Oral Morphine Research Articles

Cannabis use and acute postoperative pain outcomes in older adults: a propensity matched retrospective cohort study

IntroductionCannabis use is increasing among older adults, but its impact on postoperative pain outcomes remains unclear in this population. We examined the association between cannabis use and postoperative pain levels...

Text message questionnaires for Patient-Reported Outcome Measures after Cesarean section-A feasibility study.

Inadequate pain relief with moderate to severe pain remains a challenge after cesarean section and may significantly impair postoperative recovery. However, detailed assessment on the timing of severe pain, opioid consumption, influence on activities such as mobilization, breastfeeding, and caring for the infant are difficult to conduct, especially after discharge. Short message services (SMS)-based questionnaires may offer a low-cost way of providing such data but with the risk of insufficient response rates. We assessed the feasibility of collecting detailed, prospective data on postoperative pain and recovery during the initial hours and days following cesarean section using SMS-based questionnaires. Prospective Danish single-center cohort study involving elective cesarean sections under spinal anesthesia with fentanyl and bupivacaine. The postoperative pain regimen consisted of paracetamol, NSAID and oral morphine by request. Patients received an SMS-based questionnaire at 6, 12, 18, 24, and 48 h postoperatively, as well as on days 7 and 30. Response rate and time from receiving the SMS to completion of the questionnaires. Opioid consumption and Patient Reported Outcomes Measures on pain and recovery. From December 2022 to June 2023; 100 patients were included. The response rate was 78% at 6 h postoperatively, decreasing to 63% at 24 h. The median response time from receiving to answering the SMS-based questionnaire at 6 h after cesarean section was 23 min (IQR 2-72), decreasing to 20 min (IQR 2-78) after 24 h. Severe pain, corresponding to a Numeric Rating Scale (NRS) score >6, was reported by 57% (95% CI 65-84) at 6 h, decreasing to 28% (95% CI 34-58) at 24 h. Median opioid consumption within the first 24 h was 30 mg (IQR 20-50). SMS-based questionnaires on Patient Reported Outcome Measures are a feasible and cost-effective way of prospectively collecting frequent data with acceptable response rates, even shortly after cesarean section. Secondarily 66% of patients reported severe pain during the first 24 h following cesarean section, with the highest pain scores within the initial 12 h. Future studies should focus on optimizing pain-management within this timeframe.

Pericapsular nerve group (PENG) block combined with local infiltration analgesia is not superior to local infiltration analgesia for the management of postoperative pain after primary elective total hip arthroplasty: A prospective, randomized, controlled, single-blind trial

BackgroundLocal infiltration analgesia (LIA) has been advocated for the pain management after total hip arthroplasty (THA). The analgesic benefits of an added pericapsular nerve group (PENG) block remain questionable. MethodsThis randomized, single-blind trial enrolled patients undergoing elective THA under general anaesthesia and standardized postoperative analgesia. Patients were allocated to receive either a PENG block (20 mL of ropivacaine 0.475 %) combined with intraoperative LIA (PENG + LIA group, n = 32), or intraoperative LIA alone (LIA group, n = 32). The primary outcome was oral morphine equivalent (OME) consumption at day 1. Secondary outcomes were: pain scores at post anaesthesia care unit (PACU) discharge and on day 2, times for the Timed to Up and Go (TUG) test and measurement of adductor strength on day 1, and patients’ satisfaction using the EVAN-G questionnaire. ResultsCompared with LIA alone, PENG + LIA resulted in similar OME consumption on day 1 (78 [51–91.5] mg vs 58 [30–80] mg respectively, median difference (95%CI) of −17 (−34 to 1) mg, p = 0.09). Pain scores and morphine consumption were not different between groups at any time point. TUG and thigh adduction tests were similar between LIA and PENG + LIA groups (respectively 35 [25–48.5] vs 31.5 [19.5–46.5] sec, p = 0.39; and 105 [85–150] vs 100 [80–125] mmHg, p = 0.61). No difference in the patients’ satisfaction was found. ConclusionThe addition of a PENG block to large-volume LIA did not significantly improve the analgesia for elective THA in the setting of an adequate basic postoperative analgesia regimen. The results of the lower limb functional tests confirmed the PENG block to be motor-sparing.

Postoperative analgesic consumption for primary versus first repeat Cesarean delivery: a historical cohort study.

It is unclear if postoperative pain experience and opioid consumption differ in patients undergoing primary vs repeat Cesarean delivery (CD) as prior studies have yielded conflicting results and none used the same patients as their own controls. We sought to compareopioid consumption and pain scores in patients undergoing both a primary and a first repeat CD, using the same patients as their own controls. We conducted a single-centre historical cohort study of patients who underwent both a primary and a first repeat CD under neuraxial anesthesia between 1 January 2016 and 30 November 2022. The same standardized multimodal analgesic regimen was used for all patients. The primary outcome was opioid consumption in oral morphine equivalents (OME) at 48hr after surgery. Secondary outcomes included area under the curve for pain scores at 24 and 48hr, and opioid consumption at 24hr. We included 409 patients. In unadjusted analysis, there were no significant differences between primary and repeat CD in median [interquartile range] opioid consumption at 48hr (45 [15-89] mg vs 45 [15-83] mg OME) or in any of the secondary outcomes. In the multivariable model adjusting for age, body mass index, anxiety, depression, priority, surgery duration, gestational age, receipt of postoperative ketorolac, and neuraxial type, repeat CD was still not associated with increased opioid consumption compared with primary CD (adjusted rate ratio, 1.20; 95% confidence interval, 0.95 to 1.51). In this retrospective study, we found no differences in postoperative opioid consumption or reported pain scores in patients who underwent both a primary and a first repeat CD.

Trajectories of Opioid Use Before and After Cancer Diagnosis: A Population-Based Cohort Study

BackgroundOpioid use prior to cancer diagnosis increases the likelihood of long-term use during survivorship, however, patterns of use before and after diagnosis are not understood. MethodsWe used population-based dispensing data linked with cancer and death notifications to identify two cohorts of adults residing in New South Wales initiating opioids within 24 months prior to a first cancer diagnosed between 2014 and 2016: ‘survivors’ (alive 24 months following diagnosis) and ‘decedents’ (died within 24 months). We used group-based trajectory modelling to identify trajectories of monthly opioid dispensings and dispensed oral morphine equivalent milligrams (OMEmg) during the 24 months before/after cancer diagnosis. ResultsThere were 21,843 survivors with four prediagnosis opioid dispensing trajectories: infrequent (58% of the cohort), late increasing (26%), moderate (10%), and sustained dispensing (6%). We observed an overall increase in dispensed OMEmg of 83 OMEmg (95% CI: 76–91) during the month of diagnosis, with strong opioid formulations comprising most treatment postdiagnosis. Within each prediagnosis opioid trajectory group, we observed five to six postdiagnosis trajectory groups, including no opioid dispensing. Moderate and sustained prediagnosis groups had large proportions of people continuing or increasing opioid dispensing after diagnosis, while small proportions discontinued opioid treatment. We observed similar trajectories in the decedent cohort. ConclusionsThere is considerable heterogeneity in opioid use before and after cancer diagnosis. Our findings suggest noncancer factors drive a significant proportion of postdiagnosis opioid use, but use increased significantly from the month of cancer diagnosis and never returned to prediagnosis levels.

Prolonged Opioid Use and Associated Factors After Open Reduction and Internal Fixation of Tibial Shaft Fractures.

The aim of this retrospective cohort study was to determine the rate of prolonged opioid use and identify associated risk factors after perioperative opioid exposure for tibial shaft fracture surgery. We used the MarketScan Commercial Claims and Encounters database (IBM) to identify patients 18 to 64 years old who filled a peri-operative opioid prescription after open reduction and internal fixation of a tibial shaft fracture from January 2016 to June 2020. Multivariable logistic regression identified factors (eg, demographics, comorbidities, medications) associated with prolonged opioid use (ie, filling an opioid prescription 91 to 180 days postoperatively); adjusted odds ratios (ORs) and 95% CIs were reported. The rate of prolonged opioid use was 10.5% (n=259/2475) in the full cohort and 6.1% (n=119/1958) in an opioid-naive subgroup. In the full cohort, factors significantly associated with increased odds of prolonged use included preoperative opioid use (OR, 4.76; 95% CI, 3.60-6.29; P<.001); perioperative oral morphine equivalents in the 4th (vs 1st) quartile (OR, 2.68; 95% CI, 1.75-4.09; P<.001); age (OR, 1.03; 95% CI, 1.02-1.04; P<.001); and alcohol or substance-related disorder (OR, 1.66; 95% CI, 1.15-2.40; P=.01). Patients in the Northeast and North Central (vs South) regions had decreased odds of prolonged use (OR, 0.61-0.69; P=.02-.04). When removing preoperative use, findings were similar in the opioid-naive subgroup. Prolonged opioid use is not uncommon in this orthopedic trauma population, with the strongest risk factor being preoperative opioid use. Nevertheless, shared risk factors exist between the opioid-naive and opioid-tolerant subgroups that can guide clinical decision-making. [Orthopedics. 2024;47(4):e188-e196.].

Liposomal Bupivacaine Versus Bupivacaine and Dexamethasone Intercostal Nerve Blocks for Robotic Thoracic Surgery: A Randomized Clinical Trial.

Introduction For peripheral nerve blocks, using either the liposomal formulation of bupivacaine or plain bupivacaine with epinephrine and dexamethasone as an adjuvant has been shown to improve postoperative pain scores. In a single-blinded, randomized controlled study of patients undergoing robotic-assisted thoracoscopic surgery, we determined if bupivacaine with epinephrine and dexamethasone was noninferior to liposomal bupivacaine mixed with plain bupivacaine when administered intraoperatively as an intercostal nerve block (INB). Methods A total of 34 patients undergoing robotic-assisted thoracoscopic surgery were randomized to receive one of two injectate mixtures during their intraoperative INB. Group LB was administered 266 mg of 13.3 mg/mL liposomal bupivacaine with 24 mL of 0.5% plain bupivacaine, while Group BD was given 42 mL of 0.5% bupivacaine with epinephrine and 8 mg of dexamethasone. The primary outcomes were mean postoperative numerical pain ratings and mean postoperative opioid analgesic requirements. Secondary outcomes included adjuvant pain medication consumption, hospital length of stay, and total opioid use in oral morphine equivalents. Results Group LB exhibited no significant difference in pain scores (p = 0.437) and opioid analgesic requirement (p = 0.095) within the 72-hour postoperative period when compared to Group BD. The median total postoperative opioid requirement was 90 mg in Group LB, compared to 45 mg in Group BD. There were no significant differences in the use of postoperative adjuvant pain medications (gabapentin, p = 0.833; acetaminophen, p = 0.190; ketorolac, p = 0.699). Hospital length of stay did not differ between the groups. Conclusions INBs with the addition of dexamethasone as an adjuvant to 0.5% bupivacaine with epinephrine provided noninferior postoperative analgesia compared to liposomal bupivacaine mixed with plain 0.5% bupivacaine.

Data-Driven Identification of Potentially Successful Intervention Implementations Using 5 Years of Opioid Prescribing Data: Retrospective Database Study.

We have previously demonstrated that opioid prescribing increased by 127% between 1998 and 2016. New policies aimed at tackling this increasing trend have been recommended by public health bodies, and there is some evidence that progress is being made. We sought to extend our previous work and develop a data-driven approach to identify general practices and clinical commissioning groups (CCGs) whose prescribing data suggest that interventions to reduce the prescribing of opioids may have been successfully implemented. We analyzed 5 years of prescribing data (December 2014 to November 2019) for 3 opioid prescribing measures-total opioid prescribing as oral morphine equivalent per 1000 registered population, the number of high-dose opioids prescribed per 1000 registered population, and the number of high-dose opioids as a percentage of total opioids prescribed. Using a data-driven approach, we applied a modified version of our change detection Python library to identify reductions in these measures over time, which may be consistent with the successful implementation of an intervention to reduce opioid prescribing. This analysis was carried out for general practices and CCGs, and organizations were ranked according to the change in prescribing rate. We identified a reduction in total opioid prescribing in 94 (49.2%) out of 191 CCGs, with a median reduction of 15.1 (IQR 11.8-18.7; range 9.0-32.8) in total oral morphine equivalence per 1000 patients. We present data for the 3 CCGs and practices demonstrating the biggest reduction in opioid prescribing for each of the 3 opioid prescribing measures. We observed a 40% proportional drop (8.9% absolute reduction) in the regular prescribing of high-dose opioids (measured as a percentage of regular opioids) in the highest-ranked CCG (North Tyneside); a 99% drop in this same measure was found in several practices (44%-95% absolute reduction). Decile plots demonstrate that CCGs exhibiting large reductions in opioid prescribing do so via slow and gradual reductions over a long period of time (typically over a period of 2 years); in contrast, practices exhibiting large reductions do so rapidly over a much shorter period of time. By applying 1 of our existing analysis tools to a national data set, we were able to identify rapid and maintained changes in opioid prescribing within practices and CCGs and rank organizations by the magnitude of reduction. Highly ranked organizations are candidates for further qualitative research into intervention design and implementation.

Effect of an opioid-free anesthetic on postoperative opioid consumption after laparoscopic bariatric surgery: a prospective, single-blinded, randomized controlled trial

IntroductionOpioid administration has the benefit of providing perioperative analgesia but is also associated with adverse effects. Opioid-free anesthesia (OFA) may reduce postoperative opioid consumption and adverse effects after laparoscopic bariatric...

Palliative care progress in Benin: a situation analysis using the WHO development indicators

ContextPalliative care (PC) in most African countries remains under-assessed. Benin has piloted the implementation of a set of indicators proposed by the WHO to measure PC development.ObjectivesTo examine the current status of PC in Benin.MethodsA workshop with stakeholders was organized to assess the WHO indicators in the Beninese context. Indicators were rated based on relevance and feasibility, data sources were agreed upon, and a survey was adapted. Data were collected between March and May 2023.ResultsThere is emerging community involvement in PC through the presence of patients’ rights promoters, as well as a political commitment expressed in the National PC strategy, the inclusion of PC services in the list of basic health services, and an assigned national authority –within the Ministry of Health–responsible for PC. Although no PC-oriented research has been documented, the celebration of the National PC Conference represents the first step to ground PC delivery in evidence. The reported annual consumption of opioids is 0.18 (ME) milligrams per capita, 34% of healthcare establishments have essential medicines for pain and PC, and 16.5% of patients with palliative needs have access to oral morphine. To date, no medical or paramedical schools offer PC training, and there is no official specialization in palliative medicine for doctors. PC is provided by 11 specialist teams (0.08/100,000 inhabitants), none of which provides pediatric care.ConclusionDespite growing political, professional, and community commitments to palliative care, there are challenges in education, research, essential medicines, and access to PC services.

Pharmacokinetic and neuroimmune pharmacogenetic impacts on slow-release morphine cancer pain control and adverse effects

The aim was to determine if opioid neuroimmunopharmacology pathway gene polymorphisms alter serum morphine, morphine-3-glucuronide and morphine-6-glucuronide concentration-response relationships in 506 cancer patients receiving controlled-release oral morphine. Morphine-3-glucuronide concentrations (standardised to 11 h post-dose) were higher in patients without pain control (median (interquartile range) 1.2 (0.7–2.3) versus 1.0 (0.5–1.9) μM, P = 0.006), whereas morphine concentrations were higher in patients with cognitive dysfunction (40 (20–81) versus 29 (14–60) nM, P = 0.02). TLR2 rs3804100 variant carriers had reduced odds (adjusted odds ratio (95% confidence interval) 0.42 (0.22–0.82), P = 0.01) of opioid adverse events. IL2 rs2069762 G/G (0.20 (0.06-0.52)), BDNF rs6265 A/A (0.15 (0.02–0.63)) and IL6R rs8192284 carrier (0.55 (0.34–0.90)) genotypes had decreased, and IL6 rs10499563 C/C increased (3.3 (1.2–9.3)), odds of sickness response (P ≤ 0.02). The study has limitations in heterogeneity in doses, sampling times and diagnoses but still suggests that pharmacokinetics and immune genetics co-contribute to morphine pain control and adverse effects in cancer patients.

Pilot study of early integration of interventional pain management for patients with chronic cancer pain.

e24080 Background: Pain is a common, distressing, and costly complication of cancer. Treatment guidelines recommend consideration of interventional pain procedures in addition to pharmacotherapy, yet they are underutilized and often only considered for refractory pain despite high-dose opioids. We examined the feasibility of early integration of interventional pain management among ambulatory patients with chronic cancer pain. Methods: This single arm pilot feasibility study recruited patients from outpatient clinics at the Dana-Farber Cancer Institute. Eligible patients had metastatic or locally advanced solid tumors, persistent pain secondary to cancer/cancer treatment, average pain rating of 4 or higher (0-10 scale), and prognosis &gt; 6 months. Patients could not be taking more than 200 oral morphine equivalents per day. Patients were systematically referred to an interventional pain specialist for consideration of pain procedures, with monthly visits for 4 months. Measures of feasibility included the proportion of patients seen by the pain specialist within 4 weeks, and the proportion undergoing pain procedures. Patients completed surveys at baseline, 2 and 4 months; using the Consumer Assessment of Healthcare Providers and Systems (CAHPS), patients rated their satisfaction with pain clinic (range 0-10), and how often the pain doctor treated them with courtesy and respect, listened carefully, and explained things in a way they could understand (range 1-4, higher scores better). Among those undergoing procedures, patients indicated the percent pain relief they had from the procedure. Results: Between May 2022 and October 2023, 30 patients were enrolled (4 remain on study); mean age, 59.5, 50% male, with a variety of solid tumors; baseline “average pain” and “worst pain” scores were 4.3( SD,1.2) and 6.5( SD,1.6). All but one patient (96.7%) was seen in the pain clinic within four weeks; 57% (n = 17) received one or more pain procedure, with 20% (n = 6) undergoing repeat procedures. The most common procedures were neural blockade (8), celiac plexus neurolysis (n = 4), trigger point injection (n = 3), and epidural steroid injection (n = 3). Among patients receiving a procedure, the median percentage relief was 65% (IQR:30,80). Patients rated the quality of care from the pain clinic highly, with a mean score of 8.6( SD,1.6); and were satisfied with their pain physicians with a mean rating of 3.8( SD,0.4) on treating with respect, 3.7( SD,0.6) for listening, and 3.6( SD,0.6) for explaining. Conclusions: In this study of patients with cancer pain, systematic referral to interventional pain management specialists was feasible, and led to most patients receiving a pain procedure. Patients were satisfied with their pain care and reported meaningful relief of symptoms. Further study is needed to examine whether early integration of interventional pain management improves pain control. Clinical trial information: NCT05366413 .

Evaluation of Postoperative Efficacy and Safety of Celecoxib in Children Hospitalized After Adenotonsillectomy.

The choice of optimal analgesia following an adenotonsillectomy is a clinical issue because of the risk of respiratory depression and bleeding. The objective of this study was to assess the effect of celecoxib on opioid use and pain scores in children hospitalized after adenotonsillectomy and to document its adverse effects. This retrospective study was conducted in a tertiary care pediatric hospital. We compared a group of subjects aged 1 to 17 years who were prescribed celecoxib and opioids between January 2017 and June 2020 following an adenotonsillectomy during a 3-day or less hospitalization to a group of matched controls for sex, age, and length of stay who were prescribed opioids. A total of 228 patients were identified (76 in the celecoxib + opioids group, 152 in the control group). Opioid use, in oral morphine equivalent daily dose, was lower in the celecoxib + opioids group at 0 to 24 hours of hospitalization (0.15 vs 0.20 mg/kg/day, p = 0.05). Initiating celecoxib within 24 hours of surgery (n = 60) significantly reduced opioid requirement for up to 48 hours compared with controls (0-24 hours: 0.12 vs 0.20 mg/kg/day, p = 0.002; 25-48 hours: 0.02 vs 0.09 mg/kg/day, p = 0.001). A shorter length of stay was observed for patients receiving celecoxib + opioids during the first 24-hour post--operative period (27 vs 32 hours, p = 0.01). With celecoxib use, no significant change in pain scores and occurrence of adverse effects including bleeding was found. Using celecoxib early after an adenotonsillectomy has reduced both opioid use and duration of hospital stay without increasing adverse effects or bleeding.

How is postoperative pain after hip and knee replacement managed? An analysis of two large hospitals in Australia

BackgroundMultimodal analgesia regimens are recommended for the postoperative period after hip and knee replacement surgeries. However, there are no data on practice patterns for analgesic use in the immediate postoperative period after hip and knee replacements in Australia.ObjectivesTo describe analgesic prescribing patterns in the inpatient postoperative phase for patients undergoing hip and knee replacement.MethodsRetrospective study of electronic medical record data from two major hospitals in Sydney, Australia. We identified analgesic medication prescriptions for all patients aged 18 years and older who underwent hip or knee replacement surgery in 2019. We extracted data on pain medications prescribed while in the ward up until discharge. These were grouped into distinct categories based on the Anatomical Therapeutic Chemical classification. We described the frequency (%) of pain medications used by category and computed the average oral morphine equivalent daily dose (OMEDD) during hospitalisation.ResultsWe identified 1282 surgeries in 1225 patients. Patients had a mean (SD) age of 69 (11.8) years; most (57.1%) were female. Over 99% of patients were prescribed opioid analgesics and paracetamol during their hospital stay. Most patients (61.4%) were managed with paracetamol and opioids only. The most common prescribed opioid was oxycodone (87.3% of patients). Only 19% of patients were prescribed nonsteroidal anti-inflammatories (NSAIDs). The median (IQR) average daily OMEDD was 50.2 mg (30.3–77.9).ConclusionWe identified high use of opioids analgesics as the main strategies for pain control after hip and knee replacement in hospital. Other analgesics were much less frequently used, such as NSAIDs, and always in combination with opioids and paracetamol.

Evaluation of the Erector spinae plane block for postoperative analgesia in laparoscopic ventral hernia repair: a randomized placebo controlled trial

BackgroundThe Erector spinae plane block (ESPB) reduces postoperative pain after several types of abdominal laparoscopic surgeries. There is sparse data on the effect of ESPB in laparoscopic ventral hernia repair. The purpose of this study was to test the postoperative analgesic efficacy of an ESPB for this procedure.MethodsIn this prospective, double-blind, randomized controlled study, adult patients undergoing laparoscopic ventral hernia repair were randomly assigned to either bilateral preoperative ESPB with catheters at the level of Th7 (2 × 30 ml of either 2.5 mg/ml ropivacaine or saline), with postoperative catheter top ups every 6 h for 24 h. The primary outcome was rescue opioid consumption during the first hour postoperatively. Secondary outcomes were total opioid consumption at 4 h and 24 h, pain scores, nausea, sedation, as well as Quality of Recovery 15 (QoR-15) and the EuroQol-5 Dimensions (EQ-5D-5L) during the first week.ResultsIn total, 64 patients were included in the primary outcome measure. There was no significant difference in rescue opioid consumption (oral morphine equivalents (OME)) at one hour postoperatively, with the ESPB group 26.9 ± 17.1 mg versus 32.4 ± 24.3 mg (mean ± SD) in the placebo group (p= 0.27). There were no significant differences concerning the secondary outcomes during the seven-day observation period. Seven patients received a rescue block postoperatively, providing analgesia in five patients.ConclusionWe found no difference in measured outcomes between ESPB and placebo in laparoscopic ventral hernia repair. Future studies may evaluate whether a block performed using higher concentration and/or at a different thoracic level provides more analgesic efficacy.Trial registrationNCT04438369; 18/06/2020.

Comparing Post-operative Pain and Other Outcomes in Carotid Endarterectomy Versus Transcarotid Artery Revascularization.

Transcarotid artery revascularization (TCAR) is growing in popularity. Although major clinical end-points such as stroke rate and mortality are well-known, patient reported outcomes such as pain, and length of stay are among the purported benefits that are as yet untested. We sought to determine if there are differences in pain and other clinical outcomes when comparing carotid endarterectomy (CEA) and TCAR. We performed a retrospective review of 326 patients undergoing TCAR (n = 50) or CEA (n = 276) from 2019-2023. Primary outcomes of interest were maximum pain numeric rating scales (NRS) reported in the post-anesthesia care unit (PACU) and on postoperative days (POD) zero and 1, and oral morphine milligram equivalents (OMMEs) received intraoperatively through POD1. Secondary outcomes included length of stay (LOS), complications, and 30-day emergency department (ED) returns/readmissions. Fifty TCAR and 150 CEA patients were included in the propensity score matched cohorts. TCAR patients reported lower pain-NRS in PACU (P < .001) and on POD0 (P = .002), but similar pain scores on POD1 (P = .112). Postoperatively, TCAR patients were less likely to receive opioids (52% vs 75.3%, P = .003) and received less OMME from PACU through POD1 (12.8 ± 16.2 vs 23.2 ± 27.2, P = .001). After adjusting for age, sex, BMI, prior chronic opioid use, and prior carotid surgery, TCAR patients were approximately 70% less likely to receive post-operative opioids. No significant differences in LOS, 30-day ED returns/readmissions, or complications were observed between groups. Compared with CEA, patients undergoing TCAR reported lower pain scores and consumed fewer narcotics overall. However, the absolute difference was modest, and pain scores were low in both cohorts. Differences in pain and post-operative narcotic use may be of less importance when deciding between TCAR and CEA. Total non-opioid protocols may be feasible in both approaches.

A bundle of opioid-sparing strategies to eliminate routine opioid prescribing in a urogynecology practice

BackgroundCurrent evidence supports that many patients do not use prescribed opioids following reconstructive pelvic surgery, yet it remains unclear if it is feasible to eliminate routine opioid prescriptions without a negative impact on patients or providers. ObjectiveTo determine if there is a difference in the proportion of patients discharged without opioids after implementing a bundle of opioid-sparing strategies and tiered prescribing protocol (BOSS) compared to usual care after minimally invasive pelvic reconstructive surgery (transvaginal, laparoscopic or robotic). Secondary objectives include measures of patient-perceived pain control and provider workload. Study DesignThe BOSS intervention was implemented as a division-wide evidence-based practice change on August 1, 2022. This retrospective cohort compares a 6-month post-intervention (BOSS) cohort to 6- month pre-intervention (usual care) of patients undergoing minimally invasive pelvic reconstructive surgery. A 3-month wash out period was observed after BOSS initiation. We excluded patients <18 years, failure to consent to research, combined surgery with other specialties, urge urinary incontinence or urinary retention procedures alone, and minor procedures not typically requiring opioids. Primary outcome was measured by proportion discharged without opioids and total oral morphine equivalents (OME) prescribed. Pain control was measured by pain scores, post-discharge prescriptions and refills, phone calls and visits related to pain, and satisfaction with pain control. Provider workload was demonstrated by phone calls and post-discharge prescription refills. Data were obtained through chart review on all patients who met inclusion criteria. Primary analysis only included patients prescribed opioids according to the BOSS protocol. Two sample t tests compared continuous variables and chi-square tests compared categorical variables. Results416 patients were included in the primary analysis (207 BOSS, 209 Usual Care). Baseline demographics were similar between groups, except a lower proportion of IBS (13% vs 23%; p<0.01) and pelvic pain (15% vs 24.9%; p=0.01), and higher history of prior gynecologic surgery (69.1% vs 58.4%; p=0.02) in the BOSS cohort. The BOSS cohort was more likely to be discharged without opioids (68.1% vs 10.0%; p<.01). In those prescribed opioids, total OME on discharge was significantly lower in the BOSS cohort (48.1 vs 81.8; p<.01). The BOSS cohort had a 20.6 greater odds (CI 11.4, 37.1) of being discharged without opioids after adjusting for surgery type, arthritis/joint pain, IBS, pelvic pain, and contraindication to NSAIDs. The BOSS cohort was also less likely to receive a rescue opioid prescription after discharge (1.4% vs 9.5%; p=0.03). There were no differences in opioid prescription refills (19.7% vs 18.1%; p=0.77), emergency room visits for pain (3.4% vs 2.9%; p=0.76), postoperative pain scores (mean 4.7 vs 4.0; p=0.07), or patient satisfaction with pain control (81.5% vs 85.6%; p=0.21). After BOSS implementation, the proportion of postoperative phone calls for pain also decreased (12.6% vs 21.5%; p=0.02). Similar results were identified when non-adherent prescribing was included in the analysis. ConclusionsA bundle of evidence-based opioid sparing strategies and tiered prescribing based on inpatient use increases the proportion of patients discharged without opioids after minimally invasive pelvic reconstructive surgery without evidence of uncontrolled pain or increased provider workload.

Opioid consumption before discharge predicts outpatient opioid use in adolescents undergoing surgery

BackgroundThe majority of adolescents undergoing surgery report unused prescription opioids after surgery, increasing the risk of diversion, misuse, and addiction. Adult studies have demonstrated that opioid use 24 hours before discharge corresponds with opioid use at home. We hypothesized that inpatient opioid consumption is associated with outpatient opioid use in adolescents. MethodsAdolescents aged 13-20 years undergoing elective surgery associated with an opioid prescription were prospectively recruited. Parent-adolescent dyads were surveyed preoperatively to assess sociodemographics, health literacy, and baseline substance use, and opioid use was measured at 30- and 90-days postoperatively. Medical records were reviewed to calculate cumulative opioid use during hospitalization. Inpatient and postoperative opioid use was converted to oral morphine equivalents. Adjusting for age, sex, race, health literacy, alcohol use, pain score, and surgery, multivariable linear regression identified factors associated with outpatient oral morphine equivalent use 90 days postoperatively. ResultsOverall, 103 adolescents were enrolled. Median oral morphine equivalents used from 24 and 48 hours before discharge and throughout the hospitalization were 30.8 (interquartile range:11.7–45.0), 67.5 (interquartile range:37.5–94.3), and 97.5 (interquartile range:18.0–152.7), respectively. Regression analysis demonstrated that adolescent-reported pain at discharge (P = .028) and cumulative oral morphine equivalents used 24 hours (P < .001) and 48 hours (P = .003) before discharge were significantly associated with postoperative oral morphine equivalents use at home. Oral morphine equivalents consumption 24 hours before discharge estimated cumulative oral morphine equivalents use 90 days postoperatively at a 1-to-5 ratio in 94.1% of patients. ConclusionFor adolescents undergoing surgery, patient-reported pain at discharge and oral morphine equivalents administered 24 hours before discharge are associated with cumulative outpatient opioid use. Tailoring outpatient prescriptions to total oral morphine equivalent consumption 24 hours before discharge could reduce excess opioid prescribing.

Ultrasound-guided suprainguinal fascia iliaca compartment block and early postoperative analgesia after total hip arthroplasty: a randomised controlled trial

BackgroundHip replacement surgery can be painful; postoperative analgesia is crucial for comfort and to facilitate recovery. Regional anaesthesia can reduce pain and postoperative opioid requirements. The role of ultrasound-guided suprainguinal fascia iliaca block for analgesia after elective total hip arthroplasty is not well defined. This randomised trial evaluated its analgesic efficacy. MethodsConsenting participants (134) scheduled for elective primary total hip arthroplasty under spinal anaesthesia were randomly allocated to receive ultrasound-guided fascia iliaca block with ropivacaine 0.5% or sham block with saline. The primary outcome was opioid consumption in the first 24 h after surgery. Additional outcomes included pain scores at 4, 8, 12, and 16 h, opioid-related side-effects (nausea, vomiting, pruritis), ability to perform physiotherapy on the first postoperative day, and physiotherapist-assessed quadriceps weakness. ResultsThere were no significant differences in 24-h opioid consumption (block vs sham block, mean difference −3.2 mg oral morphine equivalent, 95% confidence interval −15.3 to 8.1 mg oral morphine equivalent, P=0.55) or any other prespecified outcomes. ConclusionsIn patients undergoing primary total hip arthroplasty, ultrasound-guided suprainguinal fascia iliaca block with ropivacaine did not confer a significant opioid-sparing effect compared with sham block. There were no differences in other secondary outcomes including pain scores, opioid-related side-effects, or ability to perform physiotherapy on the first postoperative day. Clinical trial registrationwww.clinicaltrials.gov (NCT03069183).

3-Dimensional versus standard 2-D laparoscopy for benign hysterectomy: A randomized clinical trial

ObjectiveOur aim was to evaluate possible short and long-term benefits of 3-dimensional (3-D) compared to 2-dimensional (2-D) laparoscopy for benign hysterectomy.Primary outcomes were long-term quality of life and postoperative pain. Secondary outcomes were operative time, surgical complications, time to return to work and length of hospitalization. Study designA randomized controlled trial conducted at two Danish university hospitals. In each arm, 190 patients were needed for an alpha of 3.3 % and a power of 90 %. For various reasons, however, the study was prematurely terminated after including 97 patients. Patients were randomized to either 2-D (n = 48) or 3-D (n = 49) laparoscopy. A laparoscopic hysterectomy was performed. Quality of life was assessed by the Short Form Health Survey 36 (SF-36) questionnaire at the time of inclusion and 6 weeks postoperatively. Postoperative pain was assessed using a Numeric Rating Scale (NRS) and by monitoring the amount of analgesic consumption. ResultsOut of the 97 randomized patients, 77 patients completed both SF-36 questionnaires. No significant differences in mental (p = 0.5) and physical status (p = 0.9) were found. The 2-D group had significantly higher pain-score registered in the post anesthesia care unit (PACU) (p = 0.004) and higher consumption of oral morphine equivalent dose (MEqD) (p = 0.003) than the 3-D group. This regardless a higher rate of minilaparotomies in the 2D (n = 7) than in the 3D (n = 1) group (p < 0.03). The 2-D group had also higher rate of Clavien-Dindo 2 (CD2) (n = 2) and Clavien-Dindo 3 (CD3) complications (n = 3) (p = 0.03) than 3-D (n = 0). The other secondary outcome parameters did not vary between groups. ConclusionsThe results are severely hampered by the premature termination of the study, as less than 25 percent of the patients were recruited. Thus, no firm conclusions can be drawn regarding the quality of life and many of the secondary outcomes, as the lack of difference may be attributed to a type 2 error. However, the significant differences in postoperative pain and in complication rates suggest a greater advantage of 3-D laparoscopy than originally expected. Despite the methodological problems, the current data deserve attention in a sparsely investigated field, emphasizing the urgent need for further studies.