Reduction In Opioid Use Research Articles

Safety and Effectiveness of Urologist-Directed Extracorporeal Shock Wave Lithotripsy for Pancreatolithiasis.

Introduction: Extracorporeal shock wave lithotripsy (SWL) can be used in conjunction with endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of large (≥5 mm) or impacted pancreatolithiasis. We report our experience demonstrating the safety and effectiveness of urologist-directed SWL for pancreatolithiasis. Methods: We performed a retrospective review of all patients undergoing SWL for pancreatolithiasis at our institution between 2016 and 2020. We defined a treatment cycle as one in which the patient underwent a predefined number of SWL procedures prior to performance of a post-SWL ERCP. Stone-free status was defined as the absence of stone fragments at post-SWL ERCP. Multivariable logistic regression was performed to determine characteristics associated with stone persistence after a treatment cycle. Results: There were 44 patients who underwent 59 treatment cycles consisting of 118 pancreatic SWL procedures. Forty-two cycles (71.2%) were staged, and 17 (28.8%) were not staged. The median size of the largest pancreatic stone was 9 mm [IQR 6-11] and was impacted in 38 cases (64.4%). Patients reported pain in 51 cases (86.4%), of which 28 required the use of opioid analgesics. Patients were rendered stone free in 38 cycles (64.4%). Pain improvement was noted in 39 cases (66.1%), and the reduction in opioid use was statistically significant (28 cases vs. 10 cases, P = 0.004). Impacted stones were associated with an increased odds of stone persistence (OR 7.04, 95% CI 1.14-43.43, P = 0.04). Conclusions: In this joint venture with gastroenterology, we demonstrate that urologist-directed SWL for pancreatolithiasis is safe, effective, and in line with published rates.

A novel opioid/pramipexole combination treatment for the management of acute pain: a pilot study.

Despite their dangerous side effects, opioid drugs remain a standard of care for moderate to severe pain with few alternatives. Strategies to maintain the analgesic effects of opioids while minimizing the associated risks are needed. Pre-clinical studies have shown using a dopamine 3 receptor (D3R) agonist as an adjuvant to morphine provides superior analgesia against painful stimuli compared to morphine alone. Our objective was to test if adjunct treatment with a D3R agonist can lead to a reduction in opioid use while maintaining effective analgesia. This study was set up as a double-blinded, placebo-controlled randomized trial. Enrollment included acute renal colic patients presenting to the emergency department, from which patients were randomized to either the "control" or "study arm". The control group received standard treatment of care (morphine, 0.1 mg/kg; i.v.) and an oral placebo pill. The experimental group received half-dosed morphine and oral pramipexole pill (0.25 mg). Pain measurements including a numerical pain scale and visual analog scale were collected from enrollees at baseline and every subsequent 15 min. A total of 19 patients completed the study, 10 in the experimental arm and 9 in the control arm. During the study period, effective analgesia (50% decrease from baseline) was achieved in 80% of patients in the experimental arm vs. 33.3% in the control arm. Our pilot clinical trial demonstrated that D3R recruitment can serve as an effective adjuvant to low-dose morphine for control of renal colic pain and potentially other acute pain conditions. ClinicalTrials.gov, identifier, (NCT04160520).

Analgesic Efficacy of Single-Shot Erector Spinae Block in Video-Assisted Thoracoscopic Surgery: A Propensity Score-Matched Retrospective Cohort Study.

Introduction Video-assisted thoracic surgery (VATS) is a minimally invasive surgical technique though effective analgesia remains a challenge. Erector spinae plane block (ESPB) has gained popularity due to its ease and safety of placement. In this study, we evaluated the analgesic efficacy of ESPB in patients undergoing VATS through a propensity score-matched retrospective cohort study. The primary outcome is the total opioid use in the first 12 postoperative hours. Methods We used binomial logistic regression to model whether patients received ESPB as a function of age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, and surgery type to generate a propensity score for each patient for matching. Results After screening 286 patients, 55 patients each in the ESPB and no-block groups were matched. ESPB was associated with a 1.2 mg (95% CI: -2.2 to -0.2) reduction in opioid use in IV hydromorphone equivalents when compared to no block. However, there was no reduction in the 12-hour pain score area under the curve or incidence of complications between the two groups. Conclusions ESPB was associated with a modest reduction in total opioid consumption although not a difference in pain score. While its analgesic efficacy may be limited, ESPB could be considered a component of multi-modal analgesia in VATS.

Buprenorphine Induction in Trauma Patients With Opioid Use Disorder — A Single Center Experience?

IntroductionBuprenorphine is a Food and Drug Administration-approved therapy for opioid use disorder, with proven efficacy in treatment retention and reduction in opioid use and mortality. Low-dose buprenorphine initiation or microinduction is a novel means of initiation that may allow for an easier transition in patients. Trauma patients have high rates of opioid use disorder and patient directed discharges (PDD). We hypothesized that patients initiated on a buprenorphine microinduction program would have increased protocol completion and fewer PDD compared with patients initiated historically on a traditional induction. MethodsOur retrospective cohort study compared buprenorphine microinduction and traditional induction in trauma patients at an urban level one trauma center between December 2020 and June 2022. Patients aged 18-89 y with traumatic injuries who received buprenorphine were included. Our primary outcome was in-hospital protocol completion, defined as reaching 16 mg of buprenorphine within 24 h or a documented stable dose. Statistical analysis was performed using chi-square for categorical variables and two sample t-tests for continuous variables. ResultsNinety-eight patients were included, with 46 initiating with microinduction and 52 initiating with traditional induction. There was no difference in protocol completion, (P = 0.29) and 83% of subjects who started an induction protocol completed it. Those who completed a protocol were more likely to be discharged home (P = 0.0002), had less PDD (P = 0.001), and had an increased likelihood of attending outpatient addiction clinic follow-up (P = 0.038). ConclusionsRegardless of the protocol type, buprenorphine induction can be implemented in trauma patients with high protocol completion rates. In our population, those who complete a protocol had a higher likelihood of discharge home and postdischarge follow-up in addiction medicine clinic.

Evidence for the use of cannabis-based medicines in osteoarthritis: a scoping review.

The purpose of this study was to conduct a scoping review to describe the evidence on the efficacy and safety of using cannabis-based medicines for osteoarthritis. The review was conducted following the framework proposed by Arksey and O'Malley and reported following PRISMA extension for scoping reviews guidelines. We conducted a comprehensive search across various databases including MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, and Proquest, spanning from inception of each database to March 2023. We retrieved 2533 citations, and after deduplication, title and abstract screening, and full-text screening, 10 articles were included for analysis. These studies were composed of randomized-controlled trials (n = 4/10), cross-sectional surveys (n = 3/10), case studies (n = 2/10), and a cohort study (n = 1/10). Evidence for using cannabis-based medicines was mixed, with just 60% (n = 6/10) of included studies reporting statistically significant improvements in pain. Studies with larger samples sizes and longer durations of exposure did not find significant benefits for pain. The few adverse effects reported were generally mild and affected a minority of participants. Several studies also discovered that cannabis-based medicines were associated with a reduction in opioid use. Currently available data on the use of cannabis-based medicines in osteoarthritis is insufficient to make recommendations. Future research should address concerns regarding small sample sizes and short treatment durations to provide a more robust evidence base. Key Points • Current evidence remains mixed; studies that found a positive benefit with using cannabis-based medicines had limitations with small sample sizes and short durations of exposure • The use of cannabis-based medicines in osteoarthritis appears to be generally well tolerated, adverse effects are mild and experienced by a minority of participants • Cannabis-based medicines may decrease the use of opioids in patients with osteoarthritis • Future research should address the gaps in long-term efficacy and safety data.

Effects of liposomal bupivacaine on opioid use and healthcare resource utilization after outpatient spine surgery: a real-world assessment

BACKGROUND CONTEXTPerioperative pain management affects cost and outcomes in elective spine surgery. PURPOSEThis study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization. STUDY DESIGNThis was a retrospective comparative study. PATIENT SAMPLEEligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores. OUTCOME MEASURESOutcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis. METHODSDeidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc. RESULTSIn total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, −52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, −50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, −31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts. CONCLUSIONSUse of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery.

Government Direct-to-Consumer Education to Reduce Prescription Opioid Use

Direct-to-consumer education reduces chronic sedative use. The effectiveness of this approach for prescription opioids among patients with chronic noncancer pain remains untested. To evaluate the effectiveness of a government-led educational information brochure mailed to community-dwelling, long-term opioid consumers to reduce prescription opioid use compared with usual care. This cluster randomized clinical trial was conducted from July 2018 to January 2019 in Manitoba, Canada. All adults with long-term opioid prescriptions were enrolled (n = 4225). Participants were identified via the Manitoba Drug Program Information Network. Individuals receiving palliative care or with a diagnosis of cancer or dementia were excluded. Data were analyzed from July 2019 to March 2020. Participants were clustered according to their primary care clinic and randomized to the intervention (a codesigned direct-to-consumer educational brochure sent by mail) or usual care (comparator group). The main outcome was discontinuation of opioid prescriptions at the participant level after 6 months, ascertained by pharmacy drug claims. Secondary outcomes included dose reduction (in morphine milligram equivalents [MME]) and/or therapeutic switch. Reduction in opioid use was assessed using generalized estimating equations to account for clustering, with prespecified subgroup analyses by age and sex. Analysis was intention to treat. Of 4206 participants, 2409 (57.3%) were male; mean (SD) age was 60.0 (14.4) years. Mean (SD) baseline opioid use was comparable between groups (intervention, 157.7 [179.7] MME/d; control, 153.4 [181.8] MME/d). After 6 months, 235 of 2136 participants (11.0%) in 127 clusters in the intervention group no longer filled opioid prescriptions compared with 228 of 2070 (11.0%) in 124 clusters in the comparator group (difference, 0.0%; 95% CI, -1.9% to 1.9%). More participants in the intervention group than in the control group reduced their dose (1410 [66.0%] vs 1307 [63.1%]; difference, 2.8% [95% CI, 0.0%-5.7%]). Receipt of the brochure led to greater dose reductions for participants who were male (difference, 3.9%; 95% CI, 0.1%-7.7%), aged 18 to 64 years (difference, 3.7%; 95% CI, 0.2%-7.2%), or living in urban areas (difference, 5.9%; 95% CI, 1.9%-9.9%) compared with usual care. In this cluster randomized clinical trial, no significant difference in the prevalence of opioid cessation was observed after 6 months between the intervention and usual care groups; however, the intervention resulted in more adults reducing their opioid dose compared with usual care. ClinicalTrials.gov Identifier: NCT03400384.

Impact of Liposomal Bupivacaine on Enhanced Recovery After Surgery Protocol for Lung Resection

BackgroundThere is limited data showing the benefit of liposomal bupivacaine as part of an Enhanced Recovery After Surgery (ERAS) protocol in reducing opioid use in minimally invasive lobectomies. MethodsA retrospective observational study compared 3 cohorts of patients who underwent lobectomies between January 2015 and December 2021. The control group neither received liposomal bupivacaine intraoperatively nor underwent an ERAS protocol. The liposomal bupivacaine cohort only received a nerve block, whereas the ERAS cohort received a nerve block intraoperatively and underwent an ERAS protocol. The primary outcome was postoperative opioid consumption. ResultsThe study included 433 patients, comprising 87 in the control group, 138 in the liposomal bupivacaine alone cohort, and 208 in the ERAS/liposomal bupivacaine cohort. There was a statistically significant difference in the amount of opioids used between the control (43 oral morphine equivalents [OME]) and liposomal bupivacaine alone cohort (30.5 OME; P < .001), between control vs the ERAS/liposomal bupivacaine cohort (17 OME; P < .001), and between the liposomal bupivacaine alone and ERAS/liposomal bupivacaine cohorts (P < .001). Hospital stay was not statistically different between the 2 groups of interest (3 days); however, hospital stay differed from the control (4 days). Readmission at 30 days was not significantly different between the 3 groups (P = .43). ConclusionsLiposomal bupivacaine alone as part of a larger ERAS protocol significantly reduced opioid use and hospitalization duration; however, the reduction in opioid use was much greater with incorporation of liposomal bupivacaine into an ERAS protocol rather than in isolation. Prospective studies are needed to determine reproducibility and applicability of liposomal bupivacaine for opioid use reduction in other United States hospital systems.

Perioperative Cannabinoids Significantly Reduce Postoperative Opioid Requirements in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Background Opioids, commonly used to control pain associated with surgery, are known to prolong the duration of mechanical ventilation and length of hospital stay. A wide range of adjunctive strategies are currently utilized to reduce postoperative pain, such as local and regional nerve blocks, nerve cryoablation, and adjunctive medications. We hypothesized that dronabinol (a synthetic cannabinoid) in conjunction with standard opioid pain management will reduce opioid requirements to manage postoperative pain. Methods Sixty-eight patients who underwent isolated first-time coronary artery bypass graft surgery were randomized to either the control group, who received only standard opioid-based analgesia, or the dronabinol group, who received dronabinol (a synthetic cannabinoid) in addition to standard opioid-based analgesia. Dronabinol was given in the preoperative unit, before extubation in the ICU, and after extubation on the first postoperative day. Preoperative, intraoperative, and postoperative parameters were compared under an IRB-approved protocol. The primary endpoints were the postoperative opioid requirement, duration of mechanical ventilation, and ICU length of stay, and the secondary endpoints were the duration of inotropic support needed, left ventricular ejection fraction (LVEF), and the change in LVEF. This study was undertaken at Northwest Medical Center, Tucson, AZ, USA. Results Sixty-eight patients were randomized to either the control group (n = 37) or the dronabinol group (n = 31). Groups were similar in terms of demographic features and comorbidities. The total postoperative opioid requirement was significantly lower in the dronabinol group [39.62 vs 23.68 morphine milligram equivalents (MMEs), p = 0.0037], representing a 40% reduction. Duration of mechanical ventilation (7.03 vs 6.03h, p = 0.5004), ICU length of stay (71.43 vs 63.77h, p = 0.4227), and inotropic support requirement (0.6757 vs 0.6129 days, p = 0.7333) were similar in the control and the dronabinol groups. However, there was a trend towards lower durations in each endpoint in the dronabinol group. Interestingly, a significantly better preoperative to postoperative LVEF change was observed in the dronabinol group (3.51% vs 6.45%, p = 0.0451). Conclusions Our study found a 40% reduction in opioid use and a significantly greater improvement in LVEF in patients treated with adjunctive dronabinol. Mechanical ventilation duration, ICU length of stay, and inotropic support requirement tended to be lower in the dronabinol group, though did not reach statistical significance. The results of this study, although limited by sample size, are very encouraging and validate our ongoing investigation.

Impact of dexmedetomidine use on pediatric PACU length of stay and practice patterns: A single center study

BackgroundDexmedetomidine has been increasingly incorporated in pediatric anesthesia owing to its opioid sparing analgesic effect. In theory, dexmedetomidine may lower the use of intraoperative and postoperative opioids but increase post anesthesia care unit (PACU) patient recovery time. In 2020, the Anesthesia Department of Albany Medical Center implemented an opioid reducing initiative with dexmedetomidine incorporation as a major strategy. As such, we have carried out this retrospective study to examine the effect of dexmedetomidine on pediatric PACU length of stay (LOS) across a blend of invasive surgical procedures requiring general anesthesia. MethodsThe present study is a single-institution, retrospective chart review of children undergoing invasive procedures requiring general anesthesia at an academic center during 2021 and 2022. Convenience sampling of the first 200 patients from each of those years was analyzed (n=400). Here, we compared PACU LOS between patients who did or did not receive dexmedetomidine using the propensity-score matching treatment effects analysis. We also examined changes in perioperative medication patterns between patients who did versus did not receive dexmedetomidine. Results344 patients over the study period met inclusion criteria. The matched cohort consisted of 118 patients without dexmedetomidine administration and 122 patients with dexmedetomidine administration. The average treatment effect for administration of dexmedetomidine was an increase in PACU LOS of 19.4 min (p < 0.001). Dosages and proportion of patients receiving intraoperative or postoperative opioids did not significantly change during the study period. ConclusionsIn our center, dexmedetomidine use in pediatric procedures with general anesthesia was associated with prolonged recovery times, without a corresponding reduction in opioid use. Further investigations are therefore warranted to understand the role of dexmedetomidine as an anesthetic adjunct and in multimodal pain management.

(041) Pre-Operative Bilateral Pudendal Nerve Blocks can Reduce Opioid Utilization for Patients Undergoing Urologic Prosthetic Procedures

Abstract Introduction Opioid related overdoses and deaths have been increasing in recent decades, and recent studies have shown that even short courses of opioids can result in dependence and misuse. Urologic prosthetic procedures can be painful, and historically pain management has been predominantly through opioid-based analgesia. Multimodal pain management plans have been shown to help reduce exposure to opioids, and these include local nerve blockade. Objective Our study aims to assess the efficacy of bilateral pudendal nerve block in post-operative pain management and reduction of opioid use. Methods We conducted a retrospective review of all patients undergoing urologic prosthetic surgeries at a single Canadian institution between September 2020 and June 2023. Prosthetic surgeries included inflatable penile prosthesis (IPP) and artificial urethral sphincter (AUS) implants and explantation/reimplantation, but patients were only included once during the study period. Patients with chronic pain or missing pain data were excluded. Patients received bilateral pudendal nerve blocks at the discretion of the surgeon as a practice change starting in 2021 and compared to a control group (no blocks). Pain was assessed by the nursing care team using an analogue rating scale (out of 10), and all opioid and non-opioid pain medications were blindly recorded by nursing as their part of their usual documentation. Opioid utilization was converted to oral morphine equivalents (OMEs). Primary outcome was OMEs utilization in the post-operative period while in hospital, with a secondary of overall pain scores. Data was analysed using two-sample t-tests, and significance set to a p-value of 0.05. Results Our study included a total of 134 patients, with 59 patients receiving preoperative bilateral pudendal nerve blocks (54 IPP, 5 AUS), and 75 patients receiving the standard protocol (31 IPP, 44 AUS). The median age of patients receiving pudendal nerve blocks was 62.51 compared to the control group median age of 67.81. (p&amp;lt;0.05). There was no difference in ages in sub-analysis of IPP and AUS cohorts. Sub-analysis of the AUS cohort demonstrated a lower median pain score immediately post-op for those receiving blocks compared to control (0.8 vs. 2.73 respectively, p&amp;lt;0.05), with no difference in pain scores otherwise. AUS patients with pudendal nerve blocks consumed significantly less OMEs on day of surgery (median 0 vs. 6.75 OMEs, p&amp;lt;0.05). The IPP cohort with pudendal nerve blocks had no difference in pain scores compared to control, but consumed significantly less OMEs on day of surgery (9.06 vs. 12.56 OMEs respectively, p&amp;lt;0.05) and on post-operative day one (2.99 vs. 7.30 OMEs respectively, p&amp;lt;0.05). Conclusions Preoperative bilateral pudendal nerve blocks appear to reduce post-operative opioid use for patients undergoing urologic prosthetic surgery. Regular use of pudendal nerve blocks for patients undergoing prosthetic and pelvic surgeries may be an efficient means to reduce patient exposure to opioids. Bilateral pudendal nerve blockade for all genital and pelvic surgeries may be an effective opioid harm reduction strategy and warrants further investigation and patient satisfaction outcomes. Disclosure No.

Bringing Enhanced Recovery After Surgery to the NICU: An Implementation Trial

IntroductionEnhanced Recovery After Surgery (ERAS) guidelines are bundled evidence-informed recommendations implemented to improve quality and safety of perioperative care. This study aims to determine feasibility of NICU implementation of an ERAS Guideline for Intestinal Resection, describing clinical outcomes and adherence to recommendations following light-touch implementation. MethodsInfants <28 days undergoing laparotomy for intestinal resection in a closed-NICU were prospectively enrolled. Exclusion criteria included prematurity (<32wks), instability, or major comorbidity. Clinical data reflecting 13 ERAS recommendations were collected through chart review. Descriptive statistics are presented as median [interquartile range]. Thirty-day post-discharge outcomes include NICU and hospital length of stay (LOS), ventilator days, surgical site infection (SSI), re-intubation, readmission, reoperation, and mortality. Adherence was calculated as the percentage of patients eligible for each recommendation whose care was adherent. ResultsTen infant-parent dyads were enrolled (five females; GA 37 weeks [35, 38.8]; birthweight 2.97 kg [2.02, 3.69]). Surgical diagnoses included intestinal atresia/web (n = 6), anorectal malformation (n = 3), and segmental volvulus (n = 1). NICU LOS was 16 days [11, 21], hospital LOS 20 days [18, 30], and 2.5 ventilator days/patient [2, 3]. There was reduced opioid use, no SSIs, one re-intubation, three readmissions, three reoperations, and no mortalities. Adherence to ERAS recommendations ranged 0–100 % with a pooled adherence rate of 73 %. ConclusionIt is feasible to introduce ERAS to the NICU with acceptable overall adherence. Assessing adherence was challenging for some measures. There were promising early clinical findings including a reduction in opioid use. This implementation trial will inform development of an ERAS protocol for surgical NICUs. Level of evidenceIV (Cohort Study).

Digital Behavioural Interventions to Reduce Opioid Use in Chronic Non-Cancer Pain Patients: A Systematic Review

Abstract Introduction Opioid medications have become increasingly prevalent in the treatment of chronic non-cancer pain1. This increase in opioid usage has given rise to the ‘Opioid Crisis’ which refers to the significant increase in overdose, addiction, and deaths in the USA and Canada particularly2. Furthermore, the World Health Organisation has declared there to have been approximately 0.5 million deaths in relation to drug use worldwide, with more than 70% of those deaths related to opioids3. Advances in technology have paved the way for the use of digital behavioural interventions, such as mobile applications, virtual reality, and online therapies, to potentially mitigate opioid use in patients suffering from chronic non-cancer pain. These interventions aim to assist individuals in modifying health behaviours to promote overall well-being and may serve as a preventive measure against the detrimental effects of long-term opioid use. Aim This systematic review aimed to evaluate the current evidence regarding the effectiveness of digital behavioural interventions in reducing opioid use among chronic non-cancer pain patients. Methods A comprehensive search was conducted in three electronic databases (MEDLINE, EMBASE, and Web of Science) using specific search terms. Primary outcomes focused on opioid usage measurements, while secondary outcomes pertained to pain measurements. Eligible studies included adult patients with chronic non-cancer pain (excluding cancer/palliative patients) who received opioid prescriptions and engaged in digital behavioural interventions in any setting. Two researchers double-screened eligible studies based on titles and abstracts, excluding duplicates and those not meeting the eligibility criteria. Data extraction was performed, and study quality was assessed using the Cochrane Risk of Bias Tool (double-screened). Ethical approval was not required as this study was a systematic review. Results Out of 30,388 articles identified, six studies conducted in the USA met the inclusion criteria. Risk of bias assessment revealed one study with a low risk, two with some concerns, and the majority with a high risk of bias. The publication dates of the identified papers ranged from 2016 to 2021. There was an overall participant population of 605. The interventions included virtual reality, mobile health applications, web-based cognitive-behavioural therapy, guided audio-visual relaxation, and an electronic health toolkit. Two studies reported a specific reduction in opioid use, while three studies did not provide direct measurements for opioid use. However, these studies indicated a reduction in opioid analgesic usage by reporting either over-the-counter analgesic measures or a Current Opioid Misuse Measure score. Discussion/Conclusion This systematic review was conducted in response to the need for updated pain management strategies. The literature suggests that digital behavioural interventions hold promise for reducing opioid use among chronic non-cancer pain patients. However, due to limitations in the included studies, such as sample size, heterogeneity, and potential bias, further research is needed to fully understand their effectiveness. Future studies should focus on optimising the design and delivery of the interventions tailored to this patient population. Continued research in this area has the potential to address the societal burden of opioid misuse and improve patients' quality of life.

Benefits of the Enhanced Recovery After Surgery (ERAS) Pathway With Quadratus Lumborum Blocks for Minimally Invasive Gynecologic Surgery Patients: A Retrospective Cohort Study.

This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery. This retrospective cohort study was performed in a tertiary care hospital. A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck HospitalofUniversity of Southern California (USC), California, USA, from 2016 to 2020 were included in this study. The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared towarda satisfactory, safe, and expeditious discharge. The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block. The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.

Treatment Initiation, Substance Use Trajectories, and the Social Determinants of Health in Persons Living With HIV Seeking Medication for Opioid Use Disorder.

People living with HIV and opioid use disorder (OUD) are disproportionally affected by adverse socio-structural exposures negatively affecting health, which have shown inconsistent associations with uptake of medications for OUD (MOUD). This study aimed to determine whether social determinants of health (SDOH) were associated with MOUD uptake and trajectories of substance use in a clinical trial of people seeking treatment. Data are from a 2018 to 2019 randomized trial comparing the effectiveness of different MOUD to achieve viral suppression among people living with HIV and OUD. SDOH were defined by variables mapping to Healthy People 2030 domains: education (Education Access and Quality), income (Economic Stability), homelessness (Neighborhood and Built Environment), criminal justice involvement (Social and Community Context), and recent SUD care (Health Care Access and Quality). Associations between SDOH and MOUD initiation were assessed with Cox proportional hazards models, and SDOH and substance use over time with generalized estimating equation models. Participants (N = 114) averaged 47 years old, 63% were male, 56% were Black, and 12% Hispanic. Participants reported an average of 2.3 out of 5 positive SDOH indicators (SD = 1.2). Stable housing was the most commonly reported SDOH (61%), followed by no recent criminal justice involvement (59%), having a high-school level education or greater (56%), income stability (45%), and recent SUD care (13%). Each additional favorable SDOH was associated with a 25% increase in the likelihood of MOUD initiation during the study period [adjusted HR = 1.25, 95% CI = (1.01, 1.55), P = .044]. Positive SDOH were also associated with a decrease in the odds of baseline opioid use and a greater reduction in opioid use during subsequent weeks of the study (P < .001 for a joint test of baseline and slope differences). Positive social determinants of health, in aggregate, may increase the likelihood of MOUD treatment initiation among people living with HIV and OUD.

Concentrated Alpha-2 Macroglobulin Rich Autologous Plasma Injections for Chronic Pain and Reduction in Opioid Use

The US Opioid Epidemic has been a serious continuous threat to Americans since the early 2000s. "More than 932,000 people have died since 1999 from a drug overdose. Nearly 75% of drug overdose deaths in 2020 involved an opioid" (CDC, 2022). Prescription opioids are highly addictive and are commonly prescribed to treat moderate, severe, or chronic pain. Chronic pain is a multidimensional experience that encompasses both sensory and emotional elements in patients who suffer from it. Opioids are highly effective in treating these symptoms, however chronic opioid use causes many unwanted side effects. Thus, the challenge of providing effective pain treatment while minimizing these unwanted side effects is an ongoing issue with significant clinical and societal impact. Researchers also see that in many situations, medical care providers are more willing to prescribe opioid drugs for chronic pain in clinical settings.

Cannabis use to manage opioid cravings among people who use unregulated opioids during a drug toxicity crisis.

Accumulating evidence has indicated that cannabis substitution is often used as a harm reduction strategy among people who use unregulated opioids (PWUO) and people living with chronic pain. We sought to investigate the association between cannabis use to manage opioid cravings and self-reported changes in opioid use among structurally marginalized PWUO. The data were collected from a cross-sectional questionnaire administered to PWUO in Vancouver, Canada. Binary logistic regression was used to analyze the association between cannabis use to manage opioid cravings and self-reported changes in unregulated opioid use. A total of 205 people who use cannabis and opioids were enrolled in the present study from December 2019 to November 2021. Cannabis use to manage opioid cravings was reported by 118 (57.6%) participants. In the multivariable analysis, cannabis use to manage opioid cravings (adjusted Odds Ratio [aOR]=2.13, 95% confidence interval [CI]: 1.07, 4.27) was significantly associated with self-reported reductions in opioid use. In the sub-analyses of pain, cannabis use to manage opioid cravings was only associated with self-assessed reductions in opioid use among people living with moderate to severe pain (aOR=4.44, 95% CI: 1.52, 12.97). In the sub-analyses of males and females, cannabis use to manage opioid cravings was only associated with self-assessed reductions in opioid use among females (aOR=8.19, 95% CI: 1.20, 55.81). These findings indicate that cannabis use to manage opioid cravings is a prevalent motivation for cannabis use among PWUO and is associated with self-assessed reductions in opioid use during periods of cannabis use. Increasing the accessibility of cannabis products for therapeutic use may be a useful supplementary strategy to mitigate exposure to unregulated opioids and associated harm during the ongoing drug toxicity crisis.

Case Series: Novel Use of a Erector Spinae Plane Block At A Lumbar Spinal Level For Coverage Of Sacral Dermatomes

The erector spinae plane (ESP) block is a recent and novel regional anesthesia procedure used primarily for the thoracic region. There is limited use of this block for the lumbar and sacral regions. Here we investigate the use of lumbar ESP blocks for three cases; hip disarticulation, penile burn, and perineal injury. For each case, an 18-gauge Tuohy needle was inserted into the paraspinous region at the L4 level and caudally directed towards the interfacial plane posterior to the transverse process via ultrasound. Once in place, 20-30 mL of 0.5% bupivacaine was injected. Opioid consumption was measured before and after block placement to evaluate for pain control. The ESP block yielded a significant reduction in opioid use for the penile burn and perineal injury cases, while a non-significant reduction was observed in the hip disarticulation case. The use of lumbar ESP block has shown the feasibility and effectiveness for sacral innervated injuries. This nerve block technique has strong potential to improve patient satisfaction and pain control while minimizing opioid reliance in the postoperative and traumatic injury recovery periods for lumbar and perineal injury patients.

Enhanced recovery after microdiscectomy: reductions in opioid use, length of stay and cost

BackgroundEnhanced recovery after surgery (ERAS) protocols are widely used worldwide. Recently, studies of the ERAS program in spinal surgery subspecialties have been reported. The aim of this study was to evaluate the impacts of ERAS in minimally invasive microdiscectomy (MD) surgery.MethodsThis was a retrospective cohort study of patients undergoing MD at a single center. From March 2018 to March 2021, 286 patients were in the ERAS group. A total of 140 patients from March 2017 to February 2018 were in the conventional group. The outcomes included length of stay (LOS), the postoperative numeric rating scale (NRS), complications, 30-day readmission rate, 30-day reoperation rate and cost. Moreover, perioperative factors were also evaluated.ResultsCompared with the conventional group, the LOS and cost were reduced in the ERAS group. There were no significant differences in the NRS, complication rate, 30-day readmission or reoperation rates between the groups. Furthermore, postoperative drainage volume, and postoperative opioid use were lower in the ERAS group.ConclusionsThe ERAS protocol for MD surgery reduces LOS, cost and opioid use and accelerates patient recovery.

Effects of intraoperative liposomal bupivacaine on postoperative opioid usage in kidney transplant recipients.

This study retrospectively evaluated the use of intraoperative locally infiltrated peri-incisional liposomal bupivacaine in kidney transplant recipients with the primary outcome of oral morphine equivalent reduction during the transplant admission. Secondary outcomes included pain scores, time to first bowel movement and length of stay. Postoperative morphine equivalents were significantly lower in the liposomal bupivacaine group <24 hours (50% reduction, p < 0.05) and 24-48 hours (56.5% reduction, p < 0.05). When accounting for analgesic medication choices, liposomal bupivacaine did not result in a significant reduction in opioid use within 48 hours postoperatively with the exception of a 51% (p = 0.02) median reduction in fentanyl patient-controlled analgesia morphine equivalents <24 hours postoperatively. Morphine equivalence reductions >48 hours, differences in pain scores, time to first bowel movement or length of stay did not reach significance. Intraoperative liposomal bupivacaine reduced kidney transplant recipient's postoperative opioid requirements, but this benefit did not reliably extend past 24 hours postoperatively.