Postoperative Opioid Use Research Articles

Anaesthetist prediction of postoperative opioid use: a multicentre prospective cohort study

BackgroundThe Apfel simplified risk score includes four risk factors: female sex, non-smoking status, postoperative nausea and vomiting or motion sickness history, and postoperative opioid use. The score is calculated preoperatively, so postoperative opioid use must be predicted. We aimed to determine whether anaesthetists can predict patients' postoperative opioid use and dose. MethodsSpecialist anaesthetists from eight hospitals preoperatively predicted opioid use and dose in the post-anaesthesia care unit (PACU) and for the first 24 h postoperatively, which was compared with actual opioid use and dose. Opioid doses were converted to oral morphine equivalents (MEQ). Correlations between predicted and actual opioid use and dose were analysed with Spearman's rho and linear regression. ResultsA total of 487 anaesthetist–patient pairs were included. Anaesthetists overpredicted opioid use (398 [82%] predicted vs 251 [52%] actual patients requiring opioids in the PACU; 396 [81%] predicted vs 291 [60%] actual in the first 24 h) (Spearman's rho [95% confidence interval] 0.24 [0.16–0.33], P<0.001 in the PACU; 0.36 [0.28–0.44], P<0.001 in the first 24 h). Anaesthetists also overpredicted opioid dose (median [inter-quartile range] 12 [8–20] mg predicted MEQ vs 4 [0–18] mg actual MEQ in the PACU; 32 [18–60] mg vs 24 [0–65] mg MEQ in the first 24 h) (Spearman's rho 0.21 [0.13–0.29], P<0.001 in the PACU; 0.53 [0.40–0.60], P<0.001 in the first 24 h). ConclusionsSpecialist anaesthetists cannot accurately predict opioid use or dose in the PACU or the first 24 postoperative hours. The Apfel risk criterion for postoperative opioid use may be inaccurate in clinical practice.

Association Between Complications after Vascular Surgery and Prolonged Postoperative Opioid Use

Few studies have looked at the long-term risk of opioid use following major vascular surgery and no study has investigated the potential association between major complications and prolonged opioid use. We analyzed a population-based database linked to a prescription database to investigate factors associated with prolonged opioid use following major vascular surgery. This population-based cohort study included all adults who underwent open lower extremity revascularization (LER) or non-ruptured abdominal aortic aneurysm repair (open [AAA] and endovascular [EVAR]) in the province of Ontario, Canada, between 2013-2018. Prolonged opioid use was defined as 2 or more opioid prescriptions filled 6-12 months following surgery. Potential predictors of prolonged use were explored using modified Poisson regression with a generalized estimating equation (GEE) approach to account for the clustering of patients within physicians and institutions. This study included a total of 11,104 patients with 5,652 patients undergoing open LER, 3,285 patients undergoing EVAR, and 2,167 patients undergoing AAA. The rates of prior opioid use were 35.4% for LER, 15.8% for AAA and 14.3% for EVAR. Major complication rates following each procedure were 59.5% for AAA, 35.1% for LER, and 21.0% for EVAR. Following surgery, prolonged opioid use was identified in 26.1% of LER, 13.2% of AAA, and 11.6% of EVAR patients. The strongest predictor of prolonged opioid use was prior use with an OR of 13.27 (95%CI10.63-16.57) for AAA, 11.24 (95%CI 9.18-13.75) for EVAR, and 4.69 (95%CI 4.16-5.29) for LER. The occurrence of a major complication was only associated with prolonged opioid use for patients undergoing LER (OR 1.10; 95% CI:1.03-1.19), while it had a protective effect on patients undergoing EVAR (OR 0.83; 95% CI 0.69-0.99) and no association for patients undergoing open AAA repair (OR 1.11; 95% CI: 0.95-1.29). Older age was also protective with a reduced rate of prolonged opioid use for every 10 years of age increase: AAA (OR 0.87; 95% CI 0.77-0.99); EVAR (OR 0.83; 95% CI: 0.76-0.91); and LER (OR 0.91; 95% CI: 0.87-0.94). Prolonged opioid use is common following major vascular surgery, occurring in over 10% of patients undergoing either open or endovascular aneurysm repair and over 25% of patients undergoing open lower extremity revascularization. Prior opioid use is the strongest predictor for prolonged use, while the occurrence of postoperative complications is associated with a slight increased risk of prolonged use in patients undergoing lower extremity revascularization. These patient populations should be targeted for multimodal methods of opioid reduction following their procedures.

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

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

Perioperative Implementation of Low-Dose Pregabalin in an Enhanced Recovery After Cardiac Surgery Protocol: A Pre-Post Observational Study

Determine the effect of low-dose pregabalin in the perioperative enhanced recovery after cardiac surgery protocol. Pre-post observational study. Tertiary care hospital. Patients undergoing off-pump coronary artery bypass graft procedures. Pregabalin 75 mg BID for 48 hours postoperatively versus no pregabalin in a perioperative setting. Perioperative opioid use, pain scores, length of stay, time to extubation, and mortality were all measured. Descriptive data were presented as mean (SD), median (IQR), or N (%). Ordinal and continuous data used the t-test or Kruskal-Wallis test. Categorical data were compared between groups using the chi-square test or Fisher's exact test, as appropriate. Low-dose pregabalin administration (75 mg twice daily for 48 hours after surgery) was associated with a clinically significant reduction in opioid consumption on postoperative day 0 by 30.6%, with a median requirement of 318 (233, 397) morphine milligram equivalents (MME) in the pregabalin group compared with 458 (375, 526) MME in the control group (p < 0.001). There was no significant difference in pain scores between the groups with the exception at 0-to-12 hours, during which the pregabalin group had greater pain scores (median 3.32 [1.65, 4.36] v 2.0 [0, 3.25], p=0.013) (Table 3). Moreover, there was no significant difference in pain scores on postoperative day 1 (p=0.492), day 2 (p=0.442), day 3 (p=0.237), and day 4 (p=0.649). The difference in average Richmond Agitation Sedation Score scores was also not statistically significant between groups at 12 hours (p=0.954) and at 24 hours (p=0.301). The pregabalin group had no increased incidence of adverse events or any significant differences in intensive care unit length of stay, time to extubation, or mortality. In this evaluation of perioperative pregabalin administration for patients requiring cardiac surgery, pregabalin reduced postoperative opioid use, with significant reductions on postoperative day 0, and without any significant increase in adverse reactions. However, no differences in intensive care unit length of stay, time to extubation, or mortality were noted. The implementation of low-dose perioperative pregabalin within an Enhanced Recovery After Cardiac Surgery protocol may be effective at reducing postoperative opioid use in the immediate postoperative period, and may be safe with regard to adverse events. Ideal dosing strategies have not been determined; thus, further randomized control trials with an emphasis on limiting confounding factors need to be conducted.

Does the Association Between Psychosocial Factors and Opioid Use After Elective Spine Surgery Differ by Sex in Older Adults?

Psychosocial disorders have been linked to chronic postoperative opioid use and the development of postoperative pain. The potential interaction between sex and psychosocial factors with respect to opioid use after elective spine surgery in the elderly has not yet been evaluated. Our aim was to assess whether any observed association of anxiety or depression indicators with opioid consumption in the first 72 hours after elective spine surgery varies by sex in adults ≥65 years. Secondary analysis of a retrospective cohort of 647 elective spine surgeries performed at Brigham and Women's Hospital, July 1, 2015-March 15, 2017, in patients ≥65. Linear mixed-effects models were used to test whether history of anxiety, anxiolytic use, history of depression, and antidepressant use were associated with opioid consumption 0-24, 24-48, and 48-72 post surgery, and whether these potential associations differed by sex. History of anxiety, anxiolytic use, history of depression, and antidepressant use were more common among women (51.3% of the sample). During the first 24 hours after surgery, men with a preoperative history of anxiety consumed an adjusted mean of 19.5 morphine milligram equivalents (MME) (99.6% CI: 8.1, 31.0) more than men without a history of anxiety; women with a history of anxiety only consumed an adjusted mean 2.9 MME (99.6% CI: -3.1, 8.9) more than women without a history of anxiety (P value for interaction between sex and history of anxiety <0.001). No other interactions were detected between sex and psychosocial factors with respect to opioid use after surgery. Secondary analysis of this retrospective cohort study found minimal evidence that the association between psychosocial factors and opioid consumption after elective spine surgery differs by sex in adults ≥65.

Intraoperative Methadone Use in Patients Undergoing Minimally Invasive Colorectal Surgical Procedures

Abstract Background: Postoperative pain control is an important aspect in the recovery of patients. Recent literature suggests that the extended half-life of methadone may reduce overall opioid utilization in postoperative patients. However, there have yet to be any studies examining the efficacy of methadone as part of the protocol for enhanced recovery after colorectal surgery in patients. Objectives: To review the efficacy of perioperative methadone in reducing postoperative opioid usage and patient pain control. Design: Retrospective observational study. Settings: Tertiary academic center. Patients and Methods: Eighty-nine patients were identified from a prospectively maintained database having received methadone perioperatively from 2019 to 2021. These were compared to 89 historical controls identified from the same database and matched on procedure type, age, and American Society of Anesthesiology status. Main Outcome Measures: Primary outcomes were postoperative opioid use and subjective pain scores. Secondary outcomes were length of hospital stay, return of bowel function, and hospital cost. Sample Size: 89 patients receiving methadone and 89 historical control patients. Conclusions: The patients who received methadone used significantly more opioids overall compared to non-methadone patients (P = 0.015). In addition, there was no significant difference in pain scores for methadone vs non-methadone patients (P = 0.630). Furthermore, there was no difference in the length of stay and return of bowel function (P = 0.512 and P = 0.140, respectively). Moreover, opioid-naïve patients, regardless of methadone status, showed reduced average pain compared to non-naïve patients (P = 0.010 and P = 0.010, respectively). Despite support in surgical literature, we failed to find clinical benefit in including methadone as a part of the enhanced recovery pathway for patients undergoing minimally invasive colorectal surgery. Limitations: Retrospective design limited to minimally invasive techniques. Conflicts of interest The authors have no conflicts of interest to declare.

Combined Pericapsular Nerve Group Block and Intrapelvic Lateral Femoral Cutaneous Nerve Block Is Associated With Decreased Opioid Consumption After Hip Arthroscopy: A Retrospective Cohort Study.

Ambulatory hip arthroscopies are associated with moderate-to-severe pain often requiring opioid analgesia. Novel motor-sparing blocks, the pericapsular nerve group (PENG) and lateral femoral cutaneous nerve (LFCN) block, have shown efficacy in hip surgery. We sought to investigate the analgesic benefits of these novel blocks in terms of opioid-sparing and discharge efficiency. We conducted a retrospective cohort study with propensity score matching of 224 patients who underwent ambulatory elective unilateral hip arthroscopy. One group received a combined PENG and LFCN block (PENG/LFCN, n = 86), while a second group received only a PENG block (n = 26). A control group (n = 112) received no blocks. The primary outcome was postanesthesia care unit (PACU) mean opioid consumption. Secondary outcomes were maximum numeric rating scale (NRS) pain score, intravenous rescue analgesia, and PACU readiness-for-discharge times. The PENG/LFCN-block group required significantly less opioids than the control group in the PACU (25.98 ± 13.04 vs 14.58 ± 5.77, respectively) and were discharged earlier 2.72 ± 1.16 vs 4.42 ± 1.63 hours, respectively). The combined PENG/LFCN group also used less intravenous rescue opioids than the control group (0.47 ± 1.18 vs 1.44 ± 2.1 mg, respectively) and showed a significant difference in the highest NRS pain scores than the control group (6.01 ± 2.38 vs 6.77 ± 2.1 respectively). The PENG block alone group did not show a significant difference in opioid reduction (21.95 ± 15.83 vs 27.72 ± 15.01, respectively). This retrospective study found that in patients who underwent ambulatory elective unilateral hip arthroscopy, a combined PENG and LFCN block was associated with expedited PACU discharge and a clinically significant reduction in postoperative opioid use. Further study is warranted.

Post-Operative Analgesia and Enhanced Recovery after Pecs 1 and Pecs 2 Blocks in Patients Undergoing Modified Radical Mastectomy/Breast-Conserving Surgery with Axillary Lymph Nodal Clearance

Background Patients undergoing modified radical mastectomy (MRM)/breast-conserving surgery (BCS) with axillary nodal clearance experience significant post-operative pain, resulting in immobilization and increased usage of analgesics. These factors in turn result in delayed discharge. The pecs 1 and pecs 2 blocks have proven to be of significant benefit in relieving post-operative pain in such patients. Objectives A case series was performed at our institute to note the effects of pecs 1 and pecs 2 blocks on post-operative opioid use, early mobilization of the upper limbs, decreased incidence of early post-operative limb swelling and enhanced recovery after surgery. Material and Methods We included six patients who underwent BCS with axillary lymph node dissection/MRM wherein intraoperative pecs 1 and pecs 2 blocks were used. Patients were given pecs 1 and 2 blocks with 10+20 mL 0.25% injection of bupivacaine under ultrasound guidance after induction. Results In our study, opioids were completely avoided and it was seen that post-operative pain was adequately controlled with single doses of non-steroidal anti-inflammatory drugs if patients received intra-operative pecs 1 and 2 blocks. The pain control was rather sustained and adequate for the institution of early post-operative physiotherapy and thus early discharge and enhancing recovery after surgery. Conclusion Post-operative analgesia provided by pecs 1 and 2 blocks resulted in adequate and sustained pain control for early institution of upper limb physiotherapy and mobilization of patients after MRM/BCS with axillary lymph node dissection, which subsequently results in decreased incidence of early post-operative oedema of limb on operated side and early recovery after surgery.

Post-operative Opioid Reduction Protocol Reduces Racial Disparity in Clinical Outcomes in Children

IntroductionRacial disparities in health outcomes continue to exist for children requiring surgery. Previous investigations suggest that clinical protocols may reduce racial disparities. A post-operative opioid reduction protocol was implemented in children undergoing abdominal surgery who were less than 1 years old at a tertiary level hospital. The purpose of this investigation was to determine if the clinical protocol was associated with a reduction in racial disparity in post-operative opioid prescribing patterns and associated clinical outcomes. MethodsA post-operative opioid reduction protocol based on standing intravenous acetaminophen, educational sessions with nursing staff, and standardized post-operative sign-out between the surgical and NICU teams was implemented in children under 1 year old in 2016. A time series and before and after analysis was conducted using a historical pre-intervention cohort (Jan 2011–Dec 2015) and prospectively collected post-intervention cohort (Jan 2016–Jan 2021). Primary outcomes included post-operative opioid use and post-operative pain scores stratified by race. Secondary outcomes included associated clinical outcomes also stratified by race. ResultsA total of 249 children were included in the investigation, 117 in the pre-intervention group and 132 in the post intervention group. The majority of patients in both cohorts were either White or Black. The two cohorts were equally matched in terms of pre-operative clinical variables. In the pre-intervention cohort, the median post-operative morphine equivalents in White children was 2.1 mg/kg (IQR 0.2, 11.1) while in Black children it was 13.1 mg/kg (IQR 2.4, 65.3), p-value = 0.0352. In the post-intervention cohort, the median value for White children and Black children was statistically identical (0.05 mg/kg (IQR 0, 0.5) and 0.0 mg/kg (IQR 0, 0.3), respectively, p-value = 0.237). This pattern was also demonstrated in clinical variables including length of stay, intubation length and total parenteral nutrition use. In the pre-intervention cohort, the total length of stay for white children was 16 days while for black children it was 45 days (p = 0.007). In the postintervention cohort the length of stay for both White and Black children were identical at 8 days (p = 0.748). ConclusionThe use of a clinical opioid reduction protocol implemented at a tertiary medical center was associated with a reduction in racial disparity in opioid prescribing habits in children. Prior to the protocol, there was a racial disparity in clinical variables associated with prolonged opioid use including length of stay, TPN use, and intubation length. The clinical protocol reduced variability in opioid prescribing patterns in all racial groups which was associated with a reduction in variability in associated clinical variables. Level of EvidenceLevel III.

Erector Spinae Plane Block on Postoperative Pain and Opioid Consumption After Lumbar Spine Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

PurposeEvaluate the effectiveness of the erector spinae plane (ESP) block in lumbar spine surgeries. DesignSystematic review with meta-analysis. MethodsPubMed, Cochrane Library, CINAHL, Google Scholar, and other gray literature were searched for eligible studies. Risk ratio (RR), mean difference (MD), and standardized mean difference were used to estimate outcomes with suitable effect models. The quality of evidence was assessed using the Risk of Bias algorithm and the grades of recommendation, assessment, development, and evaluation (GRADE) approach. FindingsTwenty-two randomized controlled trials involving 1,327 patients were included. The erector spinae plane (ESP) block demonstrated a lower cumulative pain score within the first 48 hours at rest (MD, –1.03; 95% CI, –1.19 to –0.87; P < .00001) and during activity (MD, –1.16; 95% CI, –1.24 to –1.08; P < .00001). In addition, ESP block decreased opioid consumption (MD, –6.25; 95% CI, –8.33 to –4.17; P < .00001) and prolonged the time to first analgesic rescue (MD, 5.66; 95% CI, 3.11-8.20; P < .0001) resulting in fewer patients requesting rescue analgesic (RR, 0.33; 95% CI, 0.13-0.83; P = .02), lower incidence of postoperative nausea and vomiting (RR, 0.29; 95% CI, 0.10-0.79; P = .02) with improved patient satisfaction score (standardized mean difference, 2.17; 95% CI, 1.40-2.94; P < .00001). ConclusionsESP block can provide effective postoperative pain control for lumbar spine surgery, improve patient satisfaction, and reduce the amount of postoperative opioid use.

Chronic obstructive pulmonary disease is an independent risk factor for increased opioid use in total hip arthroplasty: A retrospective PearlDiver study

BackgroundTotal hip arthroplasty (THA) has become an incredibly common procedure due to its’ predictability and high success rate. The success of surgery is related to strict indications and careful optimization of medical comorbidities to decrease risk and improve outcomes. Chronic obstructive pulmonary disease (COPD) has been associated with increased medical and surgical complications. A regulatory focus on opioid utilization does not usually consider COPD as a risk factor, but limited research exists on the impact of COPD on outcomes and risks after THA. MethodsRetrospective all-inclusive database analysis of Medicare patients who had undergone THA between 2007 and 2017 included in the PearlDiver Database were studied. Postoperative opioid usage was examined at 1-, 3-, 6-, and 12 months, along with surgical infection, implant complications, and revisions. Post-operative complications within 30 days, either medical or implant related, were identified. Controlling for comorbidities, age, and sex, odds ratios were calculated using multivariable logistic regression with a significant α value of 0.05. ResultsCOPD patients had significantly higher rates of opioid usage postoperatively. COPD patients also had an increased rate of readmissions, medical/implant complications, and revision surgeries. DiscussionThis is the only study raising concern regarding opioid use in COPD patients after total hip arthroplasty, which may be critical considering the associated respiratory depression further exacerbating the COPD. Considering the evidence of poor outcomes associated with COPD in arthroplasty, appropriately screening for COPD and counseling or planning for post-operative pain control and complications is paramount.

Transversus Abdominis Plane Block VS. Local Wound Infiltration for Elective Minimally Invasive Cholecystectomy in Children: A Prospective Randomized Trial

BackgroundThe efficacy of transversus abdominis plane (TAP) block versus local anesthetic wound infiltration (LWI) in pediatric laparoscopic surgery is largely unknown. The objective of this study was to prospectively analyze this in minimally invasive cholecystectomy. We hypothesized that TAP block would be superior to LWI in terms of pain control and post-operative complications. MethodsWe conducted a prospective, randomized, single-blinded, controlled trial between 2017 and 2022 after obtaining Institutional Review Board (IRB) approval. After randomization, patients received a standard amount of ropivacaine via either 1) ultrasound-guided TAP block after general anesthesia induction or 2) local injection at port insertion by the operating surgeon. We collected data including operative time, pain scores, and medication usage post-operatively. We used descriptive statistics to report all endpoints and compared data with t-tests and Fisher's exact tests. A p-value less than 0.05 was considered statistically significant. ResultsWe enrolled 85 patients (43 LWI, 42 TAP). Mean [standard deviation] age and body mass index (BMI) in the LWI and TAP groups were 14.8 [1.9] and 14.7 [2] years and 29.9 [7.2] and 27.4 [8.2] kilogram/meter2 (kg/m2) respectively. We did not find any significant differences in postoperative opioid use, pain scores, and gastrointestinal symptoms. TAP patients had significantly longer time between anesthesia-start and procedure-start (p < 0.001), although total time under anesthesia was not significantly different (p = 0.540). ConclusionThere are no significant differences between equal administration of local anesthetic by TAP block and surgeon administered LWI during minimally invasive cholecystectomy. Type of StudyRandomized clinical trial. Level of EvidenceLevel II.

Effect of Preoperative Marijuana on Patient Outcomes and Opioid Use after Lumbar Decompression.

Retrospective Cohort Study. Our study aims to analyze the effect of preoperative marijuana use on outcomes and postoperative opioid use in patients who have undergone lumbar decompression without fusion. All patients >18years of age who underwent lumbar decompression from 2017-2022 with documented preoperative marijuana use at our academic institution were retrospectively identified. A 3:1 propensity match incorporating demographics, procedure type, and levels decompressed was performed to compare preoperative marijuana users and non-users. 1-year preoperative and postoperative opioid consumption in milligrams of morphine equivalents and postoperative outcomes including readmissions, reoperations, and complications, were obtained. A multivariate regression model was performed to measure the effect of marijuana use on the likelihood of a spine reoperation. Of the 340 included patients, 85 were preoperative marijuana users. There were no significant differences in medical complications, 90-day readmissions, or opioid consumption preoperatively or postoperatively (P > .05). We identified a trend towards patients who used marijuana having more reoperations for any cause (20.0% vs 11.37%, P = .067). Multivariate logistic regression analysis suggested that preoperative marijuana use was a significant predictor of all-spine reoperations (OR = 2.06, P = .036). In lumbar decompression patients, preoperative marijuana use does not impact opioid consumption, readmissions, or medical complications, but is a significant predictor of future postoperative reoperations. Additional research is necessary to further explore the role of marijuana use in spine surgery.

Effect of transversus abdominis plane block on postoperative outcomes in gynecologic oncology patients managed on an Enhanced Recovery After Surgery pathway

ObjectivesTo characterize the effect of transversus abdominis plane (TAP) blocks on post-operative outcomes in patients undergoing laparotomy for gynecologic malignancy. MethodsThis retrospective cohort study assessed patients undergoing laparotomy in 2016–2017 and 2020 in Alberta, Canada. The primary outcome was opioid consumption in oral morphine milligram equivalent (MME). Secondary outcomes included maximum pain scores, length of stay, and patient-controlled analgesia (PCA) use. Outcomes were compared using t-test with subgroup analysis by NSAID use. Multivariate regression modelling was performed for potential confounders. ResultsData was collected on 956 patients; 828 received a TAP block, 128 did not. Opioid use in the first 24 h was lower in the TAP block group (35.9 mg MME vs 44.5 mg MME, p = 0.0294), without any increase in pain scores, this did not remain significant after regression analysis. Patients with TAP blocks had significant reduced mean length of stay (3.2 days vs. 5.0 days, p < 0.0001), and PCA use (19.9% vs. 56.25%, p < 0.0001). On subgroup analysis of patients that did not receive NSAIDs (n = 160), mean opioid use was decreased in those patients with TAP blocks compared to those without TAP blocks in the first 24 h (36.1 mg vs. 61.2 mg, p = 0.0017), and at 24 to 48 h (16.3 mg vs. 51.0 mg, p < 0.0001). ConclusionsSurgeon-administered TAP blocks were associated with decreased length of stay and post-operative opioid use in patients not receiving scheduled NSAIDs. This decrease in opioid use was not associated with any increase in average or maximum pain scores.

Postoperative Opioid Prescribing in Adolescents and Young Adults After Urologic Procedures Is Associated With New Persistent Opioid Use Disorder: A Large Claims Database Analysis

To assess the risk of persistent opioid use following various urologic procedures in adolescents and young adults. The TriNetX LLC Diamond Network was queried for patients aged 13-21years who underwent pyeloplasty, hypospadias repair, inguinal hernia repair, inguinal orchiopexy, hydrocelectomy, or circumcision. Cohorts of patients prescribed and not prescribed postoperative opioids were created and propensity-matched for age, race/ethnicity, psychiatric diagnoses, and preoperative pain diagnoses. The primary outcome was new persistent opioid use, defined as new opioid use 3-9months after index procedure without another surgery requiring anesthesia during the postoperative timeframe. Of 32,789 patients identified, 66.0% received a postoperative opioid prescription. After propensity score matching for each procedure, 18,416 patients were included: 197 for pyeloplasty, 469 for hypospadias repair, 1818 for inguinal hernia repair, 2664 for inguinal orchiopexy, 534 for hydrocelectomy, and 3526 for circumcision. Overall, 0.41% of patients who did not receive postoperative opioids developed new persistent opioid use, whereas 1.69% of patients who received postoperative opioids developed new persistent opioid use (P<.05). Patients prescribed postoperative opioids had statistically higher odds of developing new persistent opioid use for hypospadias repair (RR: 17.0; 95% CI: 2.27-127.2), inguinal orchiopexy (RR: 3.46; 95% CI: 1.87-6.4), inguinal hernia repair (RR: 2.18; 95% CI: 1.07-4.44), and circumcision (RR: 4.83; 95% CI: 2.60-8.98). The use of postoperative opioids after urological procedures in adolescents and young adults is associated with a significant risk of developing new persistent opioid use.

Effect of local anesthetic volume (20 vs. 40 ml) on the analgesic efficacy of costoclavicular block in arthroscopic shoulder surgery: a randomized controlled trial.

Among the various diaphragm-sparing alternatives to interscalene block, costoclavicular block (CCB) demonstrated a low hemidiaphragmatic paresis (HDP) occurrence but an inconsistent analgesic effect in arthroscopic shoulder surgery. We hypothesized that a larger volume of local anesthetic for CCB could provide sufficient analgesia by achieving sufficient supraclavicular spreading. Sixty patients scheduled for arthroscopic rotator cuff repair were randomly assigned to receive CCB using one of two volumes of local anesthetic (CCB20, 0.75% ropivacaine 20 ml; CCB40, 0.375% ropivacaine 40 ml). The primary outcome was the rate of complete analgesia (0 on the numeric rating scale of pain) at 1 h postoperatively. The secondary outcomes included a sonographic assessment of local anesthetic spread, diaphragmatic function, pulmonary function, postoperative opioid use, and other pain-related experiences within 24 h postoperatively. The rates of complete analgesia were not significantly different (23.3% [7/30] and 33.3% [10/30] in the CCB20 and CCB40 groups, respectively; risk difference 10%, 95% CI [-13, 32], P = 0.567). There were no significant differences in other pain-related outcomes. Among the clinical factors considered, the only factor significantly associated with postoperative pain was the sonographic observation of supraclavicular spreading. There were no significant differences in the incidence of HDP and the change in pulmonary function between the two groups. Using 40 ml of local anesthetic does not guarantee supraclavicular spread during CCB. Moreover, it does not result in a higher rate of complete analgesia compared to using 20 ml of local anesthetic in arthroscopic shoulder surgery.

Multimodal Analgesia Bundle and Postoperative Opioid Use Among Patients Undergoing Colorectal Surgery

A key objective in contemporary surgery is to reduce or eliminate the usage of opioids to minimize gastrointestinal adverse effects, fatigue, and long-term opioid dependency. To evaluate the association of the implementation of a care bundle of 3 opioid-sparing interventions with the amount of opioids consumed postoperatively among patients undergoing major abdominal surgery and to examine the respective associations of the 3 components. This retrospective cohort study was performed at Ersta Hospital, an elective teaching hospital in Stockholm, Sweden. All patients undergoing major colorectal surgery between January 1, 2016, through December 31, 2019, were included. Data analysis was conducted from February 1, 2020, to May 30, 2022. A care bundle consisting of an individualized opioid regimen, regular gabapentinoids, and clonidine as a rescue analgesic was gradually introduced early in the study period. Amount of in-hospital administered intravenous and oral opioids on the day of surgery and the first 5 postoperative days (morphine milligram equivalents [MME]). The association between exposure and outcome was examined using multivariable linear regression. Overall, 842 patients had major colorectal surgery in the study period (mean [SD] age, 64.6 [15.5] years; 421 [50%] men). Median (range) opioid usage decreased from 75 (0-796) MME in 2016 to 22 (0-362) MME in 2019 (P < .001), and the proportion of patients receiving 45 MME or less increased from 35% to 66% (P < .001). On multivariable analysis (F5, 836 = 57.5; P < .001), an individualized opioid strategy (β = -11.6; SE = 3.8; P = .003), the use of gabapentin (β = -39.1; SE = 4.5; P < .001), and increasing age (β = -1.0; SE = 0.11; P < .001) were associated with less opioid consumption, while the use of clonidine was associated with more opioid intake (β = 11.6; SE = 3.6; P = .001). In this cohort study of 842 patients undergoing colorectal surgery, a care bundle consisting of an individualized opioid regimen, regular gabapentin, and clonidine as a rescue analgesic was found to be associated with a significant decrease in opioids consumed postoperatively. Regular gabapentin and an individualized opioid regimen were particularly strongly associated with this decrease and should be further evaluated as components of multimodal, opioid-free postoperative analgesia.

The essential role of non-steroidal anti-inflammatory drugs in pain control following robotic thoracoscopic lung resections.

Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control. We investigated the effect of non-steroidal analgesic drugs (NSAIDs) on pain control by comparing patient levels and opioid requirements after robotic pulmonary resections. We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naïve robotic thoracoscopic pulmonary resections. All patients received postoperative NSAIDs unless contraindicated or at the discretion of the attending surgeons. Our original protocol (ERATS-V1) was modified to optimize opioid-sparing effect without affecting pain control (ERATS-V2). Demographics, operative outcomes, and postoperative opioid dispensed [morphine milligram equivalent (MME)] were collected. A total of 491 patients (147 ERATS-V1; 344 ERATS-V2) were included in this study. There was no difference in patient characteristics or operative outcomes between ERATS cohorts. Protocol optimization was associated with a 2- to 10-fold reduction of postoperative opioid use without compromising pain control. In ERATS-V1 cohort, there was no difference in pain levels and opioid requirements with NSAID usage. In ERATS-V2 cohort, while pain levels were similar, higher in-hospital opioid consumption was observed in no-NSAID subgroup {MME: 20.5 [interquartile range (IQR), 4.8-40.5] vs. 12.0 (IQR, 2.0-32.2), P=0.0096, schedule II: 14.2 (IQR, 3.0-36.4) vs. 6.8 (IQR, 1.4-24.0), P=0.012} as well as total postoperative schedule II opioid requirement [17.8 (IQR, 3.0-43.5) vs. 8.8 (IQR, 1.5-30), P=0.032]. The opioid-sparing effect of NSAIDs was observed only in optimized ERATS patients. Modifications of our pre-existing ERATS was associated with a significant reduction of opioid consumption without affecting pain levels. This revealed the role of NSAIDs in postoperative pain management otherwise masked by excessive opioids use.

Multimodal pain management after robotic-assisted total laparoscopic hysterectomy reduces postoperative opioid use and pain scores (1180)

Multimodal pain management after robotic-assisted total laparoscopic hysterectomy reduces postoperative opioid use and pain scores (1180)

Prevalence and predictors of long-term opioid use following orthopaedic surgery in an Australian setting: A multicentre, prospective cohort study.

Opioid analgesics prescribed for the management of acute pain following orthopaedic surgery may lead to unintended long-term opioid use and associated patient harms. This study aimed to examine the prevalence of opioid use at 90 days after elective orthopaedic surgery across major city, regional and rural locations in New South Wales, Australia. We conducted a prospective, observational cohort study of patients undergoing elective orthopaedic surgery at five hospitals from major city, regional, rural, public and private settings between April 2017 and February 2020. Data were collected by patient questionnaire at the pre-admission clinic 2-6 weeks before surgery and by telephone call after 90 days following surgery. Of the 361 participants recruited, 54% (195/361) were women and the mean age was 67.7 years (standard deviation 10.1 years). Opioid use at 90 or more days after orthopaedic surgery was reported by 15.8% (57/361; 95% confidence interval (CI) 12.2-20%) of all participants and ranged from 3.5% (2/57) at a major city location to 37.8% (14/37) at an inner regional location. Predictors of long-term postoperative opioid use in the multivariable analysis were surgery performed at an inner regional location (adjusted odds ratio 12.26; 95% CI 2.2-68.24) and outer regional location (adjusted odds ratio 5.46; 95% CI 1.09-27.50) after adjusting for known covariates. Long-term opioid use was reported in over 15% of patients following orthopaedic surgery and appears to be more prevalent in regional locations in Australia.