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Predicting Prolonged Opioid Use After Surgery

Predicting Prolonged Opioid Use After Surgery

Opioid drug use in patients with chronic pain has been linked to psychological distress and substance abuse. Studies suggest that these factors are often more influential than the intensity of pain patients are experiencing. The determinants of the duration of opioid use after surgery have not been reported in previous research. Furthermore, few analyses have explored the factors that affect ongoing use of opioids after surgery.  In Anesthesiology & Analgesia, my colleagues and I had a study published that sought to determine preoperative factors that predict continued use of opioids long after surgery. Preoperative psychological distress and prior substance use was assessed in 109 patients who were undergoing various operations. After surgery, daily use of opioids was measured until patients reported ceasing use of these drugs and having no pain. Three Important Factors According to our results, three preoperative factors were independently related to long-term opioid use: 1. Legitimate prescribed opioid use. 2. Self-perceived risk of addiction. 3. Depressive symptoms. Patients who were using opioids for pain relief before their procedure had a 73% higher likelihood of using these drugs at follow-up. Individuals who rated themselves at increased risk of developing an addiction were more likely to be long-term opioid users. The risk increased 53% for each 1-point increase on a 4-point scale of perceived addiction risk. Patients with symptoms of depression had a 42% higher risk for each 10-point increase on the Beck Depression Inventory scale. The three factors identified in our study were significant regardless of the type of surgery patients underwent. These factors were also better predictors of long-term opioid drug use than the severity of...

Examining Chronic Opioid Use in TKA

Consensus statements on the management of knee osteoarthritis have not thoroughly addressed the use of opioid medications in patients undergoing total knee arthroplasty (TKA). In order to reduce postoperative pain, most reports recommend that mild analgesics (eg, acetaminophen) be used initially after TKA, followed by NSAIDs and opioids. More recently, concerns have been raised about using opioids because of tolerance issues with these drugs as well as increased responses to pain. Other studies have suggested that opioids can worsen treatment outcomes. Opioid Dependence Worsens Outcomes In the November 2, 2011 Journal of Bone & Joint Surgery, my colleagues and I had a study published in which we compared the perioperative course, complication rates, and clinical outcomes of patients who underwent TKA and if they were treated with chronic preoperative oral opioid analgesics. We looked at 49 knees in patients who had regularly used opioids for pain control prior to TKA and compared them with patients who didn’t use these medications. According to our results, chronic opioid use prior to TKA made it much more difficult for patients to recover after their surgery. Patients who used opioids before their surgery had longer hospital stays, more postoperative pain, and higher complication rates than those who weren’t opioid dependent. They were also more likely to need additional procedures, require referrals for pain management, suffer from unexplained pain or stiffness, and have lower function and less motion in the replaced knee. The differences between patient groups in our study were even greater than we expected, and chronic opioid use was linked to poorer outcomes across the board. Seize Opportunities to Educate Patients About...

Effective Strategies for Sedation During Bronchoscopy

Studies indicate that sedation during bronchoscopy makes the procedure more comfortable for patients and provides better working conditions for physicians when compared with no sedation. Sedation can be used during most bronchoscopies with minimal risk. However, research suggests that use varies widely between geographic areas of the country and within institutions. Survey results from 1991 showed that sedation was administered to more than half (51%) of bronchoscopy patients, but data from more than a decade later revealed that this figure jumped to nearly three-fourths of patients (73%). It’s not known if the use of sedation during bronchoscopy is continuing to rise. Optimizing Use of Sedation During Bronchoscopy In the November 2011 issue of Chest, my colleagues at the American College of Chest Physicians and I had a consensus statement published on the optimal use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adults. The statement recommends that every bronchoscopy be performed with sedation if feasible because it improves patient satisfaction and procedural tolerance significantly. It should be noted, however, that patient circumstances and access to resources may prevent use of sedation during these procedures. Patients with numerous comorbidities or severe, restricting respiratory or cardiac issues may not be appropriate because of potential complications. Although it’s acceptable to fulfill the wishes of patients who don’t want to be sedated, research suggests that topical anesthetics should be used for everyone receiving bronchoscopy. If patients have allergies to lidocaine—the preferred topical anesthetic for bronchoscopy—use of other topical anesthetics may be explored. Anticholinergic agents, however, are discouraged for pre-bronchoscopy use because data have shown that they fail to produce a clinically...
A Guideline Update for Managing Acute Pain in Perioperative Settings

A Guideline Update for Managing Acute Pain in Perioperative Settings

Pain management is a critical component medical care for patients undergoing surgery, but studies suggest that up to 70% of individuals undergoing surgery complain of moderate-to-severe pain after their procedure. Under-treatment of perioperative pain can lead to unnecessary suffering, decreased physical and psychological health, and delays in patient recovery and hospital discharges. Proper pain care has the potential to reduce the risk of adverse events and to allow patients to actively participate in their recovery. In the February 2012 issue of Anesthesiology, the American Society of Anesthesiologists (ASA) updated its practice guidelines for acute pain management in the perioperative period. The ASA update focused on adult and pediatric patients undergoing inpatient or outpatient surgery. “The new ASA recommendations update guidelines that were previously released in 2004,” says Michael A. Ashburn, MD, MPH, who served as chair of the ASA’s writing task force. “The document reflects the progress that has been made in acute pain management according to findings from clinical studies over the past several years as well as expert opinion.” Providing High Quality Pain Care To provide high quality pain care to surgical patients, the ASA recommends that a dedicated interdisciplinary team consisting of surgeons, nurses, pharmacists, anesthesiologists, pain specialists, and hospital administrators be assembled and included throughout the course of patient care. Furthermore, medical centers should develop institutional plans and foster an environment that allows for effective pain therapy. “Effective and safe use of available treatment options within the institution are important,” explains Dr. Ashburn. “This requires effective patient education efforts that range from basic bedside pain assessments to sophisticated pain management techniques and non-pharmacologic techniques. Ongoing education...

Pediatric Fracture-Related Pain: The Crowding Effect

According to published studies, pain is the most common reason for seeking care in the ED, accounting for up to 78% of visits. Underuse of analgesics is common, especially among pediatric patients. There are many reasons that contribute to this problem, but key themes have emerged as culprits, says Marion R. Sills, MD, MPH. “Studies have found that higher crowding levels appear to delay treatment of pain in adult patients who visit the ED, but little research has been conducted in pediatric populations. The effect of ED crowding on children is growing as a research priority.” The Pediatric Population & ED  Crowding For adults, crowding has been associated with decreased quality across all six Institute of Medicine (IOM) quality dimensions: timeliness, effectiveness, equity, patient-centeredness, safety, and efficiency. In an effort to address these dimensions in the context of crowding in ED pediatric patients, Dr. Sills and colleagues conducted a study involving children with acute long-bone fracture-related pain who visited an ED (see also, ED Crowding: The Impact on Child Asthma Care). “Extremity fractures are among the most common reasons children seek ED care, resulting in 850,000 ED visits nationwide each year,” adds Dr. Sills. “These fractures can be especially painful for children.” The study by Dr. Sills and colleagues, which was published in the December 2011 issue of Academic Emergency Medicine, measured the association between ED crowding and the quality of pain management for children with long-bone fractures. The objective was explored in three of the IOM’s six dimensions of quality: effectiveness, timeliness, and equity. The research team measured the dose-response effect of ED crowding on quality by comparing quality...
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