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American Journal of Obstetrics and... Mar 2022There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies...
BACKGROUND
There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited.
OBJECTIVE
To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain.
STUDY DESIGN
This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant.
RESULTS
During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001).
CONCLUSION
Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.
Topics: Analgesics, Opioid; Female; Humans; Male; Morphine; Opioid-Related Disorders; Pain Management; Pain, Postoperative; Pregnancy; Prospective Studies; Retrospective Studies
PubMed: 34534504
DOI: 10.1016/j.ajog.2021.09.003 -
The Western Journal of Emergency... Feb 2020Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies... (Review)
Review
Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies comparing tenecteplase and alteplase suggest that tenecteplase is at least as efficacious as alteplase with regards to neurologic improvement. When given at 0.25 milligrams per kilogram (mg/kg), tenecteplase may have less bleeding complications than alteplase as well. This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.
Topics: Acute Disease; Brain Ischemia; Fibrinolytic Agents; Humans; Infusions, Intravenous; Tenecteplase; Treatment Outcome
PubMed: 32191176
DOI: 10.5811/westjem.2020.1.45279 -
OTA International : the Open Access... Dec 2022Fragility fractures (low-energy, minimal-trauma fractures) are common in the aging population and can lead to decreased function, increased mortality, and long-lasting... (Review)
Review
Fragility fractures (low-energy, minimal-trauma fractures) are common in the aging population and can lead to decreased function, increased mortality, and long-lasting pain. Although opioids are helpful in reducing acute postoperative pain, they present risks that may lead to increased morbidity and mortality. This was a retrospective review of medical records of all Alaska Native and American Indian people older than 50 years, who received surgery for hip fracture repair between January 2018 and June 2019 (n = 128). We found that receipt of a peripheral nerve block (PNB) is a predictor for decreased length of hospital stay. However, receipt of PNB did not predict a reduction in postoperative morphine milligram equivalents opioid doses. Further study is required to determine whether one PNB method is superior to others based on individual-level characteristics.
PubMed: 36569104
DOI: 10.1097/OI9.0000000000000207 -
Journal of Minimally Invasive Gynecology Feb 2021To assess the impact of abdominal ice packs on opioid use and pain control after laparoscopic hysterectomy DESIGN: Randomized controlled trial. (Randomized Controlled Trial)
Randomized Controlled Trial
STUDY OBJECTIVE
To assess the impact of abdominal ice packs on opioid use and pain control after laparoscopic hysterectomy DESIGN: Randomized controlled trial.
SETTING
Academic tertiary care medical center.
PATIENTS
Total of 142 adult women undergoing laparoscopic (either conventional or robotic) hysterectomy were randomized to control (n = 69) or intervention (n = 73). Exclusion criteria included preoperative opioid use, planned intensive care unit admission or same-day discharge, an incision ≥4 cm, and regional anesthesia use.
INTERVENTIONS
Subjects in the intervention group had a large ice pack placed directly on the lower abdomen before leaving the operating room. The ice pack was maintained continuously for 12 hours postoperation, as desired thereafter until discharge, and continued use encouraged after discharge for up to 48 hours.
MEASUREMENTS AND MAIN RESULTS
Total opioids administered postoperatively, while inpatient and after dismissal, were assessed in morphine milligram equivalents. Postoperative pain, as well as analgesia acceptability and side effects, were assessed using validated measures: Brief Pain Inventory and Overall Benefit of Analgesia Score. Median morphine milligram equivalent was lower in the intervention group than the controls from inpatient stay on the floor to completion of opioid use as an outpatient (22.5 vs 26.2) but was not statistically significant (p = .79). There was no significant difference between the groups in Brief Pain Inventory assessment of postoperative pain severity (p = .80) or pain interference (p = .36) or Overall Benefit of Analgesia Score total score (p = .88). Most patients in the intervention group were very satisfied with ice pack use (n = 51, 79.7%) and very likely to recommend it to friends or family (n = 54, 83.1%). There were no adverse events related to ice pack use.
CONCLUSION
There was no significant difference in postoperative opioid use or pain assessment with ice pack use after laparoscopic hysterectomy. However, most of the subjects expressed high satisfaction specific to ice pack use and would recommend its use to others, suggesting potential desirability as adjunct therapy in postoperative pain control.
Topics: Abdomen; Abdominal Muscles; Adult; Aged; Analgesics, Opioid; Cryotherapy; Female; Humans; Hysterectomy; Ice; Laparoscopy; Middle Aged; Morphine; Pain Management; Pain Measurement; Pain, Postoperative; Postoperative Period
PubMed: 32622918
DOI: 10.1016/j.jmig.2020.06.027 -
Journal of Clinical Sleep Medicine :... Apr 2023The development of restless legs syndrome (RLS) has been rarely reported during and following opioid withdrawal. We aimed to determine the presence and severity of RLS...
STUDY OBJECTIVES
The development of restless legs syndrome (RLS) has been rarely reported during and following opioid withdrawal. We aimed to determine the presence and severity of RLS symptoms during and after supervised opioid tapering.
METHODS
Ninety-seven adults enrolled in the Mayo Clinic Pain Rehabilitation Center who underwent supervised prescription opioid tapering were prospectively recruited. RLS presence and severity was assessed with the Cambridge-Hopkins Questionnaire 13 and International Restless Legs Syndrome Study Group Rating Severity Scale at admission, midpoint, and dismissal from the program as well as 2 weeks, 4 weeks, and 3 months after completion. Frequency and severity of RLS symptoms were compared between admission and each time point.
RESULTS
Average age of the cohort was 52.6 ± 13.3 years with a morphine milligram equivalent dose for the cohort of 45.6 ± 48.3 mg. Frequency of RLS symptoms increased from 28% at admission to peak frequency of 41% at 2 weeks following discharge from the Mayo Pain Rehabilitation Clinic ( = .01), returning to near baseline frequency 3 months after opioid discontinuation. International Restless Legs Syndrome Study Group Rating Severity Scale increased from baseline and then remained relatively stable at each time point following admission. Thirty-five (36.1%) participants developed de novo symptoms of RLS during their opioid taper, with those being exposed to higher morphine milligram equivalent doses having higher risk of developing RLS.
CONCLUSIONS
Moderately severe symptoms of RLS, as assessed by survey, occur commonly in individuals undergoing opioid tapering, particularly if exposed to higher doses. In many cases, symptoms appear to be self-limited, although a minority develop persistent symptoms. Our results may have implications for successful opioid tapering, but future confirmatory studies with structured clinician interview are needed to establish that these symptoms truly represent restless legs syndrome given the potential for RLS-mimicking symptoms in individuals with chronic pain syndromes.
CITATION
McCarter SJ, Labott JR, Mazumder MK, et al. Emergence of restless legs syndrome during opioid discontinuation. . 2023;19(4):741-748.
Topics: Adult; Humans; Middle Aged; Aged; Analgesics, Opioid; Restless Legs Syndrome; Pain; Surveys and Questionnaires; Severity of Illness Index; Morphine Derivatives
PubMed: 36692170
DOI: 10.5664/jcsm.10436 -
American Journal of Preventive Medicine Oct 2021This study assesses the associations between the recent implementation of robust features of state Prescription Drug Monitoring Programs and the abrupt discontinuation...
INTRODUCTION
This study assesses the associations between the recent implementation of robust features of state Prescription Drug Monitoring Programs and the abrupt discontinuation of long-term opioid therapies.
METHODS
Data were from a national commercial insurance database and included privately insured adults aged 18-64 years and Medicare Advantage enrollees aged ≥65 years who initiated a long-term opioid therapy episode between Quarter 2 of 2011 and Quarter 2 of 2017. State Prescription Drug Monitoring Programs were characterized as nonrobust, robust, and strongly robust. Abrupt discontinuation was measured on the basis of high daily morphine milligram equivalents over the last 30 days of a long-term opioid therapy episode or no sign of tapering before discontinuation. Difference-in-differences models were estimated in 2019‒2020 to assess the association between robust Prescription Drug Monitoring Programs and abrupt discontinuation.
RESULTS
Among nonelderly privately insured adults, robust Prescription Drug Monitoring Programs were associated with an increase from 14.8% to 15.4% (4% relative increase, p=0.02) in the rate of ending long-term opioid therapy with ≥60 daily morphine milligram equivalents. For older Medicare Advantage enrollees, strongly robust Prescription Drug Monitoring Programs were associated with a reduction from 4.8% to 4.3% (10.4%, p=0.01) and from 3.0% to 2.4% (17.3%, p=0.001) in the rate of ending long-term opioid therapy with ≥90 and 120 daily morphine milligram equivalents, respectively. Prescription Drug Monitoring Programs robustness was not associated with clinically meaningful changes in the rate of discontinuing long-term opioid therapy without tapering.
CONCLUSIONS
Discontinuation without tapering was the norm for long-term opioid therapies in the samples throughout the study years. Findings do not support the notion that policies aimed at enhancing Prescription Drug Monitoring Program use were associated with substantial increases in abrupt long-term opioid therapy discontinuation.
Topics: Aged; Analgesics, Opioid; Humans; Medicare; Policy; Prescription Drug Monitoring Programs; United States
PubMed: 34233856
DOI: 10.1016/j.amepre.2021.04.019 -
International Journal of Medical... Mar 2022The national increase in opioid use and misuse has become a public health crisis in the U.S. To tackle this crisis, the systematic evaluation and monitoring of opioid...
BACKGROUND
The national increase in opioid use and misuse has become a public health crisis in the U.S. To tackle this crisis, the systematic evaluation and monitoring of opioid prescribing patterns is necessary. Thus, opioid prescriptions from electronic health records (EHRs) must be standardized to morphine milligram equivalent (MME) to facilitate monitoring and surveillance. While most studies report MMEs to describe opioid prescribing patterns, there is a lack of transparency regarding their data pre-processing and conversion processes for replication or comparison purposes.
METHODS
In this work, we developed Opioid2MME, a SQL-based open-source framework, to convert opioid prescriptions to MMEs using EHR prescription data. The MME conversions were validated internally using F-measures through manual chart review; were compared with two existing tools, as MedEx and MedXN; and the framework was tested in an external academic EHR system.
RESULTS
We identified 232,913 prescriptions for 49,060 unique patients in the EHRs, 2008-2019. We manually annotated a sample of prescriptions to assess the performance of the framework. The internal evaluation for medication information extraction achieved F-measures from 0.98 to 1.00 for each piece of the extracted information, outperforming MedEx and MedXN (F-Scores 0.98 and 0.94, respectively). MME values in the internal EHR system obtained a F-measure of 0.97 and identified 3% of the data as outliers and 7% missing values. The MME conversion in the external EHR system obtained 78.3% agreement between the MME values obtained with the development site.
CONCLUSIONS
The results demonstrated that the framework is replicable and capable of converting opioid prescriptions to MMEs across different medical institutions. In summary, this work sets the groundwork for the systematic evaluation and monitoring of opioid prescribing patterns across healthcare systems.
PubMed: 35325663
DOI: 10.1016/j.ijmedinf.2022.104739 -
International Urogynecology Journal Aug 2023Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption...
INTRODUCTION AND HYPOTHESIS
Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption greater than the median.
METHODS
This was a prospective cohort study of 18- to 89-year-old women undergoing major urogynecological surgery between 1 November2020 and 15 October 2021. Subjects completed one preoperative questionnaire ("questionnaire 1") that surveyed factors expected to influence postoperative pain and opioid use. At approximately 1 and 2 weeks following surgery, patients completed two additional questionnaires ("questionnaire 2" and "questionnaire 3") about their pain scores and opioid use. Risk factors for opioid use greater than the median were assessed. Finally, a calculator was created to predict the amount of opioid used at 1 week following surgery.
RESULTS
One hundred and ninety patients were included. The median amount of milligram morphine equivalents prescribed was 100 (IQR 100-120), whereas the median amount used by questionnaire 2 was 15 (IQR 0-50) and by questionnaire 3 was 20 (IQR 0-75). On multivariate logistic regression, longer operative time (aOR 1.64 per hour of operative time, 95% CI 1.07-2.58) was associated with using greater than the median opioid consumption at the time of questionnaire 2; whereas for questionnaire 3, a diagnosis of fibromyalgia (aOR=16.9, 95% CI 2.24-362.9) was associated. A preliminary calculator was created using the information collected through questionnaires and chart review.
CONCLUSIONS
Patients undergoing surgery for pelvic floor disorders use far fewer opioids than they are prescribed.
Topics: Humans; Female; Adolescent; Young Adult; Adult; Middle Aged; Aged; Aged, 80 and over; Analgesics, Opioid; Prospective Studies; Pelvic Floor Disorders; Surgery, Plastic; Pain, Postoperative; Practice Patterns, Physicians'
PubMed: 36708404
DOI: 10.1007/s00192-022-05428-7 -
Surgery Aug 2021Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused...
BACKGROUND
Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused prescribed opioids. We hypothesized that an opioid buyback program would motivate patients to return unused opioids, and surgeons will use that data to calibrate prescribing.
METHODS
Prospective cohort study of postambulatory surgery pain management at a level II Veterans Affairs rural hospital (2017-2019). Eligible patients were offered $5/unused opioid pill ($50 limit) returned to our Veterans Affairs hospital for proper disposal. After 6 months, buyback data was shared with each surgical specialty.
RESULTS
Overall, 934 of 1,880 (49.7%) eligible ambulatory surgery patients were prescribed opioids and invited to participate in the opioid buyback. We had 281 patients (30%) return 3,165 unused opioid pills; this return rate remained constant over the study period. In 2017, 62.4% of patients were prescribed an opioid; after data was shared with providers, prescriptions for opioids were reduced to 50.7% and 38.3% of eligible patients in 2018 and 2019, respectively (P < .0001). The median morphine milligram equivalents prescribed also decreased from 108.8 morphine milligram equivalents in 2017 to 75.0 morphine milligram equivalents in 2018 and sustained at 75.0 morphine milligram equivalents in 2019 (P < .001). Surgical providers, surgeries performed, patient characteristics, and 30-day refill rates were similar throughout the study period.
CONCLUSION
A small financial incentive resulted in patients returning unused opioids after ambulatory surgery. Feedback to surgeons regarding opioids returned reduced the proportion of patients prescribed an opioid and the amount of opioid after ambulatory surgery without an increase in refills.
Topics: Adult; Aged; Aged, 80 and over; Ambulatory Surgical Procedures; Analgesics, Opioid; Female; Humans; Male; Middle Aged; Motivation; Pain Management; Pain, Postoperative; Practice Patterns, Physicians'; Prescription Drug Monitoring Programs; Prospective Studies
PubMed: 33676733
DOI: 10.1016/j.surg.2021.01.016 -
Journal of Education & Teaching in... Jul 2022The lecture and infographic are targeted towards Emergency Medicine physicians and residents.
AUDIENCE
The lecture and infographic are targeted towards Emergency Medicine physicians and residents.
INTRODUCTION
Pain is the most common presenting symptom in the emergency department.1 Various classes of medications are used to treat acute and chronic pain. Specifically, opiate medications are often used to relieve moderate to severe pain. About 20% of patients presenting with the chief complaint of non-cancer pain receive an opioid prescription.2 Since there are many different types of opiates, conversion between one opioid to another has provided a great challenge in terms of addressing the balance between adequately controlling patients' pain and preventing serious adverse effects. The lack of a readily available standard opiate equivalent guide and physicians' limited knowledge base about morphine milligram equivalents may contribute to medication errors, insufficient treatment, addiction, and overdose.
EDUCATIONAL OBJECTIVES
The primary aim of this study was to educate residents and attending physicians about opiate equivalent medications, medication metabolism, provide usual dosages, and to provide a standardized method for converting between various opiate medications in the emergency department (ED). By the end of this session, the learner will be able to: 1) define the term, "morphine milligram equivalents;" 2) describe the relative onset and duration of action of different pain medications often used in the emergency department; and 3) convert one opioid dose to another.Additionally, we aimed to evaluate the efficacy of the lecture and the infographic in increasing physicians' knowledge base of opioid medications and standardize the method of prescribing and converting between opioids in the ED. We designed and placed a simple, eye-catching infographic in the University of California, Irvine Emergency Department that depicted information pertaining to morphine equivalents and pharmacological properties of the opioids. We then presented a lecture on morphine equianalgesic doses, metabolism, and method for conversion between medications. In order to evaluate the functionality of the lecture and chart, we administered multiple surveys to ED providers pre- and post-lecture and placement of the chart in the ED. Our lecture and infographic included up-to-date literature and considered dose reductions, cross tolerance, and patient comorbidities. We designed the infographic to be visually appealing and simple for ease of use in a busy ED environment.
EDUCATIONAL METHODS
A lecture was designed to educate emergency department physicians and residents on the properties, metabolism and techniques for conversion between various opioid medications. Following the lecture, we walked through an example question with the participants. The lecture was presented at an Emergency Department conference.
RESEARCH METHODS
This lecture was presented at emergency medicine residency grand rounds. To evaluate the efficacy of our chart and educational lecture, we implemented a pre-presentation survey consisting of questions related to opiate conversions, metabolism, and medication characteristics without the help of the chart. After the presentation participants were once again asked to fill out the same set of questions on a post-presentation survey with the help of the chart. The effectiveness of the lecture and infographic was assessed by comparing participants' scores between the pre-presentation survey and post-presentation survey. A second post-presentation survey with the same set of questions was also sent out about 7 months after the presentation, to assess for retention of the information presented during the lecture. The responses were kept anonymous, though participants were asked for their level of training and four screening questions for the purpose of matching individual responses between the pre-presentation, initial post-presentation, and 7-month post-presentation surveys.
RESULTS
Seven initial post-presentation survey responses were matched to pre-presentation survey responses, while five 7-month post-presentation survey responses were matched to pre-presentation survey responses. Only one participant filled out all three surveys; this participant was found to have increased in score from pre-presentation survey (4/10) to immediate post-presentation survey (10/10), but decreased in score at the 7-month post-presentation survey (8/10). Five of the participants who filled out both the pre- presentation survey and immediate post-presentation survey showed improvement in their scores, one participant received the same score on both surveys, and one participant had a decrease in score. Between the five participants who filled out the pre-presentation survey and the 7-month post-presentation survey, one participant showed an increase in scores, two participants received the same score each time, and two participants decreased in scores.
DISCUSSION
Overall, the educational content and infographic allowed for improvement in a majority of the participants' scores between the pre-presentation survey and immediate post-presentation survey. However, it seems that retention of knowledge gained by the presentation waned as time passed, which manifested in most participants showing a decrease or no change in score between the pre-presentation survey and the 7-month post-presentation survey. In other words, through implementation of the infographic in the Emergency Department and educational lecture, we learned that the presentation and the walk-through of an example question contributed to immediate retention of knowledge of morphine equivalents. However, long-term retention of the knowledge about morphine equivalents was lacking. Given the small sample size of eleven participants, we are unable to definitively conclude whether this infographic and lecture are overall effective in improving knowledge, retention of knowledge, and change in clinical management. However, our results suggest that further larger studies could be conducted with the infographic and presentation as useful tools to advance EM physicians' knowledge and awareness of morphine milligram equivalents. Therefore, our hypothesis still stands that this infographic and lecture are useful tools that other EM programs could use and conduct studies to evaluate improvement in their learners' knowledge. The main takeaways are that educational lectures and visually-appealing graphics are able to enhance physicians' understanding of morphine equianalgesic doses in the immediate period after exposure, but must also be conducted with consistent follow-up to improve preservation of knowledge.
TOPICS
Morphine milligram equivalents, morphine equianalgesic doses, opioids, opiates, infographic.
PubMed: 37465775
DOI: 10.21980/J8RD29