Faculty Opinions recommendation of American Rhinologic Society expert practice statement: Postoperative pain management and opioid use after sinonasal surgery.

Background Although opioids are unsurpassed analgesics, experimental and clinical studies suggest that opioids activate N-methyl-d-aspartate pronociceptive systems leading to pain hypersensitivity and short-term tolerance. Because it is difficult in humans to differentiate pain from hyperalgesia during the postoperative period, the authors performed experimental studies with fentanyl using the rat incisional pain model for evaluating relations between hyperalgesia and short-term tolerance. Because N-methyl-d-aspartate receptor antagonists oppose both pain hypersensitivity and tolerance induced by opioids, the authors examined the capability of ketamine for improving exaggerated postoperative pain management. Methods During halothane anesthesia, a hind paw plantar incision was performed in rats receiving four fentanyl subcutaneous injections (100 microg/kg per injection, every 15 min). In some groups, three subcutaneous ketamine injections (10 mg/kg per injection, every 5 h) were performed in saline- or fentanyl-treated rats. One day after surgery, the analgesic effect of morphine (2 mg/kg subcutaneous) was tested. Analgesia, mechanical hyperalgesia, tactile allodynia, and pain score were assessed for several days using the paw pressure vocalization test, the von Frey application test, and the postural disequilibrium test. Results Fentanyl induced analgesia but also produced exaggerated postoperative pain as indicated by the enhancement of hyperalgesia, allodynia, and weight-bearing decrease after hind paw plantar incision. Ketamine pretreatment prevented such a fentanyl-induced enhancement of postoperative pain and improved its management by morphine. Conclusions By opposing postoperative pain hypersensitivity and subsequent short-term tolerance induced by perioperative opioid use, ketamine not only improves exaggerated postoperative pain management but also provides better postoperative rehabilitation.

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Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery

Patient Education and Counseling ◽

10.1016/j.pec.2018.09.001 ◽

2019 ◽

Vol 102 (2) ◽

pp. 383-387 ◽

Cited By ~ 19

Author(s):

Meghana Yajnik ◽

Jonay N. Hill ◽

Oluwatobi O. Hunter ◽

Steven K. Howard ◽

T. Edward Kim ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Patient Education ◽

Knee Replacement ◽

Postoperative Pain Management ◽

Opioid Use ◽

Knee Replacement Surgery ◽

Replacement Surgery

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Comparative analysis of length of stay, hospitalization costs, opioid use, and discharge status among spine surgery patients with postoperative pain management including intravenous versus oral acetaminophen

Current Medical Research and Opinion ◽

10.1080/03007995.2017.1297702 ◽

2017 ◽

Vol 33 (5) ◽

pp. 943-948 ◽

Cited By ~ 26

Author(s):

Ryan N. Hansen ◽

An T. Pham ◽

Elaine A. Böing ◽

Belinda Lovelace ◽

George J. Wan ◽

...

Keyword(s):

Comparative Analysis ◽

Pain Management ◽

Postoperative Pain ◽

Length Of Stay ◽

Spine Surgery ◽

Postoperative Pain Management ◽

Opioid Use ◽

Hospitalization Costs ◽

Discharge Status

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Implications of uninterrupted preoperative transdermal buprenorphine use on postoperative pain management

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2018-100018 ◽

2019 ◽

Vol 44 (3) ◽

pp. 342-347 ◽

Cited By ~ 3

Author(s):

Yvette N Martin ◽

Amy C S Pearson ◽

John R Tranchida ◽

Toby N Weingarten ◽

Phillip J Schulte ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Pain Score ◽

Recovery Room ◽

Severe Pain ◽

Receptor Agonist ◽

Postoperative Pain Management ◽

Opioid Use ◽

Intravenous Morphine ◽

Matched Study

Background and objectivesBuprenorphine is a partial µ-receptor agonist resistant to displacement from receptors by conventional opioids, which can block the effect of conventional opioids and may interfere with postoperative pain management. We aimed to quantify perioperative opioid use in patients receiving transdermal buprenorphine (TdBUP).MethodsWe identified patients receiving TdBUP who underwent surgery between 2004 and 2016. To compare opioid requirements (intravenous morphine equivalents (IV-MEq)), we constructed a matched study, matching each TdBUP patient with two opioid-naive patients by sex, age, and type of anesthesia and procedure.ResultsNineteen unique patients underwent 22 procedures while receiving TdBUP. Total (IQR) amounts of IV-MEq (intraoperative, recovery room, and 24 hours after recovery-room discharge) were 98 (63, 145) and 46 (30, 65) mg IV-MEq for TdBUP and opioid-naive patients, respectively (p<0.001). Postoperative IV-MEq requirements were 54 (38, 90) and 15 (3, 35) mg for TdBUP and opioid-naive patients, respectively (p<0.001). Among TdBUP patients, higher preoperative doses of TdBUP were associated with greater postoperative opioid requirements (p=0.02). Specifically, patients with a 20 µg/hour TdBUP patch required 133.8 mg IV-MEq more postoperatively than patients with a 5 µg/hour patch (p=0.002). Following discharge from the recovery room, 17 (77%) TdBUP patients and 15 (34%) opioid-naive patients reported severe pain (OR 6.6 (95% CI 2.0 to 21.3); p<0.001; adjusting for baseline pain score, 5.0 (95% CI, 1.4 to 17.8); p=0.01).ConclusionsAnalgesic management for patients receiving TdBUP therapy must account for increased opioid needs, and greater preoperative doses of TdBUP were associated with greater postoperative opioid requirements.

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A prospective study of opioid use for postoperative pain management after breast operation

The American Journal of Surgery ◽

10.1016/j.amjsurg.2019.07.032 ◽

2020 ◽

Vol 219 (1) ◽

pp. 8-14

Author(s):

Kristen E. Limbach ◽

SuEllen J. Pommier ◽

Kristen P. Massimino ◽

Rodney F. Pommier ◽

Arpana M. Naik

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Prospective Study ◽

Postoperative Pain Management ◽

Opioid Use ◽

A Prospective Study

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Postoperative Pain Management of Non–“Opioid-Naive” Patients Undergoing Hand and Upper-Extremity Surgery

Hand ◽

10.1177/1558944719828000 ◽

2019 ◽

Vol 15 (5) ◽

pp. 651-658

Author(s):

Kelvin A. Wong ◽

Kanu S. Goyal

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Upper Extremity ◽

Pain Control ◽

Control Program ◽

Postoperative Pain Management ◽

Categorical Variables ◽

Fisher Exact Test ◽

Opioid Use ◽

Opioid Users

Background: Patients with prior opioid use are often difficult to manage postoperatively. We examined potential strategies for managing these patients: (1) prescribing a different opioid; and (2) encouraging the use of nonopioid analgesics over opioids. Methods: A pain control program was implemented at an outpatient hand and upper-extremity center. Patients were recruited before (n = 305) and after (n = 225) implementation. Seventy of them were taking opioids prior to surgery. Information about pain control satisfaction and opioid use was collected. The Fisher exact test was used to compare categorical variables with small expected frequencies. Wilcoxon rank sum test was used to compare nonnormally distributed continuous variables. Results: Opioid users used 28.8 ± 25.6 opioid pills; nonopioid users used 14.5 ± 21.5 pills. Furthermore, 41.4% of opioid users sought more pills after surgery compared with 14.0% among nonopioid users. The pain control program was more effective in reducing opioid consumption and waste and increasing nonopioid consumption for nonopioid users than for opioid users. Prior opioid users who were prescribed a different opioid after surgery used 24.6 ± 22.0 opioid pills. Patients prescribed the same opioid used 37.9 ± 30.8 pills. Conclusions: Patients taking opioids prior to hand and upper-extremity surgery use more opioid pills, seek more pills after surgery, and are less satisfied with their pain control than their nonopioid user counterparts. Furthermore, the comprehensive pain plan was less effective in this patient population. Prescribing a different opioid reduced medication requirements for these patients, but additional strategies are needed to address postoperative pain management.

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Multimodal analgesia for postoperative pain in Asia: a review of evidence with clinical focus on dexketoprofen and tramadol/dexketoprofen ﬁxed-dose combination

10.22514/sv.2021.210 ◽

2021 ◽

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Postoperative Period ◽

Opioid Analgesic ◽

Postoperative Pain Management ◽

Multimodal Analgesia ◽

Fixed Dose ◽

Opioid Use ◽

Asian Patients ◽

Anti Inflammatory

The majority of patients who have undergone surgery experience moderate-to-severe postoperative pain. Asian patients tend to under-report pain and are consequently under-treated. Poor postoperative pain management increases the risk of morbidity, prolonged opioid use, lower quality of life outcomes and the risk of chronic post-surgical pain. Multimodal analgesia is the cornerstone of postoperative pain management. Non-steroidal anti-inflammatory drugs are considered a core component of multimodal analgesia due to their anti-inflammatory and analgesic properties. Use of a consistent non-steroidal anti-inflammatory throughout the postoperative period can help to achieve and maintain adequate pain relief. This review investigates the use of multimodal analgesia in postoperative pain management in Asia, with a focus on clinicians’ experience with dexketoprofen as a non-steroidal anti-inflammatory therapy throughout the postoperative period and its combination as fixed dose with Tramadol, a centrally acting synthetic opioid analgesic, in Asian patients, when necessary.

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Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Healthcare ◽

10.3390/healthcare9030333 ◽

2021 ◽

Vol 9 (3) ◽

pp. 333

Author(s):

Sara J. Hyland ◽

Kara K. Brockhaus ◽

William R. Vincent ◽

Nicole Z. Spence ◽

Michelle M. Lucki ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Perioperative Care ◽

Enhanced Recovery ◽

Interprofessional Collaboration ◽

Care Transitions ◽

Postoperative Pain Management ◽

Anesthetic Techniques ◽

Opioid Use ◽

Institutional Adoption

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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Subcutaneous sumatriptan: association with decreases in postoperative pain and opioid use after elective cranial surgery

Journal of Neurosurgery ◽

10.3171/2019.10.jns192503 ◽

2020 ◽

pp. 1-9

Author(s):

Kunal S. Patel ◽

Azim N. Laiwalla ◽

Jasmine A. T. DiCesare ◽

Matthew C. Garrett ◽

Anthony C. Wang

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Pain Score ◽

Pediatric Patients ◽

Maximum Dose ◽

Postoperative Pain Management ◽

Opioid Use ◽

Primary Headache Disorders ◽

Randomized Controlled Studies ◽

Subcutaneous Sumatriptan

OBJECTIVESumatriptan, a serotonin receptor agonist, has been used in the management of primary headache disorders and has been shown to affect trigeminal dural afferents. There is limited literature on the safety and efficacy of sumatriptan for postcraniotomy pain management. This study aimed to identify whether subcutaneous sumatriptan is a safe and efficacious pain management strategy after elective craniotomy.METHODSThe authors retrospectively reviewed patients who underwent supratentorial or suboccipital craniotomy between 2016 and 2019 that was performed by a single provider at a single institution to identify patients given subcutaneous sumatriptan in the postoperative period. Pain scores and intravenous and oral opioid use were compared in patients with (n = 15) and without (n = 45) sumatriptan administration.RESULTSPatients with and without sumatriptan administration had no significant differences in baseline characteristics or surgery type. There were no sumatriptan-related complications. The average pain score decreased from 3.9 to 1.3 within 1 hour after sumatriptan administration (p = 0.014). In both adult and pediatric patients there was decreased postoperative pain (adults: pain score of 1.1 vs 7.1, p < 0.001; pediatric: 1.1 vs 3.9, p = 0.007) within the first 48 hours. There were decreases in intravenous opioid use, length of intravenous opioid use, maximum dose of intravenous opioid used, oral opioid use, length of oral opioid use, and maximum dose of oral opioid used in both adult and pediatric patients.CONCLUSIONSThe authors identified subcutaneous sumatriptan as a safe and efficacious tool for postoperative pain management after craniotomy. Large multicenter randomized controlled studies are needed to further evaluate the specific role of sumatriptan in postoperative pain management after craniotomy.

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