Opioid Use is Reduced in Patients Treated with NSAIDS After Arthroscopic Shoulder Instability Repair: A Randomized Study

Objectives: The current opioid epidemic necessitates physicians to seek ways to decrease patients’ requirements of narcotic medications without sacrificing their postoperative comfort level. This study evaluated patients’ pain following arthroscopic shoulder instability repair and compared the use of narcotic medications between patients prescribed NSAIDs with rescue opioid prescription to those prescribed opioids alone. We hypothesized there would not be a significant difference in postoperative pain and addition of NSAIDs would result in decreased opioid use. Methods: Forty patients scheduled to undergo an arthroscopic shoulder instability repair were randomized to receive Ibuprofen 600 mg and a 10-pill rescue prescription of Percocet 5/325 mg (n=20) or Percocet 5/325 mg (n=20). Primary outcomes were the amount of Percocet tablets used in the first week and VAS on postoperative day (POD) 1, 4, and 7. Statistical analysis was done using independent t-tests and bivariate analysis for correlation. Findings were considered significant at p<0.05. Results: Forty patients with a mean age of 35.08 (± 8.48)were enrolled between December 2017 and May 2018. The total amount of opioid consumption was statistically significantly lower in the multimodal group compared to the opioid group (p <0.04) as well as Percocet consumption between POD 0-4 (p <0.04). There were no significant differences in VAS at any point between the two groups. One patient in the Ibuprofen cohort experienced dizziness on POD 1. Two patients in the Percocet cohort experienced nausea and vomiting on POD 1 and POD 4. Conclusion: Multimodal analgesia using NSAIDs with an opioid rescue prescription has resulted in significant reduction in postoperative narcotic consumption. As both cohorts showed similar pain levels, it is possible to alleviate postoperative pain with lower amounts of opioids than are currently being prescribed. The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of post-operative narcotics distribution.

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Prospective Evaluation of Opioid Consumption in Multimodal Analgesia Following Isolated Hallux Valgus Correction or First MTP Joint Arthrodesis

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00327 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0032

Author(s):

Wonyong Lee ◽

Dan Prat ◽

Daniel C. Farber ◽

Keith L. Wapner ◽

Wen Chao

Keyword(s):

Postoperative Pain ◽

Hallux Valgus ◽

Subgroup Analysis ◽

Multimodal Analgesia ◽

Opioid Consumption ◽

Opioid Prescription ◽

Significant Difference ◽

Group A ◽

Group B ◽

Procedure Type

Category: Other; Bunion; Midfoot/Forefoot Introduction/Purpose: There is no standard guideline for prescription opioids for postoperative pain management following outpatient foot and ankle surgery. Multiple previous studies demonstrated that opioids were overprescribed. The purpose of this study was to prospectively investigate opioid consumption using multimodal analgesia regimen after two of the most common forefoot surgeries: isolated hallux valgus correction or 1st metatarsophalangeal (MTP) joint arthrodesis. Methods: We prospectively investigated opioid prescription and consumption of total 21 patients who underwent isolated hallux valgus correction with distal soft tissue procedure and proximal first metatarsal crescentic osteotomy or 1st MTP joint arthrodesis. Postoperative pain was managed using multimodal analgesia including oxycodone, ibuprofen, acetaminophen, and regional ankle block. Patients were instructed to take 5mg of oxycodone every 4 hours as needed, and 600 mg of ibuprofen as well as 1,000 mg of acetaminophen every 8 hours regularly. The number of pills patients consumed for oxycodone was recorded at postoperative follow-up at 1-week, 2-week, 4-week, 8-week, and 12-week. Subgroup analysis was performed to evaluate opioid consumption according to the prescription type: Only oxycodone was prescribed in group A while oxycodone as well as prescription strength ibuprofen and acetaminophen were prescribed in group B. Another subgroup analysis in opioid consumption was performed based on the quantity of opioid prescription and procedure type. Results: The overall mean opioid consumption in 12 weeks of the postoperative period was 16.2 pills per patient with an average of 37.3 pills prescribed. Lower opioid consumption was noted in group B when prescription ibuprofen and acetaminophen were prescribed compared to group A when patients took over-the-counter (OTC) ibuprofen and acetaminophen: 9.0 pills vs 24.1 pills, respectively (P = 0.036). There was a trend showing higher opioid consumption in patients prescribed greater than 30 pills of oxycodone compared to less than or equal to 30 pills: 22.0 pills vs 9.8 pills, respectively (P = 0.099). No significant difference was found in opioid consumption according to the procedure type: 15.8 pills in hallux valgus correction vs 16.5 pills in 1st MTP joint arthrodesis (P = 0.750). Conclusion: This study showed that on the average, patients took 16.2 pills out of 37.3 pills of the prescribed oxycodone after isolated hallux valgus correction or 1st MTP joint arthrodesis using our multimodal analgesia regimen. Patients who were prescribed prescription strength ibuprofen and acetaminophen consumed opioid significantly less than those who took the OTC strength. No significant difference was noted in opioid consumption between isolated hallux valgus correction and 1st MTP joint arthrodesis.

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No significant difference in risk of prolonged opioid use following outpatient versus inpatient total shoulder arthroplasty: A propensity matched analysis

Shoulder & Elbow ◽

10.1177/17585732211060754 ◽

2021 ◽

pp. 175857322110607

Author(s):

Michelle Xiao ◽

Daniel M Curtis ◽

Emilie V Cheung ◽

Michael T Freehill ◽

Geoffrey D Abrams

Keyword(s):

Shoulder Arthroplasty ◽

Nearest Neighbor ◽

Total Shoulder Arthroplasty ◽

Opioid Use ◽

Therapeutic Level ◽

Level Of Evidence ◽

Opioid Prescription ◽

Significant Difference ◽

Outpatient Settings ◽

Baseline Demographic

Background The purpose of this investigation was to compare rates of filled opioid prescriptions and prolonged opioid use in opioid naïve patients undergoing total shoulder arthroplasty (TSA) in inpatient versus outpatient settings. Methods A retrospective cohort study was conducted using a national insurance claims database. Inpatient and outpatient cohorts were created by identifying continuously enrolled, opioid naïve TSA patients. A greedy nearest-neighbor algorithm was used to match baseline demographic characteristics between cohorts with a 1:1 inpatient to outpatient ratio to compare the primary outcomes of filled opioid prescriptions and prolonged opioid use following surgery between cohorts. Results A total of 11,703 opioid naïve patients (mean age 72.5 ± 8.5 years, 54.5% female, 87.6% inpatient) were included for analysis. After propensity score matching (n = 1447 inpatients; n = 1447 outpatients), outpatient TSA patients were significantly more likely to fill an opioid prescription in the perioperative window compared to inpatients (82.9% versus 71.5%, p < 0.001). No significant differences in prolonged opioid use were detected (5.74% inpatient versus 6.77% outpatient; p = 0.25). Conclusions Outpatient TSA patients were more likely to fill opioid prescriptions compared to inpatient TSA patients. The quantity of opioids prescribed and rates of prolonged opioid use were similar between the cohorts. Level of evidence Therapeutic Level III.

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Analgesic Effect of Dexamethasone after Arthroscopic Knee Surgery: A Randomized Controlled Trial

Pain Research and Management ◽

10.1155/2016/4216469 ◽

2016 ◽

Vol 2016 ◽

pp. 1-6

Author(s):

Jairo Moyano ◽

Maria García ◽

Maria Caicedo

Keyword(s):

Postoperative Pain ◽

Pain Intensity ◽

Knee Surgery ◽

Controlled Study ◽

Opioid Use ◽

Arthroscopic Knee Surgery ◽

Randomized Controlled ◽

Significant Difference ◽

Intraoperative Period ◽

Arthroscopic Knee

Background.Dexamethasone is sometimes used as a coanalgesic because of its anti-inflammatory properties.Objective. To evaluate opioid use, postoperative pain intensity, and side effects after a single dose of dexamethasone in patients undergoing arthroscopic knee surgery.Methods. In this randomized controlled study patients were randomized to receive either 10 mg of intravenous dexamethasone (DM group) or 0.9% normal saline (NS group) during the intraoperative period. Primary outcomes were pain intensity and total morphine and codeine use after surgery.Results. Seventy-eight patients were included in the study. The DM group showed statistically significant higher pain intensity at the fourth postoperative hour (DM: 3.96/10, standard deviation [SD] 0.54; NS: 2.46/10, SD 0.45;p=0.036). No statistically significant difference in total opioid use (morphine plus codeine) was identified with 15.9 (SD 1.97) codeine tablets used in DM group and 20 (SD 2.14) in NS group (p=0.25).Discussion. Pain intensity tended to decrease in both groups suggesting morphine as the main source of analgesia.Conclusions. Intravenous dexamethasone during the intraoperative period has no clinical impact on postoperative pain intensity during the first 48 h after arthroscopic knee surgery. This trial is registered withR000020892.

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Postoperative Pain and Opioid Use Following Surgical Treatment of Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00339 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0033

Author(s):

Matthew Pate ◽

Jacob Hall ◽

John Anderson ◽

Donald Bohay ◽

John Maskill ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Ankle Fracture ◽

Management Practices ◽

Opioid Analgesic ◽

The United States ◽

Ankle Fractures ◽

Opioid Use ◽

Opioid Prescription ◽

Opioid Medication

Category: Ankle, Bunion, Trauma Introduction/Purpose: Chronic opioid abuse is one of the greatest public health challenges in the United States. The most common first exposure to opioids comes from acute care prescriptions, such as those after surgery. Moreover, opioids are often prescribed excessively, with current estimates suggesting ˜75% of the pills prescribed are unused. Ankle fractures are the most common operatively treated fracture in orthopaedic surgery, and management of acute pain following surgery is challenging. The optimal perioperative pain regimen is still a point of controversy, as there is limited data available regarding appropriate amount of opioid to prescribe. This study evaluates opioid prescribing techniques of multiple foot and ankle surgeons, and associated patient outcomes. We aim to help surgeons improve their pain management practices and to limit opioid overprescription. Methods: Chart review and phone survey were performed on forty two adult patients within three to six months of ankle fracture fixation at our institution. These patients were offered to voluntarily participate in a standardized questionnaire regarding pain scores, opioid use, non-opioid analgesic use, pain management satisfaction, and patient prescription education. Results: 57% of patients reported that they were given “more” or ”much more” opioid medication than needed, 38% stated that they were given the “right amount”, and 5% reported that they were given ”less” or “much less” than needed. 40.0% were on opioids prior to operation. 53.5% did not require refill of discharge opioid prescriptions, 30.2% of patients did not fill any posteroperative opioid prescription. 16.3% of patients filled their discharge prescription and at least one additionall refill (mean refill = 2.22). Mean number of reported opioid pills taken after surgery was 17.4. Mean satisfaction with overall pain management at phone follow up was 8.6/10. Conclusion: While postoperative pain and management vary substantially, a majority of patients feel that they are given more opioid medication than necessary following ankle fracture repair, and a majority of opioid prescriptions are not completely used. Going forward, it is likely that a majority of patients could experience the same beneficial results with less prescription opioid pain medication, which would reduce overpresciption and potential misuse.

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1635. Do Persons With Opioid Use Disorder and Injection-Related Infections Really Need Prolonged Hospitalizations to Complete Intravenous Antibiotic Therapy?

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy209.105 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S44-S44

Author(s):

Laura Fanucchi ◽

Sharon Walsh ◽

Alice Thornton ◽

Paul Nuzzo ◽

Michelle Lofwall

Keyword(s):

Randomized Study ◽

Early Discharge ◽

Opioid Use Disorder ◽

Opioid Use ◽

Eligibility Criteria ◽

Indwelling Catheters ◽

Early Results ◽

Significant Difference ◽

Baseline Characteristics ◽

Illicit Opioid Use

Abstract Background Persons with opioid use disorder (OUD) hospitalized with severe, injection-related infections (e.g., endocarditis) often remain inpatient to complete intravenous (IV) antibiotics due to assumptions that, if outpatient, patients will inject drugs into the IV catheter and will fail to complete prescribed antibiotic regimens. No evidence supports these assumptions, and unfortunately, the inpatient stay infrequently includes OUD pharmacotherapy. The aim is to determine whether inpatients with OUD and injection-related infections can be safely discharged to complete antibiotics through a IV catheter in the context of comprehensive outpatient OUD treatment including buprenorphine. Methods Pilot proof-of-concept, randomized study enrolling hospitalized adults with OUD and severe injection-related infections. Participants are provided inpatient buprenorphine treatment with counseling and randomized (1:1) to usual care (UC) [completing IV antibiotics inpatient] or to early discharge (ED) [completing IV antibiotics outpatient]. Both groups receive 12 weeks of comprehensive OUD treatment with buprenorphine after discharge. Results Seventy-six patients screened, 20 met eligibility criteria, provided informed consent, and randomized; 10 to UC and 10 to ED. Similar baseline characteristics; 90% in UC with endocarditis and 100% in ED. Length of stay, UC: 45.9 days (SD ±7.8), ED 22.7 (SD ±7.5) (P < 0.001). Ten in UC and 9 in ED completed recommended IV antibiotics, one in ED group is still receiving antibiotics; ED finished 19.8 days (SD ±11.7) IV antibiotics outpatient. Self-reported illicit opioid use 30 days before hospitalization compared with 12-week outpatient phase decreased in both groups (P = 0.009); no significant difference between groups (P = 0.141) (Figure 1). Conclusion Early results suggest patients with OUD and complex injection-related infections may be safely discharged to complete IV antibiotics via indwelling catheters if comprehensive OUD treatment with buprenorphine is started while inpatient and continued after discharge. Importantly, while prolonged inpatient care is common practice, viewed as protective but extremely costly, these data suggest that comprehensive outpatient care is feasible and may be equi-effective. Disclosures All authors: No reported disclosures.

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Using intravenous acetaminophen in the reduction of opioids in spinal cord surgeries by patient-controlled analgesia

International Surgery Journal ◽

10.18203/2349-2902.isj20185012 ◽

2018 ◽

Vol 5 (12) ◽

pp. 3883

Author(s):

Vadoud Nourouzi ◽

Ali Mohammadian ◽

Khatereh Isazadehfar ◽

Sona Rasouli

Keyword(s):

Spinal Cord ◽

Placebo Group ◽

Postoperative Pain ◽

Pain Relief ◽

Pain Score ◽

Postoperative Recovery ◽

Opioid Use ◽

Hospitalization Period ◽

Significant Difference ◽

Pain Pump

Background: Proper management of postoperative pain results in improved quality of patient's' life, early postoperative recovery, reduced hospitalization period and decreased treatment costs. Regarding significant efficacy and higher pain relief functions, opioids are amongst the best pain relief drugs. However, use of theses narcotics as pain killers is somehow controversial. Current study investigated the effects of IV acetaminophen in reduced use of opioids in surgeries of spinal cord by PCA method.Methods: Current double blinded clinical trial study performed upon 86 patients of 20-70 years of age who candidate for spinal CD implant with ASA class I or II. Patients randomly divided into two groups of IV Acetaminophen therapy (N=43) and placebo group (N=43) and each group were put equally under general anesthesia in which both received pain pump containing Fentanyl during recovery. Patients were examined regarding pain score, amount of opioid use and request for extra narcotics and the related complications including nausea, vomiting, dizziness, allergy, gastrointestinal bleeding and Ileus every 6 hours for 24 hours and the obtained results were recorded.Results: Regarding VAS, pain was significantly lower during 24 hours of study in IV Acetaminophen group (p<0.05). Mean use of opioid via pain pump was significantly lower in IV Acetaminophen group compared with placebo group (p=0.00). Request for extra doses of narcotics was higher in placebo group while regarding demand for extra pain relief, there was no significant difference between both groups. Regarding other results, no significant difference observed between both study groups.Conclusions: Results of the study indicated that use of a combination of IV acetaminophen along with opioids would be much more effective than use of narcotics alone in postoperative pain control of CD implant surgery of spinal cord and that leads to lower pain score and decreased use of opioids and its related complications.

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Opioid Reduction After Orthopedic Surgery (OREOS): A Scoping Review Protocol

10.31219/osf.io/g3xnd ◽

2020 ◽

Author(s):

Jessica Gormley ◽

Kyle Gouveia ◽

Seaher Sakha ◽

Veronica Stewart ◽

Ushwin Emmanuel ◽

...

Keyword(s):

Postoperative Pain ◽

Current Literature ◽

Scoping Review ◽

Orthopedic Surgery ◽

Alternative Methods ◽

Cochrane Library ◽

Opioid Use ◽

Opioid Prescription ◽

Opioid Sparing

Background. Faced with the current opioid epidemic, alternative methods to managing postoperative pain are being investigated that could eliminate or substantially reduce opioid prescription and use. Prescribing opioids peri- and post-operatively has been shown to trigger chronic abuse independent of previous drug use and increase the risk of long-term use. The postoperative pain experienced in orthopedic surgery is substantial and it is not surprising that the highest incidence of long-term opioid use occurs after total knee and total hip arthroplasty. Despite the numbers of abuse continuing to rise, there remains a need for high quality and reproducible evidence to support protocols that reduce or eliminate opioid prescription. The goal of this scoping review is to identify the current literature and on opioid reduction after orthopedic surgery, 2) describe the interventions used 3) describe the author’s conclusion on opioid use and postoperative outcomes and 4) synthesize the results of included studies to highlight patterns seen with different interventions.Methods. This is a protocol for a scoping review of opioid sparing analgesic strategies that eliminate or significantly reduce opioid prescription after orthopedic surgery. We will include studies of all designs, excluding expert opinions. We will search Cochrane Library, Embase and Medline. Literature will be managed using Rayyan QCRI software. Two reviewers will independently screen the studies for inclusion, and extract information surrounding the effectiveness of alternative strategies and reduction in opioid prescription. Our analysis will be descriptive in nature. We will group studies based on type of orthopedic procedure and nature of intervention used to report study outcomes.Discussion. Our study will consolidate the current literature on opioid-sparing analgesia after orthopedic surgery and describe the effectiveness of current alternative options. It will look to reveal gaps in our knowledge surrounding our current treatment alternatives to establish areas of interest for future research. Registration. This review was registered prospectively on PROSPERO (registration number CRD42020153418).

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Magnesium sulphate within multimodal analgesia, pre-emptive, or preventive analgesia

Ain-Shams Journal of Anesthesiology ◽

10.1186/s42077-021-00210-1 ◽

2022 ◽

Vol 14 (1) ◽

Author(s):

Walid Y. Kamel ◽

Aktham Adel Shoukry

Keyword(s):

Postoperative Pain ◽

Multimodal Therapy ◽

Multimodal Analgesia ◽

Haemodynamic Parameters ◽

Perioperative Pain ◽

Aspartate Receptor ◽

Antinociceptive Effects ◽

Significant Difference ◽

Direct Nerve ◽

Tissue Trauma

Abstract Background Magnesium (Mg) is a non-competitive N-methyl d-aspartate receptor antagonist with antinociceptive effects. Multimodal therapy is the optimal strategy for perioperative pain control to minimize the need for opioids. Inflammation caused by tissue trauma or direct nerve injury is responsible for the perioperative pain. The concept of “pre-emptive” analgesia, analgesic strategies administered prior to the stimulus, can modify the peripheral and central nervous system processing of noxious stimuli, thereby reducing central sensitization, hyperalgesia, and allodynia remains controversial. A more encompassing approach to the reduction of postoperative pain is the concept of “preventive” analgesia. The purpose of the study is to detect the proper use of MgSO4 as an analgesic being a non-competitive N-methyl d-aspartate (NMDA). Results There is no statistically significant difference in the haemodynamic parameters, intraoperative (33% vs 20%) and postoperative requirement for analgesics 6.6% vs 10% among groups I and II, respectively. There is no significant difference in the numerical analogue scale, where 16 vs 17 patients with no pain, 12 vs 10 with mild pain, and 2 vs 3 with moderate pain in groups I and II, respectively. Conclusion The use of MgSO4 in a bolus with or without infusion is comparable in the control of intraoperative and postoperative pain.

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Preoperative Gabapentin Administration and Its Impact on Postoperative Opioid Requirement and Pain in Sinonasal Surgery

Otolaryngology ◽

10.1177/0194599820952805 ◽

2020 ◽

pp. 019459982095280

Author(s):

Amarbir S. Gill ◽

Farrukh R. Virani ◽

Joshua C. Hwang ◽

Machelle D. Wilson ◽

Angela M. Beliveau ◽

...

Keyword(s):

Postoperative Pain ◽

Wilcoxon Test ◽

Opioid Use ◽

Chi Square ◽

Vas Score ◽

Significant Difference ◽

Patient Reported ◽

Chi Square Test ◽

Sinonasal Outcome Test ◽

The Mean

Objective To determine the efficacy of preoperative gabapentin on patient-reported pain levels and postoperative opioid requirements following sinonasal surgery. Study Design Retrospective review. Setting Academic institution. Methods Patients undergoing sinonasal surgery between July 2019 and January 2020 were followed. Groups were divided into those that received 600 mg of oral gabapentin 1 hour preoperatively (gabapentin) and those that did not (control). Postoperatively, each patient was counseled to use acetaminophen, ibuprofen, and oxycodone as needed for pain control. Patients completed a daily postoperative pain and medication log. Pain was measured by the visual analog scale (VAS) and opioid use by morphine equivalent dose (MED). Chi-square test and Wilcoxon test were used for data analysis. Results Fifty-seven patients were included (control, n = 28; gabapentin, n = 29). There was no significant difference in age, sex, or baseline Sinonasal Outcome Test–22 scores between the groups. The total MED, postoperative day (POD) 1-2 MED, POD 3-4 MED, and POD 5-6 MED did not differ significantly between the control (17.9, 12.2, 4.6, 1.5) and gabapentin (19.0, 8.9, 7.2, 3.5) groups ( P = .98, .25, .16, .44). The mean daily VAS score did not differ significantly between the control (3.1) and gabapentin (2.8) groups ( P = .81). The mean daily VAS score decreased significantly in both groups with each successive POD ( P = .004). Conclusion Preoperative gabapentin did not significantly reduce postoperative pain or opioid use. Postoperative discomfort following sinonasal surgery is mild, and opioid intake is minimal.

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Prescription Opioids and Patient-Reported Outcomes and Satisfaction After Carpal Tunnel Release Surgery

Hand ◽

10.1177/15589447211064365 ◽

2022 ◽

pp. 155894472110643

Author(s):

Pragna N. Shetty ◽

Kavya K. Sanghavi ◽

Mihriye Mete ◽

Aviram M. Giladi

Keyword(s):

Postoperative Pain ◽

Carpal Tunnel ◽

Patient Reported Outcomes ◽

Carpal Tunnel Release ◽

Prescription Opioid ◽

Measurement Information ◽

Opioid Use ◽

Opioid Prescription ◽

Patient Reported

Background: Amount of opioid use correlates poorly with procedure-related pain; however, prescription limits raise concerns about inadequate pain control and impacts on patient-reported quality indicators. There remain no consistent guidelines for postoperative pain management after carpal tunnel release (CTR). We sought to understand how postoperative opioid use impacts patient-reported outcomes after CTR. Methods: This is a pragmatic cohort study using prospectively collected data from all adult patients undergoing uncomplicated primary CTR over 17 months at our center. Patients were categorized as having received or not received a postoperative opioid prescription, and then as remaining on a prescription opioid at 2-week follow-up or not. Questionnaires were completed before surgery and at 2-week follow-up. We collected brief Michigan Hand questionnaire (bMHQ) score, Patient-Reported Outcomes Measurement Information System Global Health score, satisfaction, and pain score. Results: Of 505 included patients, 405 received a postoperative prescription and 67 continued use at 2-weeks. These 67 patients reported lower bMHQ, lower satisfaction, and higher postoperative pain compared to those that discontinued. Multivariable regressions showed that receiving postoperative prescriptions did not significantly influence outcomes or satisfaction. However, remaining on the prescription at 2 weeks was associated with significantly lower bMHQ scores, particularly in patients reporting less pain. Conclusions: Patients remaining on a prescription after CTR reported worse outcomes compared to those who discontinued. Unexpectedly, the widest bMHQ score gap was seen across patients reporting lowest pain scores. Further research into this high-risk subgroup is needed to guide policy around using pain and patient-reported outcomes as quality measures. Level of Evidence: Level III.

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