8 pills. Conclusions: Patients taking opioids prior to hand and upper-extremity surgery use more opioid pills, seek more pills after surgery, and are less satisfied with their pain control than their nonopioid user counterparts. Furthermore, the comprehensive pain plan was less effective in this patient population. Prescribing a different opioid reduced medication requirements for these patients, but additional strategies are needed to address postoperative pain management.

Opioid Oversupply After Joint and Spine Surgery: A Prospective Cohort Study.

Many patients receive prescription opioids at hospital discharge after surgery, yet little is known regarding how often these opioids go unused. We estimated the prevalence of unused opioids, use of nonopioid analgesics, and storage and disposal practices after same-day and inpatient surgery. In this prospective cohort study at a large, inner-city tertiary care hospital, we recruited individuals ≥18 years of age undergoing elective same-day or inpatient joint and spine surgery from August to November 2016. Using patient surveys via telephone calls, we assessed patient-reported outcomes at 2-day, 2-week, 1-month, and 6-month intervals, including: (1) stopping opioid treatment and in possession of unused opioid pills (primary outcome), (2) number of unused opioid tablets reported after stopping opioids, (3) use of nonopioid pain treatments, and (4) knowledge and practice regarding safe opioid storage and disposal. Of 141 eligible patients, 140 (99%) consented (35% taking preoperative opioids; mean age 56 years [standard deviation 16 years]; 47% women). One- and 6-month follow-up was achieved for 115 (82%) and 110 patients (80%), respectively. Among patients who stopped opioid therapy, possession of unused opioids was reported by 73% (95% confidence intervals, 62%-82%) at 1-month follow-up and 34% (confidence interval, 24%-45%) at 6-month follow-up. At 1 month, 46% had ≥20 unused pills, 37% had ≥200 morphine milligram equivalents, and only 6% reported using multiple nonopioid adjuncts. Many patients reported unsafe storage and failure to dispose of opioids at both 1-month (91% and 96%, respectively) and 6-month (92% and 47%, respectively) follow-up. After joint and spine surgery, many patients reported unused opioids, infrequent use of analgesic alternatives, and lack of knowledge regarding safe opioid storage and disposal. Interventions are needed to better tailor postoperative analgesia and improve the safe storage and disposal of prescription opioids.

Social & psychological factors associated with oral analgesic use in knee osteoarthritis management

Determine modifiable social and psychological health factors that are associated with use of oral opioid and non-opioid medications for OA. Patients were categorized based on use of the following oral medications: opioids (with/without other oral analgesic treatments), non-opioid analgesics, and no oral analgesic treatment. We used multinomial logistic regression models to estimate adjusted relative risk ratios (RRRs) of using an opioid or a non-opioid analgesic (vs. no oral analgesic treatment), comparing patients by levels of social support (Medical Outcomes Study scale), health literacy ("How confident are you filling out medical forms by yourself?"), and depressive symptoms (Patient Health Questionnaire-8). Models were adjusted for demographic and clinical characteristics. In this sample (mean age 64.2 years, 23.6% women), 30.6% (n=110) reported taking opioid analgesics for OA, 54.2% (n=195) reported non-opioid use, and 15.3% (n=55) reported no oral analgesic use. Opioid users had lower mean social support scores (10.0 vs 10.5 vs 11.9, P=0.007) and were more likely to have moderate-severe depressive symptoms (42.7% vs 24.1% vs 14.5%, P<0.001). Health literacy did not differ by treatment group type. Having moderate-severe depression was associated with higher risk of opioid analgesic use compared to no oral analgesic use (RRR 2.96, 95%CI 1.08-8.07) when adjusted for sociodemographic and clinical factors. Neither social support nor health literacy was associated with opioid or non-opioid oral analgesic use in fully adjusted models. Knee OA patients with more severe depression symptoms, compared to those without, were more likely to report using opioid analgesics for OA.

Perioperative use of metamizole and other nonopioid analgesics in children : Results of a survey

Nonopioid analgesics are frequently used for perioperative pain management in children. In many countries, the nonopioid metamizole (dipyrone) is administered as an alternative to paracetamol and traditional NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen and diclofenac; however, concerns over possible life-threatening adverse events (agranulocytosis) have prompted a debate over the use of metamizole. To investigate current practice and use of nonopioid analgesics, particularly of metamizole in children younger than 14years, in the perioperative setting. Furthermore, metamizole-related side effects, safety and approaches used to inform patients were addressed. Alink to an online questionnaire on the perioperative use of nonopioid analgesics in children, with a specific focus on dipyrone, was sent by e‑mail to members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and to members of the German Pain Society. Atotal of 2284 anesthesiologists filled out the questionnaire. Of these, 1476 were involved in the perioperative care of children younger than 14years. The majority of respondents worked in German hospitals (90.5%) but Austria, Switzerland and the Netherlands were also among the countries represented. Of the respondents, 99.1% reported using nonopioid analgesics in the perioperative setting. The NSAID, metamizole, paracetamol and COX-2 inhibitors were administered by 83.9%, 68.6%, 67.5% and 2% of the respondents, respectively. Intravenous metamizole was the preferred nonopioid analgesic during surgical procedures, but following surgery, NSAID, metamizole and paracetamol were given with the same frequency by anesthesiologists. Of the respondents, 49.3% reported using metamizole in combination with another nonopioid analgesic in cases of severe pain, 14.8% used it as the sole nonopioid analgesic, and 23.2% never used it at all. Nearly half of the respondents administered metamizole i.v. in doses of 15 mg/kg body weight or lower, whereas 26% administered doses of at least 16 mg/kg up to more than 20 mg/kg. Of the physicians, 298 (20.2%) restricted the duration of metamizole use, varying between one single administration (4.7%), administration for 1 day (27.5%), or for 1-2 weeks (29.2%). Of the anesthesiologists, 65.6% reported no metamizole-related adverse effects. Allergic reactions/anaphylaxis and adrop in blood pressure requiring intervention were observed by 3-4% of the respondents. No change in blood cell counts within the last 2 years was reported by 73.1% of the respondents, whereas 17anesthesiologists (1.3%) had observed children with altered blood cell counts, with 2 (0.14%) reporting agranulocytosis. In most cases these were incidental findings. No severe sequelae or deaths were reported. Few respondents (5.5%) performed routine blood cell counts to monitor metamizole therapy. Furthermore, only aminority always (3.5%) or sometimes (6.1%) informed achild's parents of possible side effects of treatment with metamizole. The survey confirmed that metamizole is frequently used in children in the perioperative setting. Intravenous metamizole is the preferred nonopioid analgesic administered intraoperatively for pain prophylaxis. Clinical symptoms of agranulocytosis should be monitored and patients should be better informed about metamizole-related side effects.

A complete national cohort study of prescriptions of analgesics and benzodiazepines to cancer survivors in Norway 10 years after diagnosis.

Chronic pain due to surgery, radiotherapy, or chemotherapy is prevalent in long-term cancer survivors. Chronic pain due to successful cancer treatment should be treated as chronic nonmalignant pain, primarily with nonpharmacological strategies. Based on complete national data from the Cancer Registry of Norway and the Norwegian prescription database, the aim of this study was to compare the use of nonopioid analgesics, opioids, and benzodiazepines 10 years after cancer diagnosis in long-term cancer survivors and the age- and sex-adjusted general population. The 1-year periodic prevalence of use was higher in long-term cancer survivors in all the studied drug classes: opioids (143.5 vs 129.6/1000), paracetamol (88.3 vs 80.7/1000), nonsteroidal anti-inflammatory drugs (229.1 vs 221.7), gabapentinoids (13.4 vs 10.0/1000), benzodiazepines (88.3 vs 77.9/1000), and benzodiazepine-like hypnotics (118.1 vs 97.4/1000). The prevalence of persistent and high-dose opioid use (>365 defined daily doses [DDDs] and >730 DDDs, respectively, during 365 days, and prescriptions all quarters of the year) was also higher in the cancer survivors than in the general population (6.5 vs 4.8/1000 for persistent use and 2.7 vs 1.3/1000 for high-dose use). Less than 10% of persistent and high-dose users received only long-acting opioid formulations. Furthermore, most long-term cancer survivors with persistent or high-dose opioid use were also high-dose users (>100 DDDs/year) of either benzodiazepines or benzodiazepine-like hypnotics. It is an issue of concern that most of those using opioids did not adhere to guidelines regarding opioid formulation and comedication with other drugs with addictive properties.

Vaso-occlusive crisis in sickle cell disease: current paradigm on pain management.

This narrative review aims to highlight the current paradigm on pain management in sickle cell vaso-occlusive crisis. It specifically examines the pathophysiologic mechanisms of sickle cell pain as well as the pharmacologic and nonpharmacologic methods of pain management. Recurrent painful episodes constitute the major morbidity in sickle cell disease (SCD). While adolescents and young adults experience mostly acute episodic nociceptive pain, it is now recognized that a significant number of adult patients develop chronic neuropathic and centralized pain. In fact, current evidence points to an age-dependent increase in the frequency of SCD patients with chronic pain. Management of disease-related pain should be based on its pathophysiologic mechanisms instead of using recommendations from other non-SCD pain syndromes. Pain management in vaso-occlusive crisis is complex and requires multiple interventions such as pharmacologic, nonpharmacologic, and preventive therapeutic interventions. Pharmacologic treatment involves the use of non-opioid and opioid analgesics, and adjuvants – either singly or in combination – depending on the severity of pain. The basic approach is to treat SCD pain symptomatically with escalating doses of non-opioid and opioid analgesics. Given the moderate-to-severe nature of the pain usually experienced in this form of SCD crisis, opioids form the bedrock of pharmacologic treatment. Multimodal analgesia and structured, individualized analgesic regimen appear more effective in achieving better treatment outcomes. Although the current evidence is still limited on the supportive role of cognitive behavioral therapy in pain management, this nonpharmacologic approach is reportedly effective, but needs further exploration as a possible adjunct in analgesia.