Preoperative Narcotic Use Research Articles

Preoperative Narcotic Use as a Predictor of Clinical Outcome

Prognostic Study, Level II (Retrospective review of prospectively collected data). To identify an association between preoperative narcotic use and clinical outcome after cervical arthrodesis. Little data exists regarding the influence that chronic preoperative narcotic use has on clinical outcomes after surgery. Cervical arthrodesis is a common procedure that has a predictably high success rate for relief of radicular pain. In addition, the patient population presenting for this procedure has a high propensity for preoperative narcotic use. Charts and prospectively collected questionnaires concerning the use of pain medication from 91 consecutive patients who underwent cervical arthrodesis for relief of radicular pain by a single surgeon at a single institution were reviewed. Group I consisted of 47 patients who took narcotic pain medication for their radicular pain on a daily basis for greater than 6 months before surgery. Group II consisted of 44 patients who were not on narcotics chronically before surgery. Postoperative narcotic use and patient outcome based on the modified Robinson criteria were assessed. Patients were observed for a minimum of 2 years. Of the group I patients, 16 (34%) continued to require chronic narcotic pain medication up to 2 years after surgery whereas only 3 (7%) of the group II patients required narcotic pain medication past 3 months (P = 0.002). Of the group I patients, 24 (51%) had a good or excellent result after surgery and 15 (32%) had a poor result whereas 38 (86%) of the group II patients had a good or excellent result and no patient had a poor result (P < 0.001). Chronic narcotic use before cervical arthrodesis was found to be associated with continued narcotic use after surgery and worse functional outcomes following surgery. While further studies will be necessary to ascertain if this relationship is generalizable to other orthopaedic procedures and to analyze for potential confounding variables, surgeons may want to counsel their patients about the potential for inferior clinical outcomes if narcotics are used before surgery.

Looks Good But Feels Bad: Factors That Contribute to Poor Results After Total Knee Arthroplasty

The purpose of this study was to evaluate patient factors that might contribute to a poor result after total knee arthroplasty (TKA). Seventy-one knees (6.9%) of 1024 primary TKAs were identified at 1 year follow-up as having a poor result because of either stiffness or pain. Radiographs demonstrated well-fixed and aligned implants. This group was compared with a matched control group of 148nonpainful or stiff TKAs, with similar range of motion preoperatively. Logistic regression analysis was performed to compare age, sex, body mass index, comorbidities, previous surgeries, preoperative narcotic use, tobacco or alcohol use, work status, insurance status, and any history of depression. Factors that were significantly associated with a stiff or painful outcome included female sex, higher body mass index, previous knee surgery, patients on disability, diabetes mellitus, pulmonary disease, and depression.

POST-OPERATIVE NARCOTIC REQUIREMENT FOLLOWING LUMBAR MICRODISCECTOMY IS RELATED TO PREOPERATIVE PAIN, NOT TO INTRA-OPERATIVE KETOROLAC OR BUPIVACAINE

Abstract S6 Introduction: Lumbar disc surgery is increasingly being performed on an outpatient basis, and poorly controlled post-operative pain is a reason for unplanned hospital admission. Various modalities to decrease post-operative narcotic requirements have been described, including epidural steroids, [1] epidural morphine [2] and oral non-steroidal agents [3]. Purpose: This randomized double-blind study compared the effect of preoperative pain and narcotic use, as well as intra-operative administration of intravenous ketorolac, intra-muscular injection of bupivacaine, or placebo on post-operative morphine (MSO (4)) requirements as measured by patient controlled analgesia in the first 24 hours after surgery. Materials and Methods: After IRB approval and informed consent, 30 patients (ASA I-II) undergoing inpatient single-level lumbar microdiscectomy with a standardized general anesthetic were randomly assigned to receive either ketorolac (30 mg intravenously), bupivacaine 0.25% (15 cc injected into the paraspinous muscles via the surgical wound), or saline placebo, immediately prior to wound closure. Post-operatively all patients received demand-only intravenous MSO4 patient controlled analgesia (PCA), with a demand dose of 1.0 mg as frequently as every 6 minutes. MSO4 demand (mg requested) and usage (mg delivered) were compared between the three groups at 30 min, 1, 4, 8, 16, 20 and 24 hours post-operatively by one way ANOVA. Pre-operative narcotic use was noted. Pre- and post-operative pain was assessed using the scale standard for PCA in this institution (0 - 5 scale with 0 = no pain and 5 = most severe pain), and pre-operative pain was correlated to post-operative MSO4 use and demand by simple regression and Pearson correlation. Significance was assumed at P < 0.05. Results: There were no group differences in age, sex, weight, disc level, pre-operative pain, nor were there differences postoperatively in time to voiding, ambulation or incidence of nausea and vomiting. With the greater access to post-operative narcotic provided by PCA, the total dose of MSO4 demanded in 24 hours in all groups (placebo=22.8 +/- 20.3 mg, bupivacaine=28.3 +/- 27.7 mg, and ketorolac=20.1 +/- 15.5 mg) was greater in this study than previously reported (12 +/- 1.9 mg); however, there was no relationship between group assignment and either post-operative use of or demand for MSO4 via PCA although sample size is small. There was, however, a significant correlation between pre-operative pain and post-operative narcotic demand (r=0.46, P < 0.01) and usage (r=0.37, P < 0.05). There was no correlation between pre-operative narcotic use and either pre-operative pain scores or post-operative MSO4 use or demand. Conclusions: No difference in post-operative narcotic requirement was seen in patients undergoing single level lumbar microdiscectomy receiving either intravenous ketorolac or intramuscular bupivacaine as compared to placebo; however, a much larger study would be necessary to demonstrate a difference. Post-operative narcotic requirements are increased, however, in those patients who are in severe pain pre-operatively, regardless of pre-operative narcotic use. This suggests that those patients in severe pain pre-operatively are less likely to be successful outpatient surgical candidates. The authors would like to thank Abbott, Inc. for the loan of two PCA pumps used in this study.

Patient experience of pain after elective noncardiac surgery.

The purpose of this study was to examine the extent and evolution of pain after common major surgical procedures and to establish correlates of three types of pain: pain at rest, pain with movement, and maximum pain over the previous 24 h. Patients completed a preoperative questionnaire to obtain data on age, gender, narcotic use, baseline level of pain, chronicity of pain, and level of anxiety. Patients were then interviewed on Postoperative Days 1, 2, and 3 to assess their pain on a scale of 0 (none) to 10 (worst imaginable). The mean pain score at rest was 2.6 on Postoperative Day 1 and decreased to 2.3 on Postoperative Day 3 (P = 0.06). The mean pain score with movement was 4.5 on Postoperative Day 1, which decreased to 4.2 on Postoperative Day 3 (P = 0.03). The mean maximum pain score over the previous 24 h was 6.3, which decreased to 5.6 (P = 0.0001). Preoperative narcotic use and high baseline preoperative pain, defined as a score > or = 4, were significantly (P < 0.05) associated with increased pain at rest, pain with movement, and maximum pain. Epidural analgesia was the only mode of analgesia significantly associated with both decreased postoperative pain at rest and decreased pain with movement (P < 0.05). These relatively high pain scores and minimum decreases in pain from Postoperative Days 1 to 3 emphasizes the need for more effective pain management continuing into the postoperative period to facilitate mobilization and recovery.

The effect of ethnicity on prescriptions for patient-controlled analgesia for post-operative pain

We studied if ethnicity influences patient-controlled analgesia (PCA) for the treatment of post-operative pain. Using a retrospective record review, we examined data from all patients treated with PCA for post-operative pain from January to June 1993. We excluded patients who did not have surgery prior to the prescription of PCA or were not prescribed PCA in the immediate post-operative period. The sample consisted of 454 subjects. While there were no differences in the amount of narcotic self-administered, there were significant differences in the amount of narcotic prescribed among Asians, Blacks, Hispanics, and Whites ( F = 7.352, P < 0.01). The ethnic differences in prescribed analgesic persisted after controlling for age, gender, pre-operative use of narcotics, pain site, and insurance status. Patient's ethnicity has a greater impact on the amount of narcotic prescribed by the physician than on the amount of narcotic self-administered by the patient.

Transduodenal sphincteroplasty. 5-25 year follow-up of 89 patients.

Between 1957 and 1977, 95 patients underwent transduodenal pancreatic sphincteroplasty (TPS) for a diagnosis of recurrent pancreatitis. Five to twenty-five year follow-up was obtained for 89 patients (94%) and was analyzed by life-table method. Short-term successful outcome was defined as relief of symptoms (e.g., pain) for one to three years; long-term successful outcome was defined as those patients who remained symptom-free at time of last follow-up. Operative mortality was 4.2% (4 patients). Fifty-six patients (66%) had a successful short-term outcome. Of these, 13 patients had recurrence of symptoms: 7 occurred at 4 years, 5 at 5 years and 1 at 6 years. Preoperative factors associated with poor short-term outcome were previous upper abdominal surgery (X2 = 5.67, p less than 0.05) and frequent diarrhea (X2 = 6.18, p less than 0.05). Preoperative factors associated with poor long-term outcome were previous upper abdominal surgery (X2 = 7.82, p less than 0.01), heavy alcohol intake (X2 = 4.71, p less than 0.05), narcotic use (X2 = 5.68, p less than 0.05) and frequent diarrhea (X2 = 4.8, p less than 0.05). Morphine Prostigmin Test (MPT) was performed preoperatively in 78 patients (82%). A significantly greater proportion of patients with a rise in serum pancreatic enzymes secondary to MPT (MPT+) had a successful long-term outcome compared with those without such a rise (MPT-) (61% v 41%, X2 = 5.13, p less than 0.05). Furthermore, of the patients with a successful short-term outcome, 88% with MPT+ remained long-term symptom-free compared to 38.5% with MPT- (X2 = 8.36, p less than 0.01). We conclude that TPS can be a successful operation for acute recurrent pancreatitis. Previous upper abdominal operations, signs of more advanced pancreatic disease, preoperative narcotic use and alcohol abuse, were associated with a worse outcome and probably associated with chronic recurrent pancreatitis. Preoperative use of MPT, coupled with accurate clinical history, defined groups with different short- and long-term prognosis after TPS.

The Preoperative and Postoperative Use of Sedatives and Narcotics in the Aged

The Preoperative and Postoperative Use of Sedatives and Narcotics in the Aged