Opioid Demand Research Articles

Patient-controlled analgesia with and without transverse abdominis plane and rectus sheath space block in cirrhotic patients undergoing liver resection

Background and Aims:Optimal pain control can be a challenge in cirrhotic patients. The aim was to compare the analgesic efficacy and side effects of intravenous fentanyl patient-controlled analgesia (PCA) with and without bupivacaine boluses in transversus abdominis plane (TAP) and rectus sheath space (RSB) in cirrhotics undergoing liver surgery.Material and Methods:A double-blinded randomized controlled trial (n = 55, child's A) was conducted. Catheters were inserted surgically in TAP and rectal sheath space during surgical closure. Fentanyl PCA + TAP + RSB group (gp) (n = 30): (0.2 ml/kg of 0.25% bupivacaine, 8 hourly) was compared with fentanyl PCA gp (n = 25): [0.2 ml/kg of saline (placebo) injected in catheters 8 hourly] for 48 h postoperatively. Plasma bupivacaine was measured with an enzyme-linked immunosorbent assay at 10 min, 30 min, 1 h, 2 h, and 4 h after each injection and 30 min before next injection.Results:Fentanyl consumption was reduced in (PCA + TAP + RSB) gp compared to PCA gp (Day 1: 325.4 ± 169.1 vs. 1034 ± 231.7, Day 2: 204.44 ± 62.9 vs. 481.6 ± 158.3 μg, P < 0.05). Both groups demonstrated effective pain control at rest [Visual Analog Scales (VAS) <3), but on movement pain control with bupivacaine was better (P < 0.05). Increased demand for rescue opioids was observed prior to next scheduled bupivacaine injection in 10/30 patients on Day 1 and 2/30 on Day 2, in association with a reduced bupivacaine serum levels compared to 10 min after injection (47.6 ± 22.7 vs. 93.6 ± 61.0 ng/ml, respectively, P < 0.05). Bupivacaine did not exceed referred toxic levels.Conclusion:Repeated bupivacaine TAP and RSB with PCA fentanyl improved pain control, reduced opioids demand with no toxicity. Time interval between injections needs to be reduced to avoid breakthrough pain.

The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse

Reports of strategies to prevent and treat the opioid epidemic are growing. Significant attention has been paid to the benefits of opioid addiction research, clinical prescribing, and public policy initiatives in curbing the epidemic. However, the role of the anaesthesiologist in minimising opioid use and misuse remains underexplored. For many patients with an opioid use disorder, the perioperative period represents the source of initial exposure. As perioperative physicians, anaesthesiologists are in the unique position to manage pain effectively while simultaneously decreasing opioid consumption. Multiple opportunities exist for anaesthesiologists to minimise opioid exposure and prevent subsequent persistent opioid use. We present a global strategy for decreasing perioperative opioid use and misuse among surgical patients. A historical perspective of the opioid epidemic is presented, together with an analysis of opioid supply and demand forces. We then present specific temporal strategies for opioid use reduction in the perioperative period. We emphasise the importance of preoperative identification of patients at risk for long-term opioid use and misuse, review the evidence supporting the opioid sparing capacity of individual multimodal analgesic agents, and discuss the benefits of regional anaesthesia for minimising opioid consumption. We describe postoperative and post-discharge tools, including effective multimodal analgesia and the role of a transitional pain service. Finally, we offer general institutional strategies that can be led by anaesthesiologists, identify gaps in knowledge, and offer directions for future research.

Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery.

The opioid epidemic demands changes in perioperative pain management. Of the 33,000 deaths attributable to opioid overdose in 2015, half received prescription opioids. Multimodal analgesia is a practice-altering evolution that reduces reliance on opioid medications. Ambulatory breast surgery is an ideal opportunity to implement these strategies. A retrospective review of 560 patients undergoing outpatient breast procedures was conducted. Patients received (1) no preoperative analgesia (n = 333); (2) intraoperative intravenous acetaminophen (n = 78); (3) preoperative oral acetaminophen and gabapentin (n = 95); or (4) preoperative oral acetaminophen, gabapentin and celecoxib (n = 54). Outcomes included postanesthesia care unit narcotic use, pain scores, postanesthesia care unit length of stay, rescue antiemetic use, and 30-day complications. Both oral multimodal analgesia regimens significantly reduced postanesthesia care unit narcotic use (oral acetaminophen and gabapentin, 14.3 ± 1.7; oral gabapentin, acetaminophen, and celecoxib, 11.9 ± 2.2; versus no drug, 19.2 ± 1.1 mg oral morphine equivalents; p = 0.0006), initial pain scores (oral acetaminophen and gabapentin, 3.9 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.4 ± 0.7; versus no drug, 5.3 ± 0.3 on a 1 to 10 scale, p = 0.0002) and maximum pain scores (oral acetaminophen and gabapentin, 4.3 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.6 ± 0.7; versus no drug, 5.9 ± 0.3 on a 1 to 10 scale; p < 0.0001). Both oral regimens were better than no medications or intravenous acetaminophen alone in multivariate models after controlling for age, body mass index, American Society of Anesthesiologists class, length of surgery, prior narcotic prescription availability, and intraoperative local anesthetic. Postanesthesia care unit length of stay, antiemetic use, and 30-day complications were not different. Preoperative oral multimodal analgesia reduces narcotic use and pain scores in outpatient breast plastic surgery. These regimens are inexpensive, improve pain control, and contribute to narcotic-sparing clinical practice in the setting of a national opioid epidemic. Therapeutic, III.

Association Between Recombinant Human Bone Morphogenetic Proteins and Postoperative Opioid Use in Lumbar Fusion Procedure Patients: A Propensity Score-Matched Analysis

Little is known about the effectiveness of recombinant human bone morphogenetic proteins (rhBMPs) in reducing the demand for opioids after surgery. We investigated the association between rhBMP use and the likelihood of achieving opioid independence and changes in opioid demand in the first postoperative year. Using the Multi-Payer Claims Database from 2007 to 2010, patients aged >20 years who had undergone a degenerative disc disease-indicated lumbar fusion procedure and had had ≥1 opioid prescription in the 3 months before surgery were identified. Propensity score matching (1:1) of rhBMP-exposed and rhBMP-unexposed patients was used to mitigate confounding. The outcomes of interest were opioid independence and decreases in opioid doses in morphine equivalent units, assessed at 3-6 and 9-12 months after the procedure. Logistic regression and analysis of covariance models were used. The data from 318 patients were analyzed. Most patients were women (61%) and aged <65 years (68%). Few had achieved opioid independence at 3-6 (n=71; 22.3%) or 9-12 (n= 115; 36.2%) months postoperatively. During the 3-6-month window, the rhBMP group reduced their opioid use rates (estimated mean difference.-28.4 vs.-19.5; P= 0.69) and achieved opioid independence (21.4% vs. 23.3%; odds ratio, 0.92; 95% confidence interval, 0.54-1.56; P= 0.74) at rates that were statistically comparable to their matched comparators. Similar patterns were observed during the 9-12-month window. We found no evidence to suggest that rhBMP use during spinal fusion procedures is associated with either the discontinuation or decrease of opioid analgesic therapy. The continued opioid use after surgery warrants further clinical and research attention.

Public Health Policy Strategies to Address the Opioid Epidemic.

Public health policy responses to the opioid epidemic require addressing both opioid supply and opioid demand. The growth in prescriptions of opioid analgesics, for example, is associated with escalating opioid overdose fatalities.1 Enhanced access to opioid agonist treatment, conversely, is required to curb demands driven by opioid use disorders. Oregon's multidimensional approaches toward opioid misuse and abuse achieved 20% reductions in opioid prescribing and a 30% reduction in the opioid overdose fatality rate.

From Pain Patient to Junkie: An Economic Theory of Painkiller Consumption and its Impact on Wellbeing and Longevity

In this paper, I propose a life cycle model of painkiller consumption that combines the theory of health deficit accumulation with the theory of addiction. Chronic pain is conceptualized as a persistent negative shock to lifetime utility that can be treated by pain relief medication. Individuals treated with opioid pain relievers (OPR) develop addiction, which increases their demand for opioids and reduces their welfare and life expectancy through side effects and potential overdose. I calibrate the model for a benchmark American and investigate the comparative dynamics of alternative drug characteristics, pain intensities, and ages of onsets of pain and their implications for welfare and life expectancy. Computational experiments are used to identify fully rational and imperfectly rational addiction behavior. Fully rational addicts quickly quit OPR use when new information about their addictive potential arrives. Imperfectly rational addicts further develop their addiction and switch to illicit opioid use. Likewise, a discontinued prescription helps fully rational addicts to quit quickly while it induces imperfectly rational individuals to take up heroin. I also discuss treatment of OPR addiction and the use of opioids in palliative care.

Implications of Entropy and Surgical Pleth Index-guided general anaesthesia on clinical outcomes in critically ill polytrauma patients. A prospective observational non-randomized single centre study.

Being highly unstable, the critically ill polytrauma patient represents a challenge for the anaesthesia team. The aim of this study was to compare the Entropy and Surgical Pleth Index (SPI)-guided general anaesthesia with standard haemodynamic monitoring methods used in the critically ill polytrauma patients and to evaluate the incidence of hemodynamic events, as well as the opioid and vasopressor demand. 72 patients were included in this prospective observational study, divided in two groups, the ESPI Group (N = 37, patients that benefited from Entropy and SPI monitoring) and the STDR Group (N = 35 patients that benefited from standard hemodynamic monitoring). In the ESPI Group general anaesthesia was modulated in order to maintain the Entropy levels between 40 and 60. Analgesia control was achieved by maintaining the SPI levels between 20 and 50. In the STDR Group hypnosis and analgesia were maintained using the standard criteria based on hemodynamic changes. ClinicalTrials.gov identifier NCT03095430. The incidence of hypotension episodes was significantly lower in the ESPI Group (N = 3), compared to the STDR Group (N = 71) (p < 0.05). Moreover, the Fentanyl demand was significantly lower in the ESPI Group (p < 0.0001, difference between means 5.000 ± 0.038, 95% confidence interval 4.9250-5.0750), as well as vasopressor medication demand (p < 0.0001, difference between means 0.960 ± 0.063, 95% confidence interval 0.8.334-1.0866). The implementation of multimodal monitoring in the critically ill polytrauma patient brings substantial benefits both to the intraoperative clinical status and to the clinical outcome of these patients by reducing the incidence of anesthesia-related complications.

Opioid Demand Before and After Anterior Cruciate Ligament Reconstruction

Background: Surgeons and health care systems have received a call to action in an effort to curtail the current opioid epidemic. Purpose: To (1) define the natural history of opioid demand after anterior cruciate ligament reconstruction (ACLR), (2) consider how filling preoperative opioid prescriptions affects opioid demand after ACLR, and (3) evaluate the effect of additional procedures during ACLR and patient age on postoperative opioid demand. Study Design: Cohort study; Level of evidence, 3. Methods: ACLRs performed in the Humana database between 2007 and 2014 were identified using Current Procedural Terminology code 29888. Patients were considered preoperative opioid users if they had filled an opioid prescription in the 3 months preceding surgery. Patients were defined as “chronic” opioid users if they had filled a prescription preoperatively at 1 to 3 months from surgery. Further categorization was performed by identifying patients who only underwent ACLR with no other procedures, those who underwent ACLR with meniscus repair, those who underwent ACLR with meniscectomy, and those who underwent ACLR with microfracture. Categorization by age was also performed. The relative risk (RR) of postoperative opioid use was calculated, and 95% CIs were determined. Results: Over the course of the study period, 4946 ACLRs were performed. At 3 months after their procedure, 7.24% of patients were still filling opioid prescriptions. At 9 and 12 months postoperatively, 4.97% and 4.71% of patients, respectively, were still filling opioid prescriptions. Nearly 35% of patients (1716/4946) were filling opioid pain prescriptions in the 3 months before ACLR. Those filling preoperative opioid prescriptions were 5.35 (95% CI, 4.15-6.90) times more likely to be filling opioid prescriptions at 3 months after ACLR than nonusers (15.38% vs 2.88%, respectively). Those filling opioid prescriptions chronically before surgery were at a 10.50 (95% CI, 7.53-14.64) times increased risk of filling postoperative opioid prescriptions at 5 months. At 5 months postoperatively, patients undergoing ACLR with microfracture had a 1.96 (95% CI, 1.34-2.87) increased risk of filling opioid prescriptions compared with ACLR alone, 2.38 (95% CI, 1.48-3.82) increased risk compared with ACLR with meniscus repair, and 1.51 (95% CI, 1.04-2.19) increased risk compared with ACLR with meniscectomy. Patients younger than 25 years of age had an increased risk of filling opioid prescriptions after ACLR at all time points of the study. Conclusion: Opioid demand after ACLR dropped significantly in the vast majority of patients by the third postoperative month. Surprisingly, 35% of patients undergoing ACLR were observed to be using opioid medication preoperatively, and this study found preoperative opioid use to be a strong predictor of postoperative opioid demand with a 5- to 7-fold increased risk in this patient population. Patients who were filling opioid prescriptions 1 to 3 months from their surgical date were at the highest risk for postoperative opioid utilization. Patients undergoing ACLR with microfracture were at an increased risk of filling opioid prescriptions. Patients less than 25 years of age were at an elevated risk of filling opioid prescriptions at all time points postoperatively.

Opioid Demand after Anterior Cruciate Ligament Reconstruction

Objectives:Surgeons and healthcare systems have received a call to action in an effort to curtail the current opioid epidemic in the United States. Postoperative opioid demand after anterior cruciate ligament reconstruction (ACLR) is not well understood. The purpose of this study was to (1) define the natural history of opioid demand after ACLR performed with and without concomitant procedures and to (2) evaluate preoperative opioid demand as a risk factor for postoperative opioid demand.Methods:Arthroscopic ACLRs performed in the Humana Inc. database between 2007-2014 were identified using CPT code 29888. Further categorization of procedures was performed by identifying patients who underwent ACLR with no other procedures, those who underwent ACLR with meniscus repair, those who underwent ACLR with menisectomy, and those who underwent ACLR with microfracture. Postoperative opioid demand was trended by month following surgery for 1 year. The effect of preoperative opioid demand on postoperative opioid demand was evaluated by comparing those who had filled preoperative opioid prescriptions with those who hadn′t. Patients were considered preoperative opioid users if they had filled an opioid prescription in the 3 months preceding surgery. Relative risk of postoperative opioid use was calculated and 95% confidence intervals (CI) were determined.Results:Over the course of the study period, 4,946 arthroscopic ACLRs were performed. Of these, 7.24% were still filling opioid prescriptions at 2-3 months after their procedure; 4.71% of patients were filling opioid prescriptions at 1 year after surgery. Patients undergoing ACLR with microfracture were at increased risk of filling narcotic prescriptions compared to the other procedure groups. At 4-5 months postoperatively, ACLR with microfracture had increased risk of filling narcotic prescriptions compared to ACLR alone 1.96 (CI=1.32-2.92), ACL with meniscus repair 2.38 (CI=1.46-3.88), and ACL with meniscectomy 1.51 (CI=1.03-2.23). Nearly 35% of patients (1,716/4,946) were taking opioid pain medications in the 3 months prior to ACLR. Those filling preoperative opioid prescriptions were 5.34 (CI=4.12-6.94) times more likely to be filling narcotic prescriptions at 2-3 months after ACL reconstruction. Those filling preoperative opioid prescriptions were 7.54 (CI=5.32-10.71) and 6.42 (CI=4.5-9.15) times more likely to be filling opioid prescriptions at 9 and 12 months respectively after ACLR.Conclusion:Opioid demand after ACLR drops significantly in the vast majority of patients by the 3rd postoperative month. Surprisingly, 35% of patients undergoing ACLR were found to be using opioid medications preoperatively and we identify preoperative opioid use to be a strong predictor of postoperative opioid demand with a 5 to 7 fold increased risk in this patient population. Surgeons can use this data when counseling patients on typical postoperative opioid demand. Surgeons and healthcare systems should be aware a large portion of patients undergoing ACLR are receiving preoperative opioid prescriptions which put these patients at increased risk for extended postoperative opioid demand. In the setting of preoperative care for patients who will undergo ACLR, healthcare providers should pursue non-opioid prescribing regimens in an effort to limit postoperative opioid demand.

Opioid Consumption After Rotator Cuff Repair

Rising perioperative opioid use in the United States is of increasing concern. The purposes of this study were (1) to define opioid consumption after rotator cuff repair (RCR) in the United States and (2) to evaluate patient factors that may be associated with prolonged opioid use after arthroscopic RCR. All arthroscopic RCRs performed between 2007 and 2014 were identified by use of Current Procedural Terminology code (29,827). Patients who filled opioid prescriptions preoperatively were divided into those who filled prescriptions at 1 to 3months preceding RCR and those who filled opioid prescriptions only in the 1month preceding RCR. Risk ratios (RRs) were calculated by dividing the cumulative incidence of opioid prescriptions in patients with each patient factor by the cumulative incidence in those without each patient factor. During the study period, 35,155 arthroscopic RCRs were performed. Of the patients, approximately 43% had filled an opioid prescription in the 3months before RCR. At 3months after RCR, patients who filled opioid prescriptions at 1 to 3months before RCR were 7.45 (95% confidence interval [CI], 6.95-7.98) times more likely to be filling opioid medication prescriptions than those who had not been prescribed opioid medications before surgery; patients who filled opioid prescriptions in the month before RCR were 3.04 (95% CI, 2.8-3.29) times more likely to be filling opioid prescriptions at 3months after RCR. Patients with psychiatric diagnoses (RR, 1.94; 95% CI, 1.85-2.04), myalgia (RR, 1.67; 95% CI, 1.6-1.75), and low-back pain (RR, 2.09; 95% CI, 2-2.2) were also found to be at risk of filling opioid prescriptions at 3months postoperatively. We found approximately 43% of patients undergoing RCR received opioid medications before RCR. Patients who are prescribed narcotics before RCR are at increased risk of postoperative opioid demand. Patients with psychiatric diagnoses, myalgia, and low-back pain may be at increased risk of prolonged opioid use after surgery. Level III, retrospective case-control study.

From Rare to Reality: The Challenge of Controlling Pain in Patients on Buprenorphine in the Acute Care Setting

Prescription opioid use has increased dramatically in the past 20 years with prescriptions for opioids and overdoses both increasing by 400% in what is now being called an opioid epidemic. The CDC’s Guidelines for Prescribing Opioids for Chronic Pain were released in March 2016 and the result has been increasing scrutiny of opioid prescriptions. For pain patients, this means minimizing opioid use and decreasing reliance, while others are being tapered off opioids altogether. Opioid tapers are predictably revealing unanticipated levels of opioid use disorder and unsupportable demand for enrollment in opioid assisted treatment (OAT) via buprenorphine/naloxone (Suboxone®) or methadone treatment programs. In July 2016, the Department of Health and Human Services released a final rule increasing prescribing limits of buprenorphine/naloxone (Suboxone®) to allow qualifying providers to treat up to 275 patients rather than capping panel size at 100. In addition to increased use in the treatment of opioid use disorder, there are new formulations of buprenorphine approved for chronic pain management. Therefore, while opioid use overall is decreasing, use of buprenorphine itself is dramatically increasing and introducing new challenges to treatment in trauma and acute pain settings based on its unique pharmacology. In recent years, case reports highlighting the challenge of managing pain when patients are treated with buprenorphine were published but until now were rarely seen in practice. It is, therefore, incumbent on all providers in these settings to become intimately familiar with buprenorphine and prepare to safely and effectively manage pain in these challenging patients.

The influence of dexmedetomidine on opioid consumption in radical prostatectomy

Objective. Multimodal analgesia and anal-gesics with different modes of action can reduce perioperative opioid demand and their undesirable side effects. In our study we presumed that patients anesthetised with additional perioperative dexmedetomidine infusion, during radi-cal prostatectomy, would need less opioids during and after surgery compared to the control group.Materials and methods. 40 patients, 18-80 years of age, ASA class 1-3 (American So-ciety of Anesthesiologists), scheduled for radical prostatectomy, were included in the study. Patients were randomly divided into two groups (20 pts in each group). In both groups, fentanyl in repeated boluses was used as an analgesic; in the studied group, an additional infusion of dexme-detomidine (0.3 µg/kg/h) was started with intravenous line insertion and continued until the beginning of wound closure. An-algesic consumption during the operation, in the post-anaesthesia care unit, in the In-tensive Care Unit on the day of the opera-tion and on the first postoperative day was recorded.Results. The patients with perioperative dexmedetomidine infusion were slightly younger (p=0.007), also the duration of their surgery was shorter (p =0.05). Differ-ences in opioid consumption between the groups were not found. Also, pain assess-ment, by visual analogue scale (VAS) after 12, 18, 24, 30, 36 and 42 hours, was not sta-tistically different between groups. Conclusion. In our study, perioperative dexmadetomidine did not reduce peri- and postoperative opioid consumption. Also, undesirable dexmedetomidine side effects, such as bradycardia and hypoten-sion, were not observed.

Catechol-oxide-methyltransferase (COMT rs4680:G>A) gene polymorphism does not affect analgesics’ demand after elective hip replaceme.

Pain in patients with hip osteoarthritis appears long before surgery, and requires effective management as it affects patient comfort and daily activities. Therefore, the search for factors influencing response rate to analgesics is mandatory. In recent years, increasing attention has been paid to genetic factors underlying pain threshold and treatment efficacy. Polymorphic gene of catechol-oxide-methyltransferase (COMT) is a candidate gene associated with pain pathology and treatment response. The aim of the study was to evaluate association between the COMT rs4680:G>A polymorphism and demand for analgesics in patients subjected to elective hip replacement. The study included 196 patients after hip replacement surgery. Opioid demand was recorded and analgesic efficacy was scored using a four-level verbal pain intensity scale. COMT rs4680:G>A polymorphism was analysed by PCR-RFLP method. The studied COMT genotypes did not influence opioid administration in the studied patients from the day of surgery till day 6 afterwards. The distribution of the COMT rs4680:G>A in the studied subjects was as follows: GA—52.04%, AA—23.98% and GG—23.98%. It can be concluded that the COMT rs4680:G>A polymorphism is not associated with opioid demand in patients after elective hip replacement.

Comparative study of injection 0.5% Bupivacaine and injection 0.75% Ropivacaine for their duration of anaesthesia/analgesia in Transversus Abdominis Plane block for unilateral inguinal hernia repair

Background: The Transversus Abdominis Plane block is a new regional anaesthesia technique described for postoperative pain management with a potential utility as a sole anaesthetic for increasing number of surgical procedures. TAP block improves postoperative pain management, decreases postoperative visual analog scale score, opioid demand and time to first administration of rescue analgesic in patients undergoing lower abdominal surgeries. Aims and objectives: In our study, we have used TAP block as a sole anaesthetic technique in elective patients undergoing unilateral inguinal hernia repair and compared two different local anaesthetics, 0.5% Bupivacaine and 0.75% Ropivacaine for their duration of anaesthesia/ analgesia and cardiovascular stability. Materials and Methods: A prospective randomized clinical study was conducted on 60 ASA I and II patients aged between 30 and 80 years coming for inguinal hernia repair fulfilling inclusion and exclusion criteria. They were divided into two groups of 30 each. Group B received injection 0.5% bupivacaine, group R received injection 0.75% ropivacaine, not exceeding 2.5 mg/kg body weight. Results and Conclusion: We have found that both the drugs give excellent anaesthesia for inguinal hernia repair with hemodynamic stability. 0.75% Ropivacaine with significant delay in onset of anaesthesia (13.46+/- 3.2 min.) compared to 0.5% bupivacaine (7.86 +/- 2.47 min.) (P value

Known unknowns: A review of opioid-induced hyperalgesia

AbstractOpioid-induced hyperalgesia (OIH) is a relatively new paradigm that has added to the already growing uncertainty surrounding long-term opioid treatment. OIH is the oversensitization to stimuli in the nervous system resulting from opioid exposure and subsequent neuroplastic changes. Because of its novelty and difficulty in identification, the true prevalence of OIH is unknown. Several mechanisms have been proposed for its development. These include changes in the N-methyl-D-aspartate system, descending pathway modulation, dynorphin activity, inflammatory changes mediated by cyclooxygenase, and increased sensitivity to excitatory neurochemicals. The clinical controversy regarding the management of OIH is due largely to the lack of guidance in diagnosis and lack of quality evidence to direct treatment. As a diagnosis of exclusion, several alternative causes of antianalgesia must be ruled out before OIH can be declared. Pharmacodynamic phenomena such as opioid tolerance share overlapping mechanisms with OIH and may present similarly. Pharmacokinetic changes such as drug-induced or disease-induced alterations to the cytochrome P450 or P-glycoprotein systems should also be excluded as causes of increased opioid demand that may be seen as OIH. Certain pharmacologic agents, such as N-methyl-D-aspartate receptor antagonists, alpha2 receptor agonists, and cyclooxygenase inhibitors, have been identified as possible treatments to reverse the effects of OIH. Opioid rotation and dose reductions have also been used with some degree of success. Pharmacist involvement in the identification and management of OIH will be central to success because of the unique expertise they offer. The quality of these studies is limited by study design, small sample sizes, and lack of generalizability to chronic pain patients with long-standing opioid use.

Prescription opioid abuse: Problems and responses

Prescription opioid abuse and addiction, along with consequences such as overdose death and increasing transition to heroin use, constitute a devastating public health problem in the United States. Increasingly it is clear that overprescription of these medications over the past two decades has been a major upstream driver of the opioid abuse epidemic. This commentary considers the factors that have led to overprescription of opioids by clinicians, discusses recent evidence casting doubt on the efficacy of opioids for treating chronic pain, and describes the ongoing efforts by federal and community stakeholders to address this epidemic—for example, supporting prescription drug monitoring programs and improved clinician training in pain management to help reduce the supply of opioids, increasing dissemination of evidence-based primary prevention programs to reduce demand for opioids, and expanding access to effective opioid agonist therapies and antagonist medications for both treatment and overdose prevention.

Preoperative opioid use and its association with perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery.

Prospective cohort. To assess whether preoperative opioid use is associated with increased perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery. Previous work has demonstrated increased opioid requirements during the intraoperative and immediate postoperative period in patients with high levels of preoperative opioid use. Despite this, they remain a common agent class used for the management of pain in patients prior to spine surgery. A total of 583 patients were included. Self-reported daily opioid consumption was obtained preoperatively and converted into morphine equivalent amounts and opioid use was recorded at the 12-month postoperative time. Intraoperative and immediate postoperative opioid demand was calculated. Linear regression analyses for intraoperative and immediate postoperative opioid demand while logistic regression analyses for opioid independence at 12 months including relevant covariates such as depression and anxiety were performed. The median preoperative morphine equivalent amount for the cohort was 8.75 mg, with 55% of patients reporting some degree of opioid use. Younger age, more invasive surgery, anxiety, and primary surgery were significantly associated with increased intraoperative opioid demand (P < 0.05). Younger age, anxiety, and greater preoperative opioid use were significantly associated with increased immediate postoperative opioid demand (P < 0.05). More invasive surgery, anxiety, revision surgery, and greater preoperative opioid use were significantly associated with a decreased incidence of opioid independence at 12 months postoperatively (P < 0.01). Greater preoperative opioid use prior to undergoing spine surgery predicts increased immediate postoperative opioid demand and decreased incidence of postoperative opioid independence. Psychiatric diagnoses in those using preoperative opioids were predictors of continued opioid use at 12 months. Patients may benefit from preoperative counseling that emphasizes minimizing opioid use prior to undergoing spine surgery. 2.

Anesthetic management of prophylactic cervical cerclage: a retrospective multicenter cohort study.

Cervical incompetence complicates approximately 1 in 500 pregnancies and is the most common cause of second-trimester spontaneous abortion and preterm labor. No prospective or large retrospective studies have compared regional and general anesthesia for cervical cerclage. Following IRB approval, we performed a retrospective study in the two main medical centers over an 8-year period to assess the association of anesthesia choice with anesthetic and obstetric outcomes. Anesthetic and perioperative details were retrospectively collected from fails of all patients undergoing cervical cerclage from 01/01/2005 until 31/12/2012. Details included demographic data, anesthetic technique, PACU data and perioperative complications. We identified 487 cases of cervical cerclage in 327 women during the study period. The most commonly used anesthetic technique was general anesthesia (GA) (402/487; 82.5%) compared with regional anesthesia (RA) (85/487; 17.5%). When GA was performed, facemask was the most commonly used technique (275/402; 68.4%), followed by intravenous deep sedation (61/402; 15.2%); LMA (51/402; 12.7%) and tracheal intubation (13/402; 3.2%). There were no significant differences in demographic characteristics between women receiving general and regional anesthesia. Average duration of suturing the cervix among the GA group was 9.8 ± 1.6 and 10.6 ± 2.1 min in the RA group (p < 0.001). Average length of stay in the operating room in the GA group was 20.5 ± 3.9 and 23 ± 4.6 min in the RA group (p < 0.001). Patients receiving GA received in the PACU more opioids (6.2 versus 1.2%; p < 0.05) and more non-opioids analgesics (36.8 versus 9.4%; p < 0.001). Duration of PACU stay was shorter after GA (49.5 ± 18 min) than after RA (62.4 ± 28 min; p < 0.001). There were no other differences in anesthetic or perioperative outcome between groups. This study was not designed to provide evidence that RA reduces the risk of pulmonary aspiration, airway complications or adverse fetal neurological effects from maternal anesthetic exposure. Both regional and general anesthesia were safely used for the performance of cerclage. Patients after general anesthesia had a shorter recovery time but a higher demand for opioids and non-opioids analgesia.

Intraperitoneal bupivacaine effect on postoperative nausea and vomiting following laparoscopic cholecystectomy.

Background:Postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy (LC) has multifactorial etiology. Pain and use of opioids are among the important factors.Objectives:The present study aimed to evaluate the efficacy of intrapritoneal (IP) injection of bupivacaine on PONV.Patients and Methods:This was a double-blind randomized clinical trial, conducted on 66 patients aged 20-60, ASA I or II, candidates for LC. Patients were randomly assigned to two groups. Bupivacaine group received 20 mL bupivacaine 0.25% in the gallbladder bed, before and after cholecystectomy and the control group did not. The incidence of nausea and postoperative pain intensity was measured with Visual analogue scale (VAS) at 1, 2, 3 and 4 hours after operation, at rest and when coughing and changing positions. Nausea and vomiting occurrence were assessed at the same times.Results:There were no demographic data differences between groups. No differences were found between the two groups, in terms of incidence of nausea and vomiting. Furthermore, both groups were similar with respect to opioid consumption, during four hours post-operation.Conclusions:Intraperitoneal bupivacaine administration at the beginning and end of laparoscopic cholecystectomy reduced only visceral and shoulder pains at the 4th postoperative hour, but had no effect on reducing neither PONV, nor opioid demand, during the first four postoperative hours.

Effectiveness of Preemptive Analgesia Using a Frequency Rhythmic Electrical Modulation System in Patients Having Instrumented Fusion for Lumbar Stenosis

Study DesignA randomized prospective study.PurposeTo assess postoperative analgesic requirements after Phyback therapy preemptively in patients undergoing lumbar stabilization.Overview of LiteratureFrequency Rhythmic Electrical Modulation System is the latest method of preemptive analgesia.MethodsForty patients were divided into two groups. Patients who were to receive tramadol were allocated to "group A" and those who were to receive Phyback therapy were allocated to "group B." In patients with a visual analog scale score of >4 or a verbal rating scale score of >2, 75 mg of diclofenac IM was administered. The amount of analgesic consumption, the bolus demand dosage, and the number of bolus doses administered were recorded. Patient satisfaction was evaluated using the visual analog patient satisfaction scale.ResultsThere were statistically significant differences in the visual analog scale and verbal rating scale scores in the fourth, sixth, 12th, and 24th hours. The number of bolus infusions was significantly lower in group B. The amount of analgesic consumption was higher in group A. There was a significant difference between the two groups in the number of bolus infusions and the total amount of analgesic consumption, and this comparison showed better results for group B.ConclusionsApplication of Phyback therapy reduced postoperative opioid consumption and analgesic demand, and it contributed to reducing patients' level of pain and increased patient satisfaction. Moreover, the application of preemptive Phyback therapy contributed to reducing preoperative pain which may have reduced patient anxiety.