Comparing Analgesia on an As-Needed Basis to Traditional Intravenous Patient-Controlled Analgesia Within Fast-Track Orthopedic Procedures: A Randomized Controlled Trial

BackgroundThe aim was to determine if the use of intravenous patient-controlled analgesia (IVPCA) in a fast-track joint replacement program is associated with increased use of perioperative opioid consumption and increased length of hospital stay.DesignA prospective, double-blind, randomized controlled trial.SettingsAcademic hospital.Participants/SubjectsA total of 80 patients aged 18-85 years, with body mass index (BMI) 18-40, undergoing elective total knee arthroplasty were recruited.MethodsPre-operatively, patients received gabapentin, celecoxib, and acetaminophen. Peri-operatively, patients received spinal anesthesia with morphine and fentanyl, and periarticular local anesthetic administration by the surgeon. Postoperatively, 80 patients were randomized by a computer-generated sequence into IVPCA group (group A, n = 40) and non-IVPCA group (group B, n = 40).ResultsThe primary outcome was 48-hour postoperative opioid consumption and length of hospital stay. Secondary outcomes included side effects of opioids, patient satisfaction, and pain scores. There was no significant difference within 48-hour postoperative opioid consumption (median 61.3 vs. 87.5, p = .181) and length of hospital stay (median 49.8 hours vs. 49.5 hours; p = .89) between the two groups. Also, there was no significant difference in patient satisfaction (median 5 in both groups), pain scores, and opioid-related side effects.ConclusionsIVPCA was associated with nonsignificant reduction in opioid exposure in elective total knee arthroplasty surgery within 48 hours. Neither group was superior in terms of length of hospital stay, opioid related side-effects, pain scores, and patient satisfaction.     

Integration of Life Care Specialists Into Orthopaedic Trauma Care to Improve Postoperative Outcomes: A Pilot Study

BackgroundAimThis pilot study assessed the feasibility and impact of integrating a Life Care Specialist (LCS) into orthopaedic trauma care.DesignThis was a prospective feasibility single group pilot study at a level 1 trauma center.MethodThe LCS is a paraprofessional behavior-based “pain coach” and delivered patient-centered opioid safety education, trained participants on nonpharmacologic pain management approaches, conducted opioid risk assessments, and coordinated care. Numeric Rating Scale pain scores were assessed on admission, at discharge, and at 2-week follow-up. Daily morphine milligram equivalents (MME) during hospitalization, opioid medication use at 2-weeks, and patient satisfaction were recorded. T test compared mean morphine milligram equivalents (MME) to historical orthopaedic trauma patient population's mean dosage at discharge from the study site. Generalized linear models assessed pain scores over time.ResultsTwenty-two percent of 121 total participants met criteria for moderate to severe risk of opioid misuse at initial hospitalization. On average, 2.8 LCS pain management interventions were utilized, most frequently progressive muscle relaxation (80%) and sound therapy (48%). Mean inpatient MME/day was 40.5, which was significantly lower than mean historical MME/day of 49.7 (p < .001). Pain scores improved over time from admission to 2-weeks postoperatively (p < .001). Nearly all participants agreed that the LCS was helpful in managing pain (99%).ConclusionsThe findings indicate feasibility to integrate LCS into orthopaedic trauma care, evident by participant engagement and satisfaction, and that LCS serve as valuable resources to assist with pain management and opioid education.     

Clinical Consumption of Opioid Analgesics in China: A Retrospective Analysis of the National and Regional Data 2006–2016

ContextThe annual consumption of opioid analgesics in the U.S. was more than 10 times the world average, whereas that in China was at a moderate level within Asia but much lower than the worldwide average. The opposite situations of opioid use in the U.S. and China revealed totally different problems in the developed versus developing world, that is, overuse versus underuse of opioids.ObjectivesThis study analyzed the clinical consumption, estimated the needs of pain treatment, and evaluated the adequacy of opioid analgesic consumption in mainland China and its seven regions.MethodsA retrospective analysis of the national and regional consumption of opioid analgesics in mainland China during 2006–2016 was conducted. The adequacy of consumption measure was used to gauge the overall adequacy of opioid analgesic consumption in morphine equivalents (MEs) for the treatment of moderate-to-severe pain in mainland China and compared with international data. Annual per capita consumption was adopted to measure the clinical consumption of opioid analgesics in MEs at a national level and across seven regions of mainland China. Needs of morphine for cancer pain treatment in mainland China and in its seven regions were estimated and compared with the clinical consumption of opioid analgesics in MEs.ResultsThe adequacy of consumption measure of mainland China ranged from 0.0041 to 0.0088 during 2006–2016, which was less than 1% of that in the reference countries. The poor North East region had only 10.85% of the cancer pain morphine needs fulfilled. The highest fulfillment rate was 36.02% in rich Southern China, which was 25.9% at the national level.ConclusionThe clinical consumption of opioid analgesics for the treatment of moderate-to-severe pain in mainland China was far below the international level. The annual per capita of clinical consumption was lower, and the adequacy of cancer pain treatment was poorer in less developed areas. All these findings call for actions to strengthen pain management.     

The Effect of a Cartoon and an Information Video About Intravenous Insertion on Pain and Fear in Children Aged 6 to 12 Years in the Pediatric Emergency Unit: A Randomized Controlled Trial

IntroductionIntravenous insertion is the most common invasive procedure made for administering intravascular fluid and medicine. Peripheral venous catheterization may cause pain, fear, and stress in children. This study aimed to compare the effects of watching a cartoon and an information video about intravenous insertion on the pain and fear levels of children aged 6-12 years.MethodsThe study was an experimental, randomized controlled clinical trial. It was conducted with 477 children aged 6-12 years randomized into 3 groups: the informative animated video group, the cartoon group, and the control group. Fear and pain perception were evaluated on the basis of the feedback from the child, observer nurse, and parents. The Children’s Fear Scale was used to evaluate the fear level and the Wong-Baker FACES Scale was used to assess pain levels. Data were analyzed using one-way analysis of variance, the chi-square test, and the intraclass correlation coefficient test.ResultsThe children who watched the information video before the intravenous insertion procedure and those who watched a cartoon during the procedure had lower mean pain and fear scores as evaluated by the child (pain: F = 278.67, P = 0.001; fear: F = 294.88, P = 0.001), parent (pain: F = 279.53, P = 0.001; fear: F = 294.47, P = 0.001), and nurse (pain: F = 286.88, P = 0.001; fear: F = 300.81, P = 0.001) than children in the control group.DiscussionThis study showed that watching an animation video or a cartoon was effective in lowering children’s perceived level of pain and fear during an intravenous insertion intervention.     

Using a Morphine Equivalence Metric to Quantify Opioid Consumption: Examining the Capacity to Provide Effective Treatment of Debilitating Pain at the Global,Regional, and Country Levels

ContextMorphine has been considered the gold standard for treating moderate-to-severe pain, although many new opioid products and formulations have been marketed in the last two decades and should be considered when examining opioid consumption. Understanding opioid consumption is improved by using an equianalgesic measure that controls for the strengths of all examined opioids.ObjectivesThe research objective was to use a morphine equivalence (ME) metric to determine the extent that morphine consumption relates to the total consumption of all other study opioids.MethodsAn ME metric was created for morphine and the aggregate consumption of each study opioid (Total ME), adjusted for country population to allow for uniform equianalgesic comparisons. Graphical and statistical evaluations of morphine use and Total ME consumption trends (between 1980 and 2009) were made for the global and geographic regional levels and selected developed and developing countries.ResultsGlobal morphine consumption rose dramatically in the early 1980s but has been significantly outpaced by Total ME since 1996. As expected, the extent of morphine and Total ME consumption varied notably among regions, with the Americas, Europe, and Oceania regions accounting for the highest morphine use and Total ME in 2009. Developing and least developed countries, compared with developed countries, demonstrated lower overall Total ME consumption.ConclusionGenerally, worldwide morphine use has not increased at the rate of Total ME, especially in recent years. Examining a country's ability to effectively manage moderate-to-severe pain should extend beyond morphine to account for all available potent opioids.     

Endogenous opioid function mediates the association between laboratory-evoked pain sensitivity and morphine analgesic responses

Predictors of responsiveness to opioid analgesic medications are not well understood. This study tested whether individual differences in endogenous opioid (EO) function are associated with analgesic responsiveness to morphine. In randomized, counterbalanced order over 3 sessions, 45 chronic low back pain participants and 31 healthy controls received an opioid antagonist (8 mg naloxone), morphine (0.08 mg/kg), or placebo. Participants then engaged in 2 laboratory-evoked pain tasks (ischemic and thermal). Outcomes included pain threshold, pain tolerance, and pain ratings. Indexes of EO function and morphine analgesic responsiveness were derived for each measure as the difference in pain responses between the placebo condition and naloxone or morphine condition, respectively. For all 7 pain measures across the 2 laboratory pain tasks, greater EO function was associated with significantly lower morphine analgesic responsiveness (P < 0.001–P = 0.02). Morphine reduced pain responses of low EO individuals to levels similar to those of high EO individuals receiving placebo. Higher placebo condition–evoked pain sensitivity was associated with significantly greater morphine analgesic responsiveness for 5 of 7 pain measures (P < 0.001–P = 0.02). These latter associations were significantly mediated by EO function for 4 of these 5 pain outcomes (all P values < 0.05). In the laboratory-evoked pain context, opioid analgesic medications may supplement inadequate EO analgesia, with little incremental benefit in those with preexisting high EO function. Implications for personalized medicine are discussed.     

Lidocaine Plus Morphine Versus Lidocaine Plus Paracetamol for Bier Block: A Double-Blind Randomized Controlled Trial

PurposeIntravenous regional anesthesia (Bier block) is widely used as an anesthetic technique for operations of short duration of the distal upper or lower extremities. We compared the efficacy of intravenous regional anesthesia with lidocaine plus paracetamol versus lidocaine plus systemic morphine for short-duration hand and forearm surgeries.DesignA double-blind randomized controlled trial with two parallel arms: lidocaine plus morphine (control) and lidocaine plus paracetamol were carried out at a University hospital.MethodsWe included men and women aged 20 to 70 years scheduled for short surgical procedures (30-60 minutes) distal to the elbow. Intravenous regional anesthesia was carried out by injecting 45 cc lidocaine 0.5% plus 300 mg paracetamol for the paracetamol group; or 45 cc lidocaine 0.5% plus 4 mg intravenous morphine for the control group. The primary outcome was postoperative pain-free period in minutes since deflation of proximal tourniquet. The secondary outcome was the highest intensity of postoperative pain on the visual analog scale within 2 hours after deflating the proximal tourniquet.FindingsThere was no significant difference between morphine and paracetamol in the duration of postoperative pain-free period (P = .078) and the mean intensity for maximum pain (P = .106). However, severe pain was significantly more frequent in the morphine group (P = .001). Paracetamol seemed to be safer than morphine as an adjuvant to lidocaine.ConclusionsWe recommend using 2 cc paracetamol (300 mg Apotel) as the adjuvant to lidocaine for intravenous regional anesthesia.     

Clinical and Economic Analysis of Morphine Versus Fentanyl in Managing Ventilated Neonates With Respiratory Distress Syndrome in the Intensive Care Setting

Purpose

Morphine and fentanyl opioids are common analgesic agents for consideration in the neonatal intensive care unit (NICU) for neonates with respiratory distress syndrome (RDS) and undergoing mechanical ventilation (MV). The aim of this study was to evaluate the clinical and economic impact of morphine versus fentanyl in neonates with RDS undergoing MV.

Preoperative Intravenous Versus Oral Acetaminophen in Outpatient Surgery: A Double-Blinded,Randomized Control Trial

PurposePreoperative acetaminophen is recognized as an effective part of the multimodal approach to perioperative pain management. The present study, conducted between April 12, 2018 and February 14, 2019, examined whether there are differences in patient-reported pain, postoperative opioid consumption, negative opioid effects, length of postanesthesia care unit stay, and patient satisfaction with pain control between patients who receive intravenous (IV) acetaminophen and patients who receive oral acetaminophen.DesignThis double-blinded, randomized controlled trial was conducted among 120 patients undergoing outpatient surgery.MethodsPatients were randomized to receive preoperatively either intravenous (IV) acetaminophen (and oral placebo) or oral acetaminophen (and IV placebo). Results were analyzed using SPSS statistical software; statistical analyses consisted of Mann-Whitney U test, independent samples t test, and χ² test. In all analyses, a P value less than .05 was considered significant.FindingsThere were no significant differences in any outcome measures based on the route of acetaminophen administration.ConclusionsThe findings of the present study support the practice of administering oral acetaminophen, as opposed to IV acetaminophen, preoperatively as part of the multimodal approach to manage postoperative pain in patients able to tolerate preoperative oral medications.     

The Influence of Information Leaflets on Morphine Consumption in Postoperative Patients Using Patient-Controlled Analgesia

ABSTRACT

Negative preconceived beliefs about the benefits of morphine use are frequently seen in hospitalized patients and may be associated with reports of severe pain, poor patient satisfaction, impaired rehabilitation, and possibly more chronic postsurgical pain. In some patients, providing information through instructive leaflets may modify negative beliefs that limit proper medication use. The purpose of this study was to determine whether the morphine-related information provided through leaflets during the postoperative period led to increased use of morphine and lower pain scores in patients using patient-controlled analgesia. One hundred patients scheduled for surgery were randomly assigned to the experimental (n = 53) or control group (n = 38). Patients included in the former group received detailed information on morphine; those in the latter group received only general information on postoperative acute pain. The results indicated that during the immediate postoperative period, morphine use was directly associated with pain intensity and satisfaction with pain management and inversely related with side effects. These results show that pain intensity is the most relevant issue in the decision to use morphine. Information leaflets did not change morphine consumption.     

The effects of a morphine shortage on emergency department pain control

ObjectiveIn 2018, due to a national morphine shortage, our two study emergency departments (EDs) were unable to administer intravenous (IV) morphine for over six months. We evaluated the effects of this shortage on analgesia and patient disposition.MethodsThis was a retrospective study in two academic EDs. Our control period (with morphine) was 4/1/17–6/30/17 and our study period (without morphine) was 4/1/18–6/30/18. We included all adult patients with a chief complaint of pain, initial pain score ≥4, and ≥2 recorded pain scores. The primary outcome was delta pain score. Secondary outcomes included final pain score, proportion of ED visits with opioids vs. non-opioids administered, and ED disposition.ResultsWe identified 6296 patients during our control period and 5816 during our study period. There was no significant difference in mean final pain score (study 4.45, control 4.44, p = 0.802), delta pain score (study −3.30, control −3.32, p = 0.556), nor admission rates (study 18.8%, control 17.8%, p = 0.131). We saw a decrease in opioid use (study 47.4%, control 60.0%, p < 0.01) and an increased use of non-opioid analgesics (study 27.3%, control 18.44%, p < 0.01).ConclusionsRemoving IV morphine in the ED, without a compensatory rise in alternative opioids, does not appear to significantly impact analgesia or disposition. These data favor a more limited opioid use strategy in the ED.     

Low-dose ketamine analgesia: patient and physician experience in the ED

ObjectiveLow-dose ketamine (LDK) may be useful for treatment for opioid-tolerant patients. We conducted a survey of patients and their treating clinicians regarding LDK for analgesia.MethodsSurvey data included the following: vital signs and pain score before and after LDK, demographics, and adverse effects. Treating physicians were queried about reasons for use of LDK and overall satisfaction.ResultsTwenty-four patients were enrolled: 21 received LDK for analgesia, and 3 received LDK for sedation. Pain level on a visual analog scale (range, 1-10) after LDK was significantly decreased from 8.9 ± 2.1 to 3.9 ± 3.4 (P < .0001). Change in vital signs after administration of LDK was not statistically significant. Overall patient satisfaction with LDK was 55%, and overall physician satisfaction was 72%. Sixteen (67%) of patients would prefer LDK again, and 23 (96%) of physicians would use LDK again for analgesia. Four patients reported an adverse experience, but there were no emergence reactions. Race subanalysis revealed no difference in pain reduction, but whites were least satisfied compared with black and Hispanic patients (P = .02). Physician reasons for using LDK included opioid failure (88%), concern for respiratory depression (17%), concern for multiple opioid allergies (13%), and concern for hypotension (8%). Most (96%) physicians believed that LDK is underused.ConclusionLow-dose ketamine may decrease patients' perception of pain. Most were satisfied with LDK for this purpose and would use it again. Whites were least satisfied with the use of LDK for analgesia. Physicians believed that ketamine is underused.     

The Effect of Maternal Voice on Venipuncture Induced Pain in Neonates: A Randomized Study

BackgroundVenipuncture is a common procedure in the neonatal intensive care unit (NICU) and causes significant pain for neonates.AimTo evaluate the effect of maternal voice on pain caused by venipuncture (including peripheral venipuncture and femoral venipuncture) in neonates hospitalized in the NICU.DesignExperimental, randomized controlled study.SettingThe study was conducted in the NICU of two hospitals in China from November 2017 to January 2019.MethodsOne hundred and sixteen neonates were randomly assigned to the maternal voice or routine care groups. The maternal voice group received recorded maternal voice intervention before, during, and after venipuncture. Three phases of procedures were videotaped. Neonatal Infant Acute Pain Assessment Scale (NIAPAS) was assessed by the same evaluator at different phases.ResultsThe study showed that NIAPAS scores, behavioral indicator scores, and physiological indicator scores in the maternal voice group were significantly lower compared with those in the routine care group.ConclusionRecorded maternal voice can improve pain caused by venipuncture in neonates. These are simple, rapid, and cost-effective methods that nurses can implement during venipuncture in neonates.     

Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial

ObjectiveTo evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions.DesignTwo-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up.SettingDepartment of Veterans Affairs medical facility.Participants103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions.InterventionsExperimental arm—a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm—usual care in a large Department of Veterans Affairs medical facility.Main Outcome MeasuresOswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect.ResultsVeterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms).ConclusionThese findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.     

Intravenous acetaminophen does not have an opioid sparing effect in Emergency Department patients with painful conditions

BackgroundPain in the Emergency Department is common and is frequently treated with opioids. Due to the opioid epidemic, it is clinically helpful to decrease opioid usage. The purpose of this study was to evaluate opioid requirement in Emergency Department patients with painful conditions who receive intravenous acetaminophen.MethodsIn this prospective cohort study, patients aged 18 years and older and treated with opioids in the acute phase were included. Patients receiving additional intravenous acetaminophen were compared to patients who did not. Primary outcome was opioid requirement, measured in Morphine Equivalent Units (MEU) during Emergency Department stay. Secondary outcomes were opioid requirement after discharge; decrease in pain scores; occurrence of adverse events and patient satisfaction.ResultsA total of 116 patients were included of whom 76 received intravenous acetaminophen. Opioid consumption in the acute phase was not significantly different (p=0.53) between patients receiving (10.0 MEU (IQR 7.5; 15.0)) and those not receiving acetaminophen: 10.0 MEU (IQR 7.1; 15.0). After discharge these numbers were 15.0 MEU (IQR 7.5; 30.0) versus 30.0 MEU (IQR 15.0; 43.8), respectively (p=0.059). In both groups median NRS pain scores decreased from 9.0 to 4.0 and >80% of patients were satisfied regarding pain treatment. Nine minor adverse events were recorded, equally divided among the groups.ConclusionsThe additional use of intravenous acetaminophen did not decrease opioid requirement in adult patients with acute pain during Emergency Department stay. There was a trend towards decreased opioid requirement during 24 h after discharge.     

A Randomized Controlled Trial of Patient-controlled Analgesia Compared with Boluses of Analgesia for the Control of Acute Traumatic Pain in the Emergency Department

Background

The use of patient-controlled analgesia (PCA) has been reported to provide effective pain relief, often resulting in less opioid consumption, and is associated with greater patient satisfaction when it is compared to other techniques of analgesia delivery.

Objectives

This study was done to compare the effectiveness of pain relief and patient satisfaction between PCA and the conventional method of administering boluses of analgesia for acute pain of traumatic origin in the Emergency Department (ED).

Methods

Study patients were randomized into two groups after being given a bolus of morphine. The PCA group was then given morphine via the PCA system, whereas the control group was given the conventional boluses of morphine via titration method. Pain levels were measured using the visual analogue scale at intervals of 0, 15, 30, 45, 60, 90, and 120 min. Any adverse events were also noted. Finally, within 24 h, these patients completed questionnaires regarding their experience with regard to the pain relief they experienced.

Results

The PCA group experienced faster and greater pain relief. No life-threatening events were encountered. The satisfaction questionnaire revealed that the PCA group was more satisfied using the PCA method of pain relief than those receiving standard boluses for delivery of analgesia.

Conclusion

PCA provides more effective pain relief and more patient satisfaction when compared to the conventional method of titrated bolus intravenous injection for the relief of traumatic pain in the ED setting.     

Hyperalgesia in Opioid-Managed Chronic Pain and Opioid-Dependent Patients

This observational study aimed to determine whether pain sensitivity in patients with noncancer chronic pain, taking either methadone or morphine, is similar to patients maintained on methadone for dependence therapy, compared with a control group. Nociceptive thresholds were measured on a single occasion with von Frey hairs, electrical stimulation, and cold pressor tests. In all subjects receiving methadone or morphine, nociceptive testing occurred just before a scheduled dose. Cold pressor tolerance values in patients with noncancer, chronic pain, treated with morphine and methadone, were 18.1 ± 2.6 seconds (mean ± SEM) and 19.7 ± 2.3 seconds, respectively; in methadone-maintained subjects it was 18.9 ± 1.9 seconds, with all values being significantly (P < .05) lower than opioid-naïve subjects (30.7 ± 3.9 seconds). These results indicate that patients with chronic pain managed with opioids and methadone-maintained subjects are hyperalgesic when assessed by the cold pressor test but not by the electrical stimulation test. None of the groups exhibited allodynia as measured using the von Frey hairs. These results add to the growing body of evidence that chronic opioid exposure increases sensitivity to some types of pain. They also demonstrate that in humans, this hyperalgesia is not associated with allodynia.PerspectiveThis article presents an observational study whereby the pain sensitivity of patients with chronic pain managed with opioids and opioid-maintained patients were compared with opioid-naïve patients. The results suggest that opioid use may contribute to an increase in the sensitivity to certain pain experimental stimuli.     

Comparison of Periarticular Injection and Intra-articular Injection for Pain Management After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

PurposeLocal infiltration analgesia, an essential component of multimodal analgesia after total knee arthroplasty (TKA), can be classified into periarticular injection (PAI) and intra-articular injection (IAI) as per administration techniques. Currently, there is no definite answer of the optimal choice between the two techniques. This meta-analysis aims to determine whether PAI provides superiority of pain relief and functional recovery than IAI after TKA.DesignSystematic review and meta-analysis.MethodsComparative studies that compared PAI and IAI in patients after TKA were searched in the Embase, PubMed, MEDLINE, and the Cochrane Library databases. The primary outcomes were visual analog scale scores for pain and opioid consumption. The secondary outcomes were complications, function of recovery, and length of hospital stay.FindingsFour randomized controlled trials and two case-controlled studies with a total of 769 patients were enrolled. There were no significant differences in mean visual analog scale scores at postoperative day 0 (P = .17) and day 1 (P = .27), maximum visual analog scale scores at day 0 (P = .89) and day 1 (P = .82), total opioid consumption at day 1 (P = .96), opioid complications (P = .15), and length of hospital stay (P = .84) between PAI and IAI.ConclusionsBased on the available evidence, PAI does not offer superior effects at pain control and discharge than IAI after TKA. However, owing to the limited sample size and heterogeneity of the included studies, further large well-designed randomized controlled trials are still needed to validate this conclusion.RegistrationThe protocol has been registered in the PROSPERO international database under number CRD42020165138.     

Efficacy and Practicality of Opioid Therapy in Japanese Chronic Noncancer Pain Patients

BackgroundMany Japanese adults suffer from chronic pain. However, 50% of these individuals discontinue treatment despite the persistence of pain. Both clinicians and patients in Japan tend to be concerned about the safety and efficacy of opioid therapy, and the use of opioids in chronic non-cancer pain remains less common in Japan than elsewhere.AimsThis study examined the effects of opioid therapy on the daily lives of patients with chronic noncancer pain in Japan, where use of opioids for this type of pain remains uncommon.DesignProspective cross-sectional questionnaire study.SettingData were collected over two periods, between March and April 2014 at one hospital, and between February and April 2015 at the other hospital. Subjects were recruited at the respective clinics by the study interviewer between March 1, 2014 and April 15, 2014 and between February 1, 2015 and April 15, 2015.Participants/SubjectsThis study included 34 outpatients with chronic non-cancer pain who were being treated with opioid analgesics at pain clinics in two hospitals in Sapporo.MethodsThirty-four Japanese patients receiving opioid medications for chronic noncancer pain in outpatient pain clinics were enrolled. Participants underwent interviews and completed the Japanese versions of the Short Form 36 (SF-36v2) and the Coping Strategies Questionnaire (CSQ).ResultsSleep disruption, claiming compensation for work-related accidents, and current pain level were negatively correlated with opioid effectiveness (p < .05). Additionally, opioid effectiveness was negatively correlated with the catastrophizing subscale of the CSQ (r = −0.50, p < .01). The effects of opioid therapy had a low positive correlation with the emotional functioning role subscale of the SF-36v2 (r = 0.38, p < .05). Daily equivalent morphine dose was positively correlated with opioid therapy duration, interference with appetite, and current pain intensity. Morphine dose was also positively correlated with scores for the catastrophizing subscale of the CSQ (r = 0.36, p < .05) and negatively correlated with scores in all subdomains of the SF-36v2.ConclusionsIt is important to focus on adaptive, cognitive, and emotional factors, such as emotional role functioning, to determine the efficacy of opioid treatment for chronic noncancer pain. Moreover, patients with catastrophizing significantly increased their morphine doses, resulting in an increased risk of overdose.