The Evolving Landscape of Acute Pain Management in the Era of the Opioid Crisis

Purpose of Review

The purpose of the study is to evaluate and analyze the role of both opioid and non-opioid analgesics in the emergency department (ED).

Recent Findings

Studies have shown that the implementation of opioid-prescribing policies in the ED has the potential to reduce the opioid addiction burden. Clinical studies point to inconsistencies in providers’ approach to pain treatment. In this review, we discuss specific aspects of opioid utilization and explore alternative non-opioid approaches to pain management.

Summary

Pain is the most common reason patients present to the ED. As such, emergency medicine (EM) providers must be well versed in treating pain. EM providers must be comfortable using a wide variety of analgesic medications. Opioid analgesics, while effective for some indications, are associated with significant adverse effects and abuse potential. EM providers should utilize opioid analgesics in a safe and rational manner in an effort to combat the opioid epidemic and to avoid therapeutic misadventures. EM providers should be aware of all of their therapeutic options, e.g., opioid and non-opioid, in order to provide effective analgesia for their patients, while avoiding adverse effects and minimizing the potential for misuse.

     

Comparative Analysis of Length of Stay and Inpatient Costs for Orthopedic Surgery Patients Treated with IV Acetaminophen and IV Opioids vs. IV Opioids Alone for Post-Operative Pain

Introduction

Recovery from orthopedic surgery is oriented towards restoring functional health outcomes while reducing hospital length of stay (LOS) and medical expenditures. Optimal pain management is a key to reaching these objectives. We sought to compare orthopedic surgery patients who received combination intravenous (IV) acetaminophen and IV opioid analgesia to those who received IV opioids alone and compared the two groups on LOS and hospitalization costs.

Methods

We performed a retrospective analysis of the Premier Database (Premier, Inc.; between January 2009 and June 2015) comparing orthopedic surgery patients who received post-operative pain management with combination IV acetaminophen and IV opioids to those who received only IV opioids starting on the day of surgery and continuing up to the second post-operative day. The quarterly rate of IV acetaminophen use for all hospitalizations by hospital served as the instrumental variable in two-stage least squares regressions controlling for patient and hospital covariates to compare the LOS and hospitalization costs of IV acetaminophen recipients to opioid monotherapy patients.

Results

We identified 4,85,895 orthopedic surgery patients with 1,74,805 (36%) who had received IV acetaminophen. Study subjects averaged 64 years of age and were predominantly non-Hispanic Caucasians (78%) and female (58%). The mean unadjusted LOS for IV acetaminophen patients was 3.2 days [standard deviation (SD) 2.6] compared to 3.9 days (SD 3.9) with only IV opioids (P < 0.0001). Average unadjusted hospitalization costs were $19,024.9 (SD $13,113.7) for IV acetaminophen patients and $19,927.6 (SD $19,578.8) for IV opioid patients (P < 0.0001). These differences remained statistically significant in our instrumental variable models, with IV acetaminophen associated with 0.51 days shorter hospitalization [95% confidence interval (CI) ?0.58 to ?0.44, P < 0.0001] and $634.8 lower hospitalization costs (95% CI ?$1032.5 to ?$237.1, P = 0.0018).

Conclusion

Compared to opioids alone, managing post-orthopedic surgery pain with the addition of IV acetaminophen is associated with shorter LOS and decreased hospitalization costs.

Funding

Mallinckrodt Pharmaceuticals.

     

Medication Overuse in Chronic Pain

Purpose of Review

Chronic pain is usually managed by various pharmacotherapies after exhausting the conservative modalities such as over-the-counter choices. The goal of this review is to investigate current state of opioids and non-opioid medication overuse that includes NSAIDs, skeletal muscle relaxants, antidepressants, membrane stabilization agents, and benzodiazepine. How to minimize medication overuse and achieve better outcome in chronic pain management?

Recent Findings

Although antidepressants and membrane stabilization agents contribute to the crucial components for neuromodulation, opioids were frequently designated as a rescue remedy in chronic pain since adjunct analgesics usually do not provide instantaneous relief. The updated CDC guideline for prescribing opioids has gained widespread attention via media exposure. Both patients and prescribers are alerted to respond to the opioid epidemic and numerous complications. However, there has been overuse of non-opioid adjunct analgesics that caused significant adverse effects in addition to concurrent opioid consumption. It is a common practice to extrapolate the WHO three-step analgesic ladder for cancer pain to apply in non-cancer pain that emphasizes solely on pharmacologic therapy which may result in overuse and escalation of opioids in non-cancer pain. There has been promising progress in non-pharmacologic therapies such as biofeedback, complementary, and alternative medicine to facilitate pain control instead of dependency on pharmacologic therapies.

Summary

This review article presents the current state of medication overuse in chronic pain and proposes precaution to balance the risk and benefit ratio. It may serve as a premier for future study on clinical pathway for comprehensive chronic pain management and reduce medication overuse.

     

Chronifizierungsmechanismen und Abhängigkeitspotenziale bei Tumorschmerz

Background

Due to advances in oncological therapy options and increasing survival rates, the number of cancer patients with persistant pain, who are in need of analgesic therapy has increased. It has been proven that biopsychosocial mechanisms exist in patients with persistant non-cancer pain leading to chronification. Furthermore, addiction has been identified as a complication of analgesic therapy.

Objective

Can the multidimensional model of chronic pain enhancement and chronification be used for patients with cancer pain, analogue to patients with non-cancer pain? Can addiction sydromes as a result of analgesic treatment be demonstrated?

Material and methods

In this non-systematic review, a literature search was carried out for somatic and psychosocial chronification mechanisms in patients with cancer pain. Indications for potential addiction syndromes in cancer patients are demonstrated based on selected publications. A Medline search provided a number of relevant publications that are listed (see Supplementary Material).

Results and discussion

Somatic chronification mechanisms, such as pain intensity, repetitive algesic stimuli, topical and demographic factors, are found both in persistant non-cancer pain and cancer pain. Cancer-induced peripheral and central sensitization mechanisms that can be due to underlying genetic variations, are specific for cancer pain. With regard to psychosocial determinants for pain chronification, both cancer and non-cancer patients show similar patterns. Furthermore, data from the literature support the existence of addiction in cancer patients.

Conclusion

In order to optimize treatment more attention should be paid to the risk of chronification and addiction in cases of chronic persistant cancer pain.

     

Technology assessment and cost-effectiveness in orthopedics: how to measure outcomes and deliver value in a constantly changing healthcare environment

Purpose of review

The purpose of this study is to review the basic concepts of healthcare value, patient outcome measurement, and cost-effectiveness analyses as they relate to the introduction of new surgical techniques and technologies in the field of orthopedic surgery.

Recent findings

An increased focus on financial stewardship in healthcare has resulted in a plethora of cost-effectiveness and patient outcome research. Recent research has made great progress in identifying orthopedic technologies that provide exceptional value and those that do not meet adequate standards for widespread adoption.

Summary

As the pace of technological innovation advances in lockstep with an increased focus on value, orthopedic surgeons will need to have a working knowledge of value-based healthcare decision-making. Value-based healthcare and cost-effectiveness analyses can aid orthopedic surgeons in making ethical and fiscally responsible treatment choices for their patients.

     

Hospitalization Costs for Patients Undergoing Orthopedic Surgery Treated With Intravenous Acetaminophen (IV-APAP) Plus Other IV Analgesics or IV Opioid Monotherapy for Postoperative Pain

Introduction

To assess the impact on hospitalization costs of multimodal analgesia (MMA), including intravenous acetaminophen (IV-APAP), versus IV opioid monotherapy for postoperative pain management in patients undergoing orthopedic surgery.

Methods

Utilizing the Truven Health MarketScan^® Hospital Drug Database (HDD), patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or surgical repair of hip fracture between 1/1/2011 and 8/31/2014 were separated into postoperative pain management groups: MMA with IV-APAP plus other IV analgesics (IV-APAP group) or an IV opioid monotherapy group. All patients could have received oral analgesics. Baseline characteristics and total hospitalization costs were compared. Additionally, an inverse probability treatment weighting [IPTW] with propensity scores analysis further assessed hospitalization cost differences.

Results

The IV-APAP group (n = 33,954) and IV opioid monotherapy group (n = 110,300) differed significantly (P < 0.0001) across baseline characteristics, though the differences may not have been clinically meaningful. Total hospitalization costs (mean ± standard deviation) were significantly lower for the IV-APAP group than the IV opioid monotherapy group (US$12,540 ± $9564 vs. $13,242 ± $35,825; P < 0.0001). Medical costs accounted for $701 of the $702 between-group difference. Pharmacy costs were similar between groups. Results of the IPTW-adjusted analysis further supported the statistically significant cost difference.

Conclusions

Patients undergoing orthopedic surgery who received MMA for postoperative pain management, including IV-APAP, had significantly lower total costs than patients who received IV opioid monotherapy. This difference was driven by medical costs; importantly, there was no difference in pharmacy costs. Generalizability of the results may be limited to patients admitted to hospitals similar to those included in HDD. Dosing could not be determined, so it was not possible to quantify utilization of IV-APAP or ascertain differences in opioid consumption between the 2 groups. This study did not account for healthcare utilization post-discharge.

     

Accessibility,accountability, affordability: healthcare policy in orthopedic trauma

Purpose of review

This review provides historical background on trauma care in the USA and summarizes contemporary trauma-related health policy issues. It is a primer for orthopedic surgeons who want to promote improvements in research, delivery, and cost reduction in trauma care.

Recent findings

As of 2010, funding for trauma research accounted for only 0.02% of all National Institutes of Health research funding. This is disproportionate to the societal burden of traumatic injury, which is the leading cause of death and disability among people aged 1 to 46 years in the USA. The diagnosis-related group model of hospital reimbursement penalizes level-I trauma centers, which typically treat the most severely injured patients. Treatment of traumatic injury at level-I and level-II trauma centers is associated with lower rates of major complications and death compared with treatment at non-trauma centers. Patient proximity to trauma centers has been positively correlated with survival after traumatic injury. Inadequate funding has been cited as a reason for recent closures of trauma centers.

Summary

Orthopedic surgeons have a responsibility to engage in efforts to improve the quality, accessibility, and affordability of trauma care. This can be done by advocating for greater funding for trauma research; choosing the most cost-effective, patient-appropriate orthopedic implants; supporting the implementation of a national trauma system; leading high-quality research of trauma patient outcomes; and advocating for greater accessibility to level-I trauma centers for underserved populations.

     

Bestandsaufnahme der Schmerzsituation von Schwerstverletzten zwei Jahre nach Trauma

Background and objectives

Trauma patients often suffer from persisting pain even years after injury, and data on long-term pain management is lacking. The aim of this study was to evaluate the frequency of persisting pain and health-related quality of life (HrQoL) among trauma victims 2 years after injury. Furthermore, the frequency of pain specialist consultation and the quality of outpatient pain management, including phamacological management, was assessed.

Materials and methods

We analyzed prospectively collected data on severely injured adult patients treated between 2008–2011 at the Cologne Merheim Medical Center (CMMC)/Germany.  Data included the ‘Polytrauma Outcome Profile’ and a standardized questionnaire on outpatient pain management. Exclusion criteria were death, inability to answer the questionnaire due to cognitive disabilities and lack of language knowledge.

Results and conclusions

207/391 (53?%) data sets were available for analysis, presenting a typical trauma collective with injury severity of ISS 19, predominantly male and a mean age of 44 years. 2 years after trauma 59?% still reported that they suffered from severe persisting pain; 53?% of these patients were under pharmacological pain medication. Only 1/5 of the patients with severe persisting pain was treated by a pain specialist. Successful treatment options do exist; improvement of treatment is required.

     

Schmerzverlauf nach operativer orthopädischer Intervention

Background

The number of cases of orthopedic surgery is still increasing and postoperative pain management is of great importance for the patients. Therefore, in this study factors influencing the pain and the developement of pain in general in the first 7 days after total knee arthroplasty were examined.

Material and methods

A total of 28 patients were included in this prospectively designed trial and underwent total knee arthroplasty with psoas compartment and sciatic nerve regional anesthesia and additionally propofol sedation. Postoperative pain scores were documented using a numerical rating scale (NRS) and anthropometric data and perioperative parameters were correlated with the postoperative pain score.

Results

Evaluation of the pain values per interval showed that the maximum and the mean postoperative pain levels decreased up to day 4 after surgery and then increased. No significant effects of the analyzed parameters age, body mass index (BMI), duration of surgery and catheter indwelling time could be found. Female patients had significantly more pain than males in this collective.

Conclusion

The results show that there were no factors which have a significant influence on the degree of postoperative pain. Female patients suffered from more pain than males. There was an increase in pain after postoperative day 4 which might be the effect of more extensive mobilization and reduced effects of regional anesthesia. It is important that pain is treated in the early postoperative period.

     

Oxycodon,Piritramid und Tramadol zur postoperativen Schmerztherapie

Background

In the context of improving perioperative pain management and shortening hospital stays, potent oral analgesics, such as slow release opioids, are gaining increasingly in importance.

Objective

The aim of this study was to compare the use and effectiveness of different opioids in postoperative pain treatment in Germany.

Materials and methods

Using data from the QUIPS database, the records of 5249 patients were evaluated. The total study population was divided into four groups: group 1 (10?mg oxycodone with or without naloxone 5?mg), group 2 (20?mg oxycodone with or without naloxone 10?mg), group 3 (piritramide) and group 4 (tramadol). Maximum pain intensity, pain-related interference with sleep and respiration, vomiting, postoperative fatigue, desire for more pain treatment and satisfaction with pain management were evaluated.

Results and discussion

The differences in pain intensity were statistically significant between groups. Patients with piritramide reported more pain, more interference with sleep and respiration and more fatigue compared to those from the other groups. In the group with 10?mg oxycodone, the desire for additional pain medication was the lowest. Postoperative vomiting and satisfaction with pain management differed significantly between the four groups. Procedure-specific analysis has shown that differences between sub-groups were also significant following cholecystectomy and total knee arthroplasty.

Conclusions

In summary, our findings suggest that postoperative pain treatment with slow release oral oxycodone does not show disadvantages compared to tramadol or piritramide with regard to pain-related impairments and opioid-induced side effects. This hypothesis needs to be further analyzed in controlled studies.

     

Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship

Purpose of Review

We performed a systematic review to elucidate the current guidelines on weaning patients from opioids in the post-operative ambulatory surgery setting, and how pain management intraoperatively can impact this process.

Design

The review highlights the most up-to-date research from clinical trials, patient reports, and retrospective studies regarding both the current guidelines and weaning of opioid analgesia in ambulatory surgery setting.

Recent Findings

A striking paucity of convincing evidence exists on ambulatory postoperative pain management discontinuation or weaning of pain medications. However, retrospective and patient-reported studies suggest our approach should be similar to acute pain management strategies. The first steps include identifying high-risk patients and devising an appropriate pain plan. This may be accomplished by implementing multimodal analgesia, anticipating opioid needs, and the proper use of regional anesthesia. The increasing roles for Transitional Pain Service (TPS), Perioperative Surgical Home (PSH), and Enhanced Recovery After Surgery (ERAS) may also guide us in this process.

Summary

Patients discharged from same-day surgery may lack the additional infrastructure of a hospital or medical establishment to monitor postoperative recovery. As such, weaning of pain medications in ambulatory surgery settings requires teams that are adept at treating varied patient populations through a tailored, novel means that invoke multimodal analgesia. Given the growth of surgeries moving toward the ambulatory sector, more data and practice guidelines are needed to direct postoperative pain regimen titration for the patients.

     

Mobilitätseinschränkungen bei Altenheimbewohnern

Background

Pain, restriction of mobility and cognitive impairment are often present in old age and intensify each other.

Objectives

Is there a relationship between mobility, pain, cognitive capacity, diagnoses and number of prescribed medication for residents of nursing homes?

Methods

Subgroup analysis of the baseline data from an intervention study for optimization of the medication safety of 120 nursing home residents.

Results

Pain was presumed in 77.8% of the residents. Persons with cognitive impairment were more frequently affected. The results of the observational and self-reported pain assessment in cognitively impaired patients did not agree for two-thirds of the cases. A correlation between prevalence of pain, pain intensity and mobility could only be shown for persons without cognitive impairment. Half of the persons were unable to walk; 80% of the residents with analgesics as a permanent medication were more restricted in their mobility.

Conclusions

Cognitive impairment is associated with pain and reduced mobility, whereby self-rated pain did not concur with the observational pain assessment for two-thirds of the residents with cognitive impairment. This illustrates the difficulty of observational pain assessment.

     

Auftreten von Obstipation bei Patienten mit ambulanter Opioidtherapie

Background

Constipation is a common complication in patients with opioid therapy. Additionally, patient-related risk factors also contribute to the development of constipation and these factors have to be integrated into an individualized treatment plan.

Objective

The aim of this study was to assess the incidence of constipation in patients with opioid therapy in an outpatient setting and to analyze the risk factors that contribute to the development of constipation.

Material and methods

This retrospective cohort study was conducted in two university affiliated outpatient departments at the Charité hospital in Berlin. The trial included all consecutively treated patients with opioid therapy of at least 4 weeks duration. The study was conducted from January 2013 to August 2013. Constipation was defined according to the Rome III criteria.

Results

Out of 1166 screened patients, altogether 171 patients were included with a median duration of opioid therapy of 5 years. The most common diagnoses were back pain, musculoskeletal pain and neuropathic pain. In 14?% of the treated patients symptoms of constipation were detected and another 35?% needed laxatives for symptom control resulting in an overall incidence of constipation of 49?%. The remaining 51?% of the patients did not use any laxatives and did not experience symptoms of constipation. Age and dosing of opioid therapy significantly increased the risk of consipation but duration of opioid therapy was not related to the incidence of constipation.

Discussion

The incidence of constipation in this population remains high although a relevant number of patients were intermittently free of symptoms without using laxatives. An individualized therapy plan and patient education seem to be important elements to control opioid-associated constipation.

     

Estimating the Effect of Intravenous Acetaminophen for Postoperative Pain Management on Length of Stay and Inpatient Hospital Costs

Introduction

The provision of safe, effective, cost-efficient perioperative inpatient acute pain management is an important concern among clinicians and administrators within healthcare institutions. Overreliance on opioid monotherapy in this setting continues to present health risks for patients and increase healthcare costs resulting from preventable adverse events. The goal of this study was to model length of stay (LOS), potential opioid-related complications, and costs for patients reducing opioid use and adding intravenous acetaminophen (IV APAP) for management of postoperative pain.

Methods

Data for this study were de-identified inpatient encounters from The Advisory Board Company across 297 hospitals from 2012–2014, containing 2,238,433 encounters (IV APAP used in 12.1%). Encounters for adults ≥18 years of age admitted for cardiovascular, colorectal, general, obstetrics and gynecology, orthopedics, or spine surgery were included. The effects of reducing opioids and adding IV APAP were estimated using hierarchical statistical models. Costs were estimated by multiplying modeled reductions in LOS or complication rates by observed average volumes for medium-sized facilities, and by average cost per day or per complication (LOS: US$2383/day; complications: derived from observed charges).

Results

Across all surgery types, LOS showed an average reduction of 18.5% (10.7–32.0%) for the modeled scenario of reducing opioids by one level (high to medium, medium to low, or low to none) and adding IV APAP, with an associated total LOS-related cost savings of $4.5 M. Modeled opioid-related complication rates showed similar improvements, averaging a reduction of 28.7% (5.4–44.0%) with associated cost savings of $0.2 M. In aggregate, costs decreased by an estimated $4.7 M for a medium-sized hospital. The study design demonstrates associations only and cannot establish causal relationships. The cost impact of LOS is modeled based on observed data.

Conclusions

This investigation indicates that reducing opioid use and including IV APAP for postoperative pain management has the potential to decrease LOS, opioid-related complication rates, and costs from a hospital perspective.

Funding

Mallinckrodt Pharmaceuticals.

     

Techniques to Optimize Multimodal Analgesia in Ambulatory Surgery

Purpose of Review

Ambulatory surgery has grown in popularity in recent decades due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. We review common approaches to multimodal analgesia.

Recent Findings

A multimodal approach can help reduce perioperative opioid requirements and improve patient recovery. Analgesic options may include NSAIDs, acetaminophen, gabapentinoids, corticosteroids, alpha-2 agonists, local anesthetics, and the use of regional anesthesia.

Summary

We highlight important aspects related to pain management in the ambulatory surgery setting. A coordinated approach is required by the entire healthcare team to help expedite patient recovery and facilitate a resumption of normal activity following surgery. Implementation and development of standardized analgesic protocols will further improve patient care and outcomes.

     

Schmerztherapie bei Kindern und Jugendlichen mit Hämophilie

Background

Children and adolescents with severe hemophilia commonly suffer from acute and chronic pain as a consequence of hemophilia-related bleeding. Intervention-related pain also plays a major role. Despite its high prevalence in this patient group, hemophilia-related pain is not always adequately addressed and sufficiently treated.

Objectives

This paper discusses how to improve pain management for children and adolescents (0–18 years) with hemophilia and which specific features in this population should influence decisions in pain management.

Materials and methods

An expert panel discussed challenges in pain treatment in children and adolescents with hemophilia. Recommendations are based on evidence and clinical experience.

Result

Pain management in children with hemophilia needs improvement. Children with hemophilia are at risk of developing chronic pain and of suffering traumatization due to insufficient pain management. Pain therapy can be challenging in these children as both their age and the underlying disease limit the options in particular in pain medication. The expert panel developed recommendations to improve pain management in children with hemophilia.