Costs and consumption of analgesics, with special reference to opiates in Serbia and Montenegro from 2015 to 2019

Background/Aim: Patients in developing countries do not always receive adequate painrelieving treatment. Monitoring of analgesic consumption is of great importance, since this can help assessing the quality of painful condition management. The aim of this paper is to present a five-year consumption and costs of drugs with analgesic effects in developing countries, exemplified by Serbia and Montenegro, and indicate the main reasons for their (in)adequate prescribing. Methods: The observational, retrospective, cross-sectional study was conducted in order to analyse consumption of all analgesics, both opioid and non-opioid, in Serbia and Montenegro, as developing countries. The data concerning analgesic consumption and drug prices were obtained from annual editions of the publications of the Medicines and Medical Devices Agency of Serbia and Montenegro. The WHO methodology with defined daily dose (DDD) as a unit of measure (it is defined by the number of DDD per 1000 inhabitants per day) was used in these publications. Results: In the course of the fiveyear period (from 2015 to 2019) in Serbia, the total allocations for analgesic therapy had a rising trend; from about 43.6 million to 63.3 million of Euros, while in Montenegro expenditures showed annual variations with highest value in 2018. Most of the money in both countries was invested in M01A group of drugs, for which the highest consumption was also recorded. Significantly higher consumption of opioid analgesics in Montenegro comparing with Serbia was observed in the same period, and it predominatly reflected the difference in fentanyl (N02AB03, transdermal patch) prescribing. In Montenegro, consumption of M01group of drugs was prominently higher in comparison to M01AE group during the whole five-year period, similarly like in Serbia in which this was not the case only in 2018. Conclusions: Taking into account the importance of analgesics for everyday medical practice, more rational prescribing of these drugs is necessary both in Serbia and Montenegro in the future.

Adding Dexmedetomidine to Bupivacaine in Ultrasound-guided Thoracic Paravertebral Block for Pain Management after Upper Abdominal Surgery: A Double-blind Randomized Controlled Trial

Background: Paravertebral blocks are one of the possible postoperative pain management modalities after laparotomy. Adjuvants to local anesthetics, including alpha agonists, have been shown to lead to better pain relief and increased duration of analgesia. Objectives: The aim of this study is to examine the effect of adding dexmedetomidine to bupivacaine for ultrasound-guided paravertebral blocks in laparotomy. Methods: In this double-blind, randomized controlled trial (RCT), we enrolled 42 patients scheduled for T6 to T8 thoracic paravertebral block (TPVB) for analgesia after laparotomy. The patients were randomly assigned into two groups of BD (bupivacaine 2.5 mg/mL 20 mL plus dexmedetomidine 100 µg) and B (bupivacaine 20 mL alone). Following surgery, intravenous fentanyl patient-controlled analgesia was initiated. The numerical rating scale (NRS) for pain, sedation score, total analgesic consumption, time to first analgesic requirement, side effects (such as nausea and vomiting), respiratory depression, and patients’ satisfaction during the first 48 hours of evaluation were compared in the two groups. Results: Pain scores and mean total analgesic consumption at the first 48 hours in the BD group were significantly lower than Group B (P = 0.03 and P < 0.001, respectively). The time of first analgesic request was significantly longer in BD group (P < 0.001). Sedation scores and side effects did not differ significantly between the two groups. Conclusions: Adding dexmedetomidine to bupivacaine for TPVB after laparotomy yielded better postoperative pain management without significant complications.

Impact of dexamethasone added to intra-articular morphine and bupivacaine for postoperative analgesia after knee arthroscopy

Background Pain relief after knee arthroscopy is very important for early recovery and rehabilitation. The study was conducted to evaluate the effects of adding dexamethasone (8 mg) to intra-articular morphine (10 mg) and bupivacaine (25 mg) combination on postoperative pain after knee arthroscopy. Results We enrolled 40 patients, 18–65 years-old of both sexes, ASA I and II scheduled for minor arthroscopic knee surgeries. The study group showed a lower visual analog score at rest and movement, prolonged postoperative analgesia, and decreased total analgesic consumption compared with the control group (P value < 0.05). Conclusions Adding dexamethasone to intra-articular combination of morphine and bupivacaine after knee arthroscopy prolongs the duration of analgesia, lowers pain scores, and decreases total analgesic consumption with no detected adverse effects.

Impact of dexamethasone added to intra-articular morphine and bupivaciane for post-operative analgesia after knee arthroscopy

Background Pain relief after knee arthroscopy is very important for early recovery and rehabilitation. Many drugs were used intra-articularly to prolong postoperative analgesia and diminish post-operative pain. The present study studies the effects of adding dexamethasone to intra-articular morphine and bupivacaine combination on postoperative pain after knee arthroscopy. Aim of the Work The aim of the study is to evaluate the effect of adding dexamethasone (8mg) to intra-articular morphine (10mg) and bupivacaine (25mg) injection on postoperative pain after knee arthroscopy. Patients and Methods A randomized double-blinded clinical trial was carried out on 40 patients undergoing knee arthroscopy. Patients were divided randomly into two equal groups. All drugs used were injected intra-articularly at the end of arthroscopy. In the control group, patients were administered 10mg morphine added to bupivacaine 25mg. In the study group, patients were administered 10mg morphine and 8mg dexamethasone added to bupivacaine 25mg. Visual analog score for pain at rest and movement, time to first analgesic request, total analgesic consumption, duration of analgesia and adverse effects were recorded. Results The study group showed lower visual analog score at rest and movement, prolonged postoperative analgesia, and decreased total analgesic consumption compared with the control group. Conclusion Adding dexamethasone to intra-articular combination of morphine and bupivacaine after knee arthroscopy prolongs the duration of analgesia, lowers pain scores, and decreases total analgesic consumption with no detected adverse effects.

Dexmedetomidine versus dexamethasone as adjunct to ropivacaine in erector spinae plane block for patients undergoing breast surgery: a randomized, prospective, double blinded study

Background: Loco-regional anaesthesia (GA) has been extensively applied in the clinical field for achieving post-operative analgesia. Erector spinae plane block (ESPB) which is a novel inter-fascial plane block has been widely used for breast surgery. Dexmedetomidine and dexamethasone as an adjunct to local anaesthesia have been widely reported to reduce postoperative pain and analgesic consumption but there are no studies comparing both these drugs in ESPB for breast surgery.Methods: Sixty ASA I-II patients scheduled for breast surgery were randomly allocated into two groups-Group DX and group DM. Group DX received 20 ml ropivacaine 0.2% with dexmedetomidine 0.5 mcg/kg while group DM received 20 ml ropivacaine 0.2 % with 8 mg dexamethasone in ESPB preemptively. All the patients were induced with standard GA and extubated at the end of surgery. In the post-operative period visual analogue scale (VAS) pain score, total tramadol consumption, time for first rescue analgesia and side effects were noted for 24 hours.Results: The demographical parameters were comparable between both the groups. The VAS score, total tramadol consumption and time for first rescue analgesia were both similar in both the groups without any significant difference. No side effects were noted in any patients in both the groups.Conclusions: Dexmedetomidine (0.5 mcg/kg) and dexamethasone (8 mg) as an adjunct to ropivacaine reduces postoperative pain and analgesic consumption with no significant difference when used in ESPB for patients undergoing breast surgery without any side effects.

Ultrasound guided erector Spinae plane block versus modified pectoral plane block in modified radical mastectomy: a prospective, randomized, single blinded study

Background: Modified radical mastectomy (MRM) is the most common surgery for cancer breast that is associated with marked postoperative pain. Effective control of this pain suppresses the surgical stress response and decreases the need for opioids and general anesthetics. This study was aimed to compare ultrasound guided erector spinae block (US-ESP) with modified pectoralis nerve block (US-PECS) in terms of post-operative pain scores as the primary objective, in patients undergoing MRM. The secondary objectives of our study were to compare the time of first rescue analgesic, total analgesic consumption and side-effects between the two groups.Methods: Group E comprised of patients receiving 20 mL of 0.2% ropivacaine plus 0.5 µ/kg dexmedetomidine and it was injected in‑between erector spinae muscle and transverse process. Group P comprised of patients receiving 30 mL of 0.2% ropivacaine plus 0.5 µg/kg dexmedetomidine divided into 10 mL that was injected between the two pectoralis muscles in the inter-fascial plane and the remaining 20 mL was injected between the serratus anterior and the pectoralis minor muscle.Results: Demographic profile was comparable between both groups. Both groups offered good analgesia, but PECS group took an upper hand up to the 6th post-operative hour (p<0.05). Beyond the 6th post-operative hour, analgesic efficacy of both groups was comparableConclusions: Modified pectoralis nerve block offered better analgesia over the erector spinae block technique up to 6th post-operative hour and it is more effective in terms of total rescue analgesic consumption and the time for request of first rescue analgesic, in patients posted for MRM.

Magnesium Sulfate Enables Patient Immobilization during Moderate Block and Ameliorates the Pain and Analgesic Requirements in Spine Surgery, Which Can Not Be Achieved with Opioid-Only Protocol: A Randomized Double-Blind Placebo-Controlled Study

Spine surgery is painful despite the balanced techniques including intraoperative and postoperative opioids use. We investigated the effect of intraoperative magnesium sulfate (MgSO4) on acute pain intensity, analgesic consumption and intraoperative neurophysiological monitoring (IOM) during spine surgery. Seventy-two patients were randomly allocated to two groups: the Mg group or the control group. The pain intensity was significantly alleviated in the Mg group at 24 h (3.2 ± 1.7 vs. 4.4 ± 1.8, p = 0.009) and 48 h (3.0 ± 1.2 vs. 3.8 ± 1.6, p = 0.018) after surgery compared to the control group. Total opioid consumption was reduced by 30% in the Mg group during the same period (p = 0.024 and 0.038, respectively). Patients in the Mg group required less additional doses of rocuronium (0 vs. 6 doses, p = 0.025). Adequate IOM recordings were successfully obtained for all patients, and abnormal IOM results denoting warning criteria (amplitude decrement >50%) were similar. Total intravenous anesthesia with MgSO4 combined with opioid-based conventional pain control enables intraoperative patient immobilization without the need for additional neuromuscular blocking drugs and reduces pain intensity and analgesic requirements for 48 h after spine surgery, which is not achieved with only opioid-based protocol.