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Background: Administrative healthcare databases, such as Medicare, are increasingly used to identify groups at risk of a crash. However, they only contain information on crash-related injuries, not all crashes. If the driver characteristics associated with crash and crash-related injury differ, conflating the two may result in ineffective or imprecise policy interventions. Methods: We linked 10 years (2008–2017) of Medicare claims to New Jersey police crash reports to compare the demographics, clinical diagnoses, and prescription drug dispensings for crash-involved drivers ≥ 68 years with a police-reported crash to those with a claim for a crash-related injury. We calculated standardized mean differences to compare characteristics between groups. Results: Crash-involved drivers with a Medicare claim for an injury were more likely than those with a police-reported crash to be female (62.4% vs. 51.8%, standardized mean difference [SMD] = 0.30), had more clinical diagnoses including Alzheimer's disease and related dementias (13.0% vs. 9.2%, SMD = 0.20) and rheumatoid arthritis/osteoarthritis (69.5% vs 61.4%, SMD = 0.20), and a higher rate of dispensing for opioids (33.8% vs 27.6%, SMD = 0.18) and antiepileptics (12.9% vs 9.6%, SMD = 0.14) prior to the crash. Despite documented inconsistencies in coding practices, findings were robust when restricted to claims indicating the injured party was the driver or was left unspecified. Conclusions: To identify effective mechanisms for reducing morbidity and mortality from crashes, researchers should consider augmenting administrative datasets with information from police crash reports, and vice versa. When those data are not available, we caution researchers and policymakers against the tendency to conflate crash and crash-related injury when interpreting their findings. [ABSTRACT FROM AUTHOR]

Purpose: Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures. Methods: A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24 h, highest in the first 24 h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24 h, discharge MME/day, total discharge MME, and opioid refills). Results: VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors. Conclusions: There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries. [ABSTRACT FROM AUTHOR]

Objectives: (1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity. Methods: This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors. Results: A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS. Conclusions for Practice: MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy. Significance: What is already known on this subject? The use of MOUD during pregnancy improves fetal outcomes, while antenatal exposure to MOUD increases the risk of NOWS. The severity of NOWS is influenced by MOUD type, co-exposures, adequacy of prenatal care, and the infant's gestational age. What this study adds? This study identifies factors that mediate the direct influence of antenatal MOUD exposure on the severity of NOWS and quantifies the degree to which this mediation influences outcomes in a large and geographically diverse population. Thus, providing clinicians with potential targets to improve care for this vulnerable population. [ABSTRACT FROM AUTHOR]

Purpose: The previous literature suggests that 25–30% of patients who undergo total knee arthroplasty (TKA) are using opioids prior to their surgery. This study aims to investigate the effect of preoperative opioid use on clinical outcomes and patient-reported outcome measures (PROMs) following TKA. Methods: We retrospectively reviewed 329 patients who underwent primary TKA from 2019 to 2020, answered the preoperative opioid survey, and had available PROMs. Patients were stratified into two groups based on whether they were taking opioids preoperatively or not: 26 patients with preoperative opioid use (8%) and 303 patients without preoperative opioid use (92%) were identified. Demographics, clinical data, and PROMs [Forgotten Joint Score (FJS-12), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR), and Veterans RAND-12 Physical and Mental components (VR-12 PCS and MCS)] were collected. Demographic differences were assessed with Chi-square and independent sample t-tests. Outcomes were compared using multilinear regression analysis, controlling for demographic differences. Results: Preoperative opioid users had a significantly longer length-of-stay (2.74 vs. 2.10; p = 0.010), surgical time (124.65 vs. 105.69; p < 0.001), and were more likely to be African-American (38.5 vs. 14.2%; p = 0.010) compared to preoperative opioid-naive patients. Postoperative FJS-12 did not statistically differ between the two groups. While preoperative KOOS, JR scores were significantly lower for preoperative opioid users (41.10 vs. 46.63; p = 0.043), they did not significantly differ postoperatively. Preoperative VR-12 PCS did not statistically differ between the groups; however, both 3-month (33.87 vs. 38.41; p = 0.049) and 1-year (36.01 vs. 44.73; p = 0.043) scores were significantly lower for preoperative opioid users. Preoperative VR-12 MCS was significantly lower for preoperative opioid users (46.06 vs. 51.06; p = 0.049), though not statistically different postoperatively. Conclusion: At 8%, our study population had a lower percentage of opioid users than previously reported in the literature. Preoperative opioid users had longer operative times and length of stay compared to preoperatively opioid-naive patients. While both cohorts achieved similar clinical benefits following TKA, preoperative opioid users reported lower postoperative scores with respect to VR-12 PCS scores. Level III Evidence: Retrospective Cohort. [ABSTRACT FROM AUTHOR]

Objectives: We aimed (1) to systematically review the efficacy of transdermal nicotine patches (NP) for postoperative analgesia, (2) to establish the current quality of evidence and assist clinical decision-making on the subject, and (3) to identify methodological limitations and the need for more well-designed studies. Materials and methods: We searched six electronic databases, protocol records, and other sources without date or language restriction until March 2022. To develop the search strategy, we formulated a clinical question by using the PICOD method. Eligibility criteria included randomised placebo-controlled trials on the analgesic potential of NP for surgical procedures. This systematic review followed the PRISMA 2020 statement, and we registered the protocol in PROSPERO (#CRD42020205956). Results: We included 10 randomised placebo-controlled trials (535 patients). The NP administered before induction of anaesthesia and at beginning of surgery reduced the pain immediately after surgery (−0.38; 95% confidence interval [CI]: −0.73 to −0.02), and 6 h (−0.34; 95% CI: −0.68 to −0.01), 12 h (−0.43; 95% CI: −0.71 to −0.15) and 24 h (−0.35; 95%CI: −0.59 to −0.10) after surgery, compared with the placebo patch (PP) group. Sensitivity testing suggests that opioid use could underestimate NP analgesia. Late demand for the first analgesic and consumption of rescue analgesics tended to be lower in the NP group. Conclusions: The current findings suggest, with low certainty of evidence, the analgesic potential of NP for surgical procedures. Clinical relevance: Perioperative use of NP significantly improved postoperative pain, even when opioids were administered or prescribed. Nevertheless, the clinical relevance should be interpreted with caution, owing to the effect sizes of the summary measures and methodological issues. The analgesic potential of NP as an adjuvant therapy to regulate pain and acute inflammation may offer certain clinical advantages, thus warranting further investigation. [ABSTRACT FROM AUTHOR]

Background: Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair, including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM.Methods: A retrospective review of all patients who underwent an open ventral hernia repair with retromuscular mesh between 2016 and 2020 was conducted. LOS was used as the primary outcome. Secondary outcomes included post-operative pain and 90-day post-operative complications.Results: An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min; P < 0.05) and larger area of mesh (461.85 vs. 338.17 cm2; P < 0.05) when compared to the TAP block group. Hospital LOS was significantly shorter for the TAP block group compared to the epidural group (4.22 vs. 5.62 days; P < 0.05). There were no differences in post-operative complications between the groups. The epidural group reported significantly lower post-operative day one (POD1) pain scores measured on a 10-point scale, compared to the IVPM and TAP block groups (5.00 vs. 6.91 vs. 7.50; P < 0.05).Conclusion: Patients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs. [ABSTRACT FROM AUTHOR]

Background: Post-operative pain relief after abdominal operations is critical for patient satisfaction and rapid recovery. Narcotics have been a traditional part of postoperative analgesia, with transversus abdominis plane (TAP) block introduced recently. The aim of this study is to assess the efficacy of laparoscopic TAP block on postoperative pain control in patients undergoing minimally invasive adrenalectomy.Methods: This was an institutional review board-approved retrospective study. Parameters related to postoperative pain control were compared between patients who underwent robotic transabdominal lateral adrenalectomy with (after December 2018) or without laparoscopic TAP block (control group) (before December 2018) by one surgeon. Statistics were performed using Mann Whitney U and Chi-square tests.Results: There were 86 patients in the TAP and 83 patients in the control group. Groups were similar regarding demographic and clinical parameters. Despite the availability of intravenous acetaminophen to a higher percentage of patients in the control (31.3%) versus the TAP group (8.1%), 0-24 h lowest postoperative pain scores were significantly lower in the TAP group (P < 0.0001). In TAP versus control group, percentage of patients requiring narcotics and amount of narcotics used was lower (P = 0.04 vs P = 0.0004, respectively). Mainly due to less pain-related over-stay, percentage of patients requiring more than a day of hospital stay was less in the TAP (12%) versus control group (18%) (P = 0.01).Conclusion: To our knowledge, the utility of TAP block in patients undergoing minimally invasive adrenalectomy has not been reported in the past. This study shows that there may be benefits of laparoscopic TAP block in reducing post-operative narcotic usage while improving pain control in these patients. [ABSTRACT FROM AUTHOR]

Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered. [ABSTRACT FROM AUTHOR]

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention. [ABSTRACT FROM AUTHOR]

Purpose: To determine the effect of the Orthopaedic Trauma Association (OTA) pain management guidelines for acute musculoskeletal injuries on opioid prescription sizes, pain control, and refills. Methods: A prospective cohort study was performed at an academic urban level 1 trauma center. 90 patients undergoing outpatient orthopaedic trauma surgery were enrolled before and after the implementation of the OTA pain management guidelines. Adherence to guidelines, pain visual analog scale, and refills were recorded postoperatively and at the 2- and 6-week follow-up visit. Results: After implementation of the guidelines, the number of patients receiving oxycodone decreased from 100 to 27%, with these patients receiving the less potent hydrocodone, instead. The discharge morphine equivalent dose (MED) decreased from a median (interquartile range) of 225 (169–300) to 140 mg (140–210) (p < 0.001). More patients required refills in the guidelines group (42% vs. 20%), resulting in no difference in total MED prescribed (210 (140–280) vs. 225 (169–307)). Adherence to the guidelines occurred in 66% of patients. As-treated analysis of patients with adherent and non-adherent prescriptions found no detectable difference in pain control, number of opioid pills used, or refills at the 2-week and 6-week follow-up. Conclusions: In the midst of a national opioid crisis, adoption of the OTA's pain management guidelines for orthopaedic trauma surgery warrants further research to determine if it's implementation can reduce the size, variability, and duration of opioid prescriptions. Level of evidence: Level II, prospective cohort. [ABSTRACT FROM AUTHOR]

Glenohumeral osteoarthritis (GH-OA) is a common cause of shoulder pain and is characterized by articular cartilage thinning, glenoid bone loss and deformity, osteophytosis, and other associated changes. The prevalence is estimated to be between 85 and 94% in men and women over the age of 80 years. A diagnosis of GH-OA is established based on clinical history, physical examination, and radiographic assessments. Non-pharmacological treatment options may serve as adjuvants to other therapies and should be incorporated for a more holistic approach to management. Pharmacological treatments include oral agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids and antidepressants. The National Institute for Health and Care Excellence (NICE) UK guidelines recommend NSAIDS as the first-line drugs for OA; topical forms of some of these agents can also be used. However, clinical evidence is largely lacking for its use in GH-OA, although patients with other types of OA, especially the knee and hip, are using these products in efforts to relieve joint pain. Intra-articular injections such as platelet-rich plasma, cortisone, and hyaluronic acid are usually used to control symptoms in moderate to advanced arthritis or in non-surgical candidates. Other non-surgical treatment options include suprascapular nerve block and radiofrequency ablation, and these options have been studied on different levels of evidence. Furthermore, all these treatments have their own indications, contraindications, and adverse effects profiles. Surgical treatment of GH-OA is reserved for patients who do not respond to conservative management or who suffer from debilitating symptoms that severely impair their quality of life. Level of Evidence IV, review article [ABSTRACT FROM AUTHOR]

Introduction: Sternal fractures are debilitating due to intractable pain, constant fracture movement and limited range of motion (ROM) of the upper extremities (UE). Traditional treatment comprises mainly of pain control, delaying return to daily activities. Recently, sternal fixation has gained popularity. There is, however, a lack of literature demonstrating efficacy. We report our experience of traumatically fractured sternal fixation. Methods: Following IRB approval, a retrospective chart review was completed for all patients undergoing sternal fixation by a single trauma surgeon at our Level I trauma center. Basic demographics were obtained. Primary outcomes included average cumulative pain scores, total cumulative narcotic amounts and total number of pain medication agents utilized prior to and after sternal fixation. Secondary outcome included physical therapy UE ROM before and after surgery. Paired t tests were used for comparison; significance set at p < 0.05. Results: Thirteen patients underwent sternal fixation from 8/2016 to 2/2018. Average age was 54.4 ± 20.8 years; 54% were female. All patients experienced blunt trauma; average injury severity score was 15.8 ± 10.9 and abbreviated chest injury score was 2.5 ± 0.51. Average intensive care unit/hospital length of stay was 2.3/10.2 days. Average pain scores significantly improved by a score of 3.5 postoperatively (preoperative = 7.08 ± 2.3, postoperative = 3.54 ± 2.5; p = 0.001). Total pain medications required by sternal fixation patients significantly decreased by 1 medication postoperatively (preoperative = 4.2 medications, postoperative = 3.2 medications; p = 0.002). Average narcotic requirements significantly decreased by 7.59 morphine milligram milliequivalents (MME) after sternal fixation (preoperative amount = 71.78 MME, postoperative amount = 64.19 MME; p = 0.041). Every patient had limited UE ROM preoperatively; however, all but one patient resumed full UE ROM postoperatively (p < 0.001). There were no postoperative complications. Conclusions: Sternal fixation is a safe and effective procedure resulting in improved pain, decreased narcotic requirements, and faster recovery. [ABSTRACT FROM AUTHOR]

Background: Major lumbar spine surgery causes severe pain in the postoperative period. There are few studies regarding the effect of erector spinae plane block (ESPB) effect on lumbar surgery and its effect is still controversial. Therefore, the study aimed to investigate the effect of ultrasound-guided low thoracic ESPB on opioid consumption and postoperative pain score.Material and Methods: Seventy-eight patients undergoing elective open lumbar spine surgery were randomized into two groups. In ESPB group (n = 35) received ultrasound-guided ESPB and in the control group (n = 35), there was no block. Postoperative opioid consumption as morphine equivalent dose, numerical rating scale, mobilization time, discharge time and side effects, bolus deliveries, rescue analgesia doses were evaluated.Results: Total opioid consumption as morphine equivalent was higher in the control group than the ESPB group (p = 0.000). Compare with the control group, the numeric rating scale scores were lower in the ESPB group at the 6th, 12th, and 24th hours (p < 0.05). The patient-controlled analgesia button pressing number in the postoperative 24-h period was lower in the ESPB group (p = 0.000). In the postoperative 24-h period, the need for paracetamol in the ESPB group was lower and the difference between the groups was statistically significant (p = 0.008). Rescue analgesia (diclofenac) doses were higher in the control group (p < 0.05). There was no statistically significant difference in terms of side effects and mobilization times.Conclusion: ESPB is adequate for postoperative analgesia in patients undergoing lumbar spine surgery and can reduce opioid consumption compared with standard analgesia. [ABSTRACT FROM AUTHOR]

Background and Objective: Pain is highly prevalent among older people, and treatment is complicated because of comorbidities and polypharmacy. Among people with major neurocognitive disorder additional difficulties might arise. The aim of this study was to describe analgesic drug use in 2012 and 2017 and associated factors among older people with major neurocognitive disorder. Methods: In this register-based study, the Swedish Dementia Registry and the Swedish Prescribed Drug Register were combined in order to obtain data regarding analgesic drug use among older people with major neurocognitive disorder. One or more filled prescriptions during the timeframe of 6 months (1 July–31 December 2012 and 1 July–31 December 2017) defined drug use during the respective period. A comparison between 2012 and 2017 was made, including a total of 56,101 people (20,889 and 35,212 respectively) with a mean age of 81.9 and 82.7 years, respectively. Results: The overall use of analgesic drugs increased significantly from 41.6% of individuals to 46.0% between the years 2012 and 2017. Users of opioid analgesics (15.2% vs 17.3%) and paracetamol (37.0% vs 42.3%) increased, while the users of non-steroidal anti-inflammatory drugs (4.9% vs 2.7%) declined between the two data collections. Multiple logistic regression analyses were performed for different drugs and drug classes, and it was found that the use of opioids and paracetamol was associated with older age and a longer time since diagnosis. In contrast, non-steroidal anti-inflammatory drugs were associated with younger age and a shorter time since diagnosis. Conclusions: The results indicate that on a population level, pharmacological drug treatment has changed in line with guidelines between 2012 and 2017, with an increase in paracetamol and strong opioids and a decrease in non-steroidal anti-inflammatory drugs and tramadol. The relatively high prevalence of opioids warrants concern given the significant risk of adverse effects among older people with major neurocognitive disorder. [ABSTRACT FROM AUTHOR]

Background: Pain is undertreated in older populations. At the same time, increased use of opioids is of concern in the Western world. Aims: We sought to analyze temporal trends in musculoskeletal pain and prescribed analgesic treatment among community-dwelling people aged 75–95 years using cross-sectional cohort data spanning 20 years. Methods: The Helsinki Aging Study recruited random samples of people aged 75, 80, 85, 90, and 95 years in 1999, 2009, and 2019. In total, 5707 community-dwelling persons participated in the study. The participants reported their medical diagnoses, regular prescription medications, and the presence of back pain or joint pain within the last 2 weeks (never, sometimes, or daily). We compared analgesic use among participants reporting and not reporting musculoskeletal pain in 1999, 2009, and 2019. Results: Of the participants, 57–61% reported intermittent or daily musculoskeletal pain. The percentage receiving a prescribed daily analgesic increased from 9% in 1999 to 16% in 2019. The use of non-steroidal anti-inflammatory drugs (NSAIDs) decreased from 1999 to 2019, while the use of paracetamol increased from 2 to 11%. Opioids were taken by 2% in 1999 and 3% in 2019. Of those reporting daily musculoskeletal pain, 20%, 35%, and 32% received regular pain medication in 1999, 2009, and 2019, respectively. Conclusions: Pain remains undertreated in the community-dwelling older population, although the use of regular prescribed analgesics increased between 1999 and 2019. The use of NSAIDs has decreased, while the use of paracetamol has increased. Daily opioid use has remained modest. [ABSTRACT FROM AUTHOR]

Background. Sleep problems are common among chronic pain patients who take opioids. There are documented effects of opioids on sleep architecture; however, the long-term effects of opioids on sleep remain unknown. This study examined whether opioid-naïve participants have better sleep quality than current and previous chronic users of opioids. We also explored whether sleep differed between methadone and buprenorphine users, and whether amount of time since abstaining from opioids was associated with sleep quality. Method. Participants were 120 people with chronic pain (84.2% Caucasian, Mage = 42.0 years, SD = 11.44). They were in one of four groups of 30 participants each: (1) current users of methadone for opioid use disorder (OUD); (2) current users of buprenorphine for OUD; (3) a history of medication-assisted therapy for OUD but currently opioid-abstinent for at least 6 months; (4) those who have less than one month of cumulative lifetime opioids (opioid-naïve group). Only participants in group 1 and group 2 were taking opioids during the time of the study. Participants completed the Pittsburgh Sleep Quality Index and the SF-36. Results. A MANCOVA revealed that all three groups with current or previous opioid use (i.e., groups 1–3) differed significantly from the opioid-naïve group (group 4) on sleep quality, sleep duration, sleep disturbances, and daytime dysfunction after controlling for sleep medications (all p <.05). For group 1 (methadone users), 2 (buprenorphine users), and 3 (prolonged abstinence), there were no statistically significant differences between each group. There was also a significant relationship between opioid-abstinent weeks and sleep disturbances in the opioid-abstinent group (r = − 0.604, p <.001). Discussion. The results of this study suggest that opioids interfere with sleep quality, even after months of abstention. Further research into the long-term effects of opioids is warranted and may contribute further to the importance of addressing sleep problems in this population. [ABSTRACT FROM AUTHOR]

Purpose: Opioids are a mainstay for pain management after total joint arthroplasty (TJA). The prevalence and risk factors for prolonged opioid use after TJA are important to understand to help slow the opioid epidemic. We aim to summarize and evaluate the prevalence and time trend of prolonged opioid use after TJA and pool its risk factors.Methods: Following the preferred reporting items for systematic reviews and meta-analysis statement, we systematically searched PubMed, the Cochrane Library, and EMBASE, etc. from inception up to October 1, 2019. Cohort studies reporting risk factors for prolonged opioids use (≥ 3 months) after TJA were included. Studies characteristics, risk ratios (RR), and prevalence of prolonged opioid use were extracted and synthesized.Results: A total of 15 studies were published between 2015 and 2019, with 416,321 patients included. 12% [95%CI 10-14%] of patients had prolonged opioid use after TJA and its time trend was associated with median enrollment years (P = 0.0013). Previous opioid use (RR = 1.73; P < 0.001), post-traumatic stress disorder (RR = 1.34; P < 0.001), benzodiazepine use (RR = 1.38; P < 0.001), tobacco abuse (RR = 1.26; P < 0.001), fibromyalgia (RR = 1.51; P < 0.001), and back pain (RR = 1.34; P < 0.001) were the largest effective risk factors for prolonged use of opioids.Conclusions: To our knowledge, this is the first meta-analysis determining the risk factors of prolonged opioid use and characterizing its rate and time trend in TJA. Understanding risk factors for patients with higher potential for prolonged opioids use can be used to implement appropriate management strategies, reduce unsafe opioid prescriptions, and decrease the risk of prolonged opioid use after TJA. [ABSTRACT FROM AUTHOR]

Background: An important strategy to address the opioid overdose epidemic involves identifying people at elevated risk of overdose, particularly those with opioid use disorder (OUD). However, it is unclear to what degree OUD diagnoses in administrative data are inaccurate.Objective: To estimate the prevalence of inaccurate diagnoses of OUD among patients with incident OUD diagnoses.Subjects: A random sample of 90 patients with incident OUD diagnoses associated with an index in-person encounter between October 1, 2016, and June 1, 2018, in three Veterans Health Administration medical centers.Design: Direct chart review of all encounter notes, referrals, prescriptions, and laboratory values within a 120-day window before and after the index encounter. Using all available chart data, we determined whether the diagnosis of OUD was likely accurate, likely inaccurate, or of indeterminate accuracy. We then performed a bivariate analysis to assess demographic or clinical characteristics associated with likely inaccurate diagnoses.Key Results: We identified 1337 veterans with incident OUD diagnoses. In the chart verification subsample, we assessed 26 (29%) OUD diagnoses as likely inaccurate; 20 due to systems error and 6 due to clinical error; additionally, 8 had insufficient information to determine accuracy. Veterans with likely inaccurate diagnoses were more likely to be younger and prescribed opioids for pain. Clinical settings associated with likely inaccurate diagnoses were non-mental health clinical settings, group visits, and non-patient care settings.Conclusions: Our study identified significant levels of likely inaccurate OUD diagnoses among veterans with incident OUD diagnoses. The majority of these cases reflected readily addressable systems errors. The smaller proportion due to clinical errors and those with insufficient documentation may be addressed by increased training for clinicians. If these inaccuracies are prevalent throughout the VHA, they could complicate health services research and health systems responses. [ABSTRACT FROM AUTHOR]

Background: The perioperative care and postoperative period after laparoscopic hernia repair have not been well described. The aim of this study was to describe the postoperative course after laparoscopic parastomal hernia repair.Methods: This was a prospective cohort study including consecutive patients undergoing laparoscopic parastomal hernia repair. The outcomes of interest were patient-reported pain, nausea and fatigue, time to stoma function, length of stay (LOS), use of transversus abdominis plane (TAP) block and epidural analgesia, the cumulative dose of morphine equivalent analgesics during the first 5 postoperative days, and postoperative complications.Results: Forty patients were included, 20% had ileostomy and 80% colostomy. The mesh was placed according to Sugarbaker (87.5%) and keyhole (12.5%) technique. Twenty-two patients (55%) required peripheral nervous blockades postoperatively. The median number of days to stoma function was 3 days (range 2-3.8). The mean cumulative dose of morphine equivalent analgesics was 21.9 mg on the day of surgery, 27.8 mg on the first postoperative day (POD1), 23.9 on POD2, 17.3 mg on POD3, 15.3 mg on POD4, 8.9 mg on POD5, and 115.2 mg in total. The median LOS was 4 days (range 3-6). The incidence of postoperative complications was 25%.Conclusion: Laparoscopic parastomal hernia repair carried a high risk of complications. Further, analgesic treatment after surgery was insufficient, with high opioid requirements postoperatively, and more than half of the patients required peripheral nervous blockades, indicating that postoperative pain is a major issue in this patient group. Improved postoperative care for these patients is required. [ABSTRACT FROM AUTHOR]

Background: The increasing trend of opioid use for non-malignant pain among older people has raised concerns about whether opioids are used for appropriate indications. On the other hand, pain in patients with dementia may be undertreated. Aims: To examine the prevalence of and indications for daily opioid use among home care clients, and to determine opioid use differs between those with and without dementia. Methods: All home care clients aged ≥ 65 years using opioids daily (n = 282) were identified based on their first Resident Assessment Instrument–Home Care assessment in 2014. Exact indications for opioid use, the opioid substance used, the median duration of use, and changes in opioid medication within 12 months from study entry were obtained from the electronic medical records. Results: The prevalence of daily opioid use was 9.3%, and the median duration of use before the study entry was 357 days (interquartile range 126–719 days). The majority of clients continued to use opioids daily during the follow-up year. Vertebral osteoporotic fractures (21.6%), degenerative spinal disorders (20.9%), and osteoarthritis (20.6%) were the most common indications for opioid use. Buprenorphine was used more frequently in persons with dementia, but otherwise there were no differences between those with and without dementia. Discussion and conclusions: Home care clients use opioids for long periods of time for pain related mostly to musculoskeletal disorders, although the effectiveness of long-term opioid use is not clear. The lack of effective or suitable options for management of pain might explain the situation. [ABSTRACT FROM AUTHOR]

Purpose: Sub-optimal opioid prescribing and use is viewed as a major contributor to the growing opioid crisis. This study aims to systematically review the nature, process and outcomes of interventions to optimize prescribed medicines and reduce their misuse in chronic non-malignant pain (CNMP) with a particular focus on minimizing misuse of opiates. Methods: A systematic review of literature was undertaken. Search of literature using Medline, EMBASE and CINAHL databases from 2000 onwards was conducted. Screening and selection, data extraction and risk of bias assessments were undertaken by two independent reviewers. Narrative synthesis of the data was conducted. Results: A total of 21 studies were included in the review, of which three were RCTs. Interventions included clinical (e.g. urine drug testing, opioid treatment contract, pill count), behavioural (e.g. electrical diaries about craving), cognitive behavioural treatment and/or educational interventions for patients and healthcare providers delivered as a single or as a multi-component intervention. Medication optimization outcomes included aspects of misuse, abuse, aberrant drug behaviour, adherence and non-adherence. Although all evaluations showed improvement in medication optimization outcomes, multi-component interventions were more likely to consider and to have shown improvement in clinical outcomes such as pain intensity, quality of life, psychological states and functional improvement compared to single-component interventions. Conclusions: A well-structured CNMP management programme to promote medicines optimization should include multi-component interventions delivered by a multidisciplinary team of healthcare professionals and target both healthcare professionals and patients. There was heterogeneity in definitions applied and interventions evaluated. There is a need for the development of clear and consistent terminology and measurement criteria to facilitate better comparisons of research evidence. [ABSTRACT FROM AUTHOR]

Background: Evidence to guide clinical decision making for pain management in nursing home residents is scant. Objective: Our objective was to explore the extent of consensus among expert stakeholders regarding what analgesic issues should be prioritized for comparative-effectiveness studies of beneficial and adverse effects of analgesic regimens in nursing home residents. Methods: Two stakeholder panels (nurses only and a mix of clinicians/researchers) were engaged (n = 83). During a three-round online modified Delphi process, participants rated and commented on the need for new evidence on nonopioid analgesic regimens and opioid regimens, short-term adverse effects, long-term adverse effects, comorbid conditions, and other factors in the nursing home setting (9-point scale; 1 = not essential to 9 = very essential to obtain new evidence). The quantitative data were analyzed to determine the existence of consensus using an approach from the RAND/UCLA Appropriateness Method User's Manual. The qualitative data, consisting of participant explanations of their numeric ratings, were thematically analyzed by an experienced qualitative researcher. Results: For nursing home residents, evidence generation was deemed essential for opioids, gabapentin (alone or with serotonin norepinephrine reuptake inhibitors [SNRIs]), and nonsteroid anti-inflammatory drugs with SNRIs. Experts prioritized the following outcomes as essential: long-term adverse effects, including delirium, cognitive decline, and decline in activities of daily living (ADLs). Kidney disease and depression were deemed essential conditions to consider in studies of pain medications. Coprescribing analgesic regimens with benzodiazepines, sedating medications, serotonergic medications, and non-SNRI antidepressants were considered essential areas of study. Experts noted that additional study was essential in residents with moderate/severe cognitive impairment and limitations in ADLs. Conclusions: Stakeholder priorities for more evidence reflect concerns related to treating medically complex residents with complex drug regimens and included long-term adverse effects, coprescribing, and sedating medications. Carefully conducted observational studies are needed to address the vast evidence gap for nursing home residents. [ABSTRACT FROM AUTHOR]

Background: Chronic low back pain (CLBP) is a highly prevalent and disabling condition in the elderly, and yet it is undertreated and understudied in this patient population. Tapentadol is a central analgesic with an improved tolerability profile that may be particularly beneficial to the elderly CLBP. Methods: We performed an observational retrospective study to comparatively assess the efficacy and tolerability of tapentadol in young and elderly patients with severe CLBP. Sixtyfive young patients (< 65 years) and 87 elderly patients (≥ 65 years) were titrated on tapentadol extended release to their optimal dose (25–250 mg bid) over 1 month and, then, maintained at that dose for 3 months. The primary endpoint were changes from baseline in 24-h pain intensity on a 0–10 Numerical Rating Scale (NRS) at month-4 of treatment (titration plus maintenance periods). Patients were assessed for several efficacy and tolerability outcomes using a battery of scales and tests for neuropathic pain intensity, quality of life and sleep, and cognitive and gastrointestinal functions. Results: At pretreatment, young and elderly patients had similar pain intensities with younger patients presenting with more intense depressive and neuropathic pain symptoms, and lesser comorbidities and durations of pain (P < 0.05). Thirty-eight patients discontinued treatment because of adverse events occurring mostly during titration. Treatment with tapentadol was associated with comparable and clinically meaningful pain reductions in 24-h NRS from baseline to treatment month-4 both in young and elderly patients (− 5.3 ± 1.4 and – 4.8 ± 2.1; P < 0.01); a 50% pain relief was achieved in 66% and 58% of young and elderly patients. The percentage of patients with a neuropathic component decreased similarly in young and elderly patients (from 38 to 0% and from 19 to 3%; P < 0.01). Quality of life and sleep improved. The performances in global cognition and sustained attention tasks remained stable or improved across all age group. Conclusions: These findings indicate that tapentadol extended release maintains efficacy and good tolerability in CLBP patients with advancing age. [ABSTRACT FROM AUTHOR]

Breakthrough cancer pain (BTcP) is a variegated phenomenon, that often presents in different ways in each individual, and may change its presentation in the same individual during the course of disease. An appropriate assessment is fundamental for depicting the pattern of BTcP in individuals. This information is determinant for a personalised management of BTcP. The use of opioids as needed, is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective, providing analgesia in 5–15 min. The most controversial point regards the opioid dose to be used. The presence of tolerance suggests using a dose that is proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested using the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never-ending question. [ABSTRACT FROM AUTHOR]

Purpose Of Review: Therapeutic use, misuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain remain a major concern for physicians, the government, payers, and patients. The challenge remains finding effective diagnostic tools that can be clinically validated to eliminate or substantially reduce the abuse of controlled prescription drugs, while still assuring the proper treatment of those patients in pain. Urine drug testing still remains an important means of adherence monitoring, but questions arise as to its relevance and effectiveness. This review examines the role of UDT, determines its utility in current clinical practice, and investigates its relevance in current chronic pain management.Recent Findings: A review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Literature was searched from year 2000 to present examining the relevance and role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse. There are only a limited number of reviews and investigations on UDT, despite the fact that clinicians who prescribe controlled medications for chronic states commonly are expected to utilize UDT. Therefore, despite highly prevalent use, there is a limited publication base from which to draw in this present study. Regardless of experience or training background, physicians and healthcare providers can much more adequately assess opioid therapy with the aid of UDT, which often requires confirmatory testing by a laboratory for clinical and therapeutic prescribing decisions. It has become a strongly recommended aspect of pain care with controlled substances locally, regionally, and nationally. Incorporating UDT for all patients in whom chronic opioid therapy is undertaken is consistent with state and national guidelines and best practice strategies. Practice standards vary as to the frequency of UDT locally, regionally, and nationally, however. [ABSTRACT FROM AUTHOR]

Patients with co-morbid chronic pain and post-traumatic stress disorder (PTSD) pose significant treatment challenges. This study evaluated the effectiveness of an interdisciplinary pain rehabilitation program (IPRP) in improving pain and PTSD outcomes, as well as reducing medication use. In addition, the mediating effect of pain catastrophizing, which is theorized to underlie the pain and PTSD comorbidity, was examined. Participants included 83 completers of an IPRP with chronic pain and a provisional PTSD diagnosis. Significant improvements were found for pain outcomes, PTSD symptomatology, depressive symptoms, physical performance, and medication use (i.e., opioids and benzodiazepines). At discharge, 86.7% of participants reliably improved in at least one key measure of functioning and 50.6% demonstrated reliable improvement in PTSD symptomatology. Change in pain catastrophizing mediated improvements in pain interference and PTSD symptomatology. Results support the potential utility of an interdisciplinary pain treatment approach in the treatment of patients with comorbid pain and PTSD. [ABSTRACT FROM AUTHOR]

Background: Despite evidence that medications to treat opioid use disorder (OUD) are effective, most people who could benefit from this treatment do not receive it. This rapid review synthesizes evidence on current barriers and facilitators to buprenorphine/naloxone and naltrexone at the patient, provider, and system levels to inform future interventions aimed at expanding treatment.Methods: We systematically searched numerous bibliographic databases through May 2020 and selected studies published since 2014. Study selection, data abstraction, coding of barriers and facilitators, and quality assessment were first completed by one reviewer and checked by a second.Results: We included 40 studies of buprenorphine (5 also discussed naltrexone). Four types of patient and provider-level barriers to OUD medication use emerged-stigma related to OUD medications, treatment experiences and beliefs (positive or negative), logistical issues (time and costs as well as insurance and regulatory requirements), and knowledge (high or low) of OUD and the role of medications. Stigma was the most common barrier among patients, while logistical issues were the most common barriers among providers. Facilitators for both patients and providers included peer supports. Most administrator-identified or system-level barriers and facilitators fit into the category of logistical issues. We have moderate confidence in buprenorphine findings but low confidence in naltrexone findings due to the small number of studies.Discussion: Stigma, treatment experiences, logistical issues, and knowledge gaps are the main barriers associated with low utilization of OUD medications. These barriers can overlap and mutually reinforce each other, but given that, it is plausible that reducing one barrier may lead to reductions in others. The highest priority for future research is to evaluate interventions to reduce stigma. Other priorities for future research include better identification of barriers and facilitators for specific populations, such as those with OUD related to prescription opioids, and for naltrexone use.Protocol Registration: PROSPERO; CRD42019133394. [ABSTRACT FROM AUTHOR]

A downward trend in opioid prescribing between 2011 and 2018 has brought per-capita opioid prescriptions below the levels of 2006, the earliest year for which the Centers for Disease Control and Prevention has published data. That trend has affected roughly ten million patients who previously received long-term opioid therapy. Any effort to reduce or replace a prior health practice is termed de-implementation. We suggest that the evaluation of opioid prescribing de-implementation has been misdirected, within US policy and health research, resulting in detrimental impacts on patients, their families and clinicians. Policymakers and implementation scientists can address these deficiencies in how we study and how we perform opioid de-implementation by applying an implementation science framework: the Consolidated Framework for Implementation Research. The Consolidated Framework lays out relevant domains of activity (internal, external, etc.) that influence implementation processes and outcomes. It can deepen our understanding of how policies are chosen, communicated, and carried out. Policymakers and researchers who embrace this framework will need a better approach to measuring success and failure in health care where both pain and opioids are concerned. This would involve shifting from a reductive focus on opioid prescription counts toward measures that are more effective, holistic, and patient-centered. [ABSTRACT FROM AUTHOR]

Oliceridine (Olinvyk™, Trevena, Inc.) is a novel μ opioid agonist that was recently approved in the USA for use in adults for the management of acute pain severe enough to require an intravenous opioid analgesic and for whom alternative treatments are inadequate. Unlike opioid agonists currently in use, the interaction of oliceridine with the opioid receptor is selective to the G protein pathway, with low potency for β-arrestin recruitment, which may lead to fewer opioid-related adverse events. This article summarizes the milestones in the development of oliceridine leading to this first approval. [ABSTRACT FROM AUTHOR]

Background: Pain control after total knee replacement (TKR) is of primary importance to joint replacement surgeons to achieve good functional outcome post-surgery. This becomes even more challenging when these major procedures are done in immunocompromised patients like rheumatoid arthritis. Good peri-operative analgesia facilitates early rehabilitation, improves patient satisfaction, and reduces the hospital stay. The adverse effects caused by epidural analgesia or parenteral opioids can be avoided by replacing it with an analgesic cocktail locally. Our prospective study was to evaluate the benefits of a periarticular cocktail injection which was given in rheumatoid patients undergoing bilateral TKR in single sitting with respect to pain and knee motion recovery. Methods: Sixty-four rheumatoid arthritis patients undergoing simultaneous primary total knee replacement were included in the study. A total of 128 knees were randomized either to receive a periarticular intra-operative injection containing ropivacaine, fentanyl, clonidine, cefuroxime and epinephrine (Group A) on one knee and to receive plain ropivacaine (Group B) on the opposite knee. The perioperative and post-operative analgesic regimens were standardized. All patients received the same standard analgesia protocol. Visual analog scores for pain, knee range of motion and quadriceps function were recorded on the day of surgery, first post-operative day, second post-operative day, day of discharge, and 2 weeks and 6 weeks during follow-up. The need for rescue analgesic requirement and adverse effects to the cocktail injection were also noted during the study period. Results: The patients who received the periarticular cocktail fared better in terms of pain scores and functional recovery. Additional rescue agents used were significantly less at 6 h, at 12 h, and over the first 24 h after the surgery in group A when compared with group B. No cardiac or central nervous system toxicity was observed. Conclusions: Periarticular cocktail injection significantly reduces the requirements for post-operative analgesia and also improves patient satisfaction, with no apparent risks, following total knee arthroplasty in rheumatoid arthritis. [ABSTRACT FROM AUTHOR]

Restless legs syndrome (RLS; also known as Willis-Ekbom disease) is a common neurological, sensorimotor disorder. RLS is initially managed with lifestyle modifications, elimination of possible iatrogenic contributors and maintenance of normal-high peripheral iron stores. Moderate-to-severe RLS may be treated with pharmacological therapy, which generally involves the use of α-2-δ ligands (e.g. gabapentin enacarbil, pregabalin, gabapentin) and dopamine agonists (e.g. pramipexole, rotigotine, ropinirole), as well as opioids for treatment-resistant RLS. The chosen drug class/specific drug depends on patient factors (e.g. the most prominent symptoms, comorbidities, age-related issues, preferences) and drug factors (e.g. tolerability profile, augmentation risk). [ABSTRACT FROM AUTHOR]

Pain management in both outpatient and inpatient settings demands a multidisciplinary approach entailing medical, physical and psychological therapies. Among these, multimodal analgesic regimens stand out as a promising treatment options. Cyclo-oxygenase (COX) inhibitor/opioid receptor agonist combinations hold great potential as effective pillars in the multimodal pain management by providing adequate analgesia with fewer safety risks due to COX inhibitors' opioid-sparing effect. Thus, these combinations, either freely or in fixed-dose formulation, offer a feasible option for the prescribing clinicians who seek to maximise therapeutic effect while simultaneously minimise adverse effects. The selection of the appropriate non-steroidal anti-inflammatory drug (NSAID) and opioid agent at optimal doses is essential. It should be tailored to the patients' analgesic necessities, and his/her gastrointestinal and cardiovascular risk, and potential concurrent aspirin use. Moreover, it should allow for addiction risk and the potential opioid-induced bowel dysfunction and constipation. To ensure an optimal match between the characteristics of the patient and the properties of the chosen medication, and to guide adequate and well-tolerated treatment decisions, it is of paramount importance to expand clinicians' knowledge of the currently available COX inhibitor/opioid receptor agonist combinations. This invited narrative review deals with the literature evidence covering the components of multimodal opioid-sparing analgesic regimens. Also, it provides insights into the clinically relevant choice criteria to ensure a patient-tailored analgesia. [ABSTRACT FROM AUTHOR]

Background: Narrow definitions of long-term opioid (LTO) use result in limited knowledge of the full range of LTO prescribing patterns and the rates of these patterns.Objective: To investigate a model of new LTO prescribing typologies using latent class analysis.Design: National administrative data from the VA Corporate Data Warehouse were accessed using the VA Informatics and Computing Infrastructure. Characterization of the typology of initial LTO prescribing was explored using latent class analysis.Participants: Veterans initiating LTO during 2016 through the Veteran's Administration Healthcare System (N = 42,230).Main Measures: Opioid receipt as determined by VA prescription data, using the cabinet supply methodology.Key Results: Over one-quarter (27.7%) of the sample fell into the fragmented new long-term prescribing category, 39.8% were characterized by uniform daily new LTO, and the remaining 32.7% were characterized by uniform episodic LTO. Each of these three broad sub-groups also included two additional sub-groups (6 classes total in the model), characterized by the presence or absence of prior opioid prescriptions.Conclusions: New LTO prescribing in the VA includes uniform daily prescribing, uniform episodic prescribing, and fragmented prescribing. Future work is needed to elucidate the safety and efficacy of these prescribing patterns. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to identify effects of psychosocial and demographic factors on patellofemoral arthroplasty (PFA) outcomes.Methods: Patients who underwent PFA by a single surgeon between 2002 and 2013 (min. 2 year follow-up) were included. Knee Society scores (KSS), UCLA, and Tegner Scores were prospectively collected in a designated arthroplasty registry. Patient records were retrospectively reviewed and univariate and multivariate statistical analyses were performed to assess the effect of psychosocial factors and demographic variables including patient sex, BMI, smoking and medication use, psychiatric history, and employment status on improvement between pre- and post-operative scores.Results: Seventy-four knees in 55 patients (88% female) with a mean age of 51.8 (SD 8.8) and mean follow-up of 46.5 (SD 26.9) months were included. Patients showed significant improvement in all functional outcomes (p < 0.001). Mean improvement in KSS-F scores and median improvement in Tegner scores was greater in males compared to females (37.8 vs 16.1, p = 0.007; 3.0 vs 2.0, p = 0.07, respectively). Smokers showed less improvement in KSS-P compared to non-smokers (17.2 vs 30.0, p = 0.028). Retired or employed patients had a greater mean improvement in KSS-F and median improvement in Tegner Scores compared to those were unemployed or on work disability (p = 0.022, p = 0.01). Patients who reported using opioids and/or anti-depressants pre-operatively showed less improvement in UCLA scores (p = 0.006). Obese patients showed less improvement in both KSS-F and Tegner score compared to non-obese patients (p = 0.009, p = 0.004).Conclusion: Psychosocial factors influence the degree of improvement following PFA. Although patients showed overall improvement compared to their baseline scores, obese patients, smokers, unemployed/work disabled, and pre-operative use of opioids and/or anti-depressants were risk factors for decreased improvement… The consideration of psychosocial variables are clinically important when assessing a patient's candidacy for PFA and improve pre-operative patient selection and counselling.Level Of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Objectives: Pain is very common among older persons living in nursing home, affecting 45% to 80% of residents, interfering with daily activities and quality of life. Aims of the study are: 1) to measure the analgesics non-prescription in nursing home residents who present pain symptoms; 2) to identify the main determinants of analgesics non-prescription. Design: Retrospective cross-sectional analysis. Setting: Data from an observational study ('Incidence of pNeumonia and related ConseqUences in nursing home Residents' [INCUR] study). Participants: 800 older persons living in 13 French nursing homes. Measurments: Pain symptoms were definied by one of the following criteria: i) Presence of pain affecting the individual's function in the Activities of Daily Living; ii) Presence of daily pain, and/or; iii) Severe pain measured with a visual analogue scale. Results: Among the patients originally included in the study, 288 (36%) reported pain symptomatology (mean age 86.9 [SD 7.2] years, 220 (76%) participants women). Amongst these, 138 (47.9%) were treated with non-opioid analgesic drugs, 52 (18.1%) with opioids, and 98 (34%) did not receive any analgesic prescription. An adjusted logistic regression analysis found that the strongest determinant of analgesics non-prescription was the number of concomitantly prescribed drugs (p<0.001). Age, education, and frailty were not associated with prescription of analgesic drugs. Conclusions: Pain undertreatment is very common among older persons living in nursing homes. The number of prescribed medications represents the most relevant risk factor for the analgesics non-prescription. Our findings document the importance of reviewing prescriptions in nursing home residents. [ABSTRACT FROM AUTHOR]

Pain is associated with emotional and physical suffering that severely impacts quality of life. Many guidelines for the treatment of moderate to severe cancer pain indicate the use of opioids. For a small proportion of the global population, opioids are readily accessible, but are consequently also subject to risk of overuse and misuse. On the other hand, many regions provide limited access to licensed opioid therapeutics and patients struggle for better pain management. The use of prescription opioids for treatment of severe cancer and acute pain is well established, but opioid use in chronic non-cancer pain is controversial and not supported by the literature. The opioid crisis and the increasing overdose fatalities in some countries have resulted in a resurgence of opiophobia in these countries, but even worse, amplified opiophobia in countries with lower opioid consumption. In this narrative review, we highlight how the opioid crisis of overuse in some countries can negatively impact appropriate access to opioids elsewhere. The availability of opioids for clinical and recreational use differs between countries worldwide—this is an important factor in determining the occurrence of a 'crisis of recreational use of opioids' or a 'crisis of under-prescription of opioids' for pain management. [ABSTRACT FROM AUTHOR]

Aim: To identify the role of age and gender in analgesic and adverse effects after administering fentanyl products for breakthrough pain (BT), given in doses proportional to opioid doses given for background pain.Methods: Data from nine studies, in which patients with BP were given fentanyl products in doses proportional to their basal opioid regimen, were analyzed.Results: A total 462 patients presenting 1905 episodes of BP were included in this analysis. In older patients, the decrease in pain intensity was more pronounced 15 min after administration of a BP medication. No gender differences were found. No significant differences in frequency and intensity of adverse effects for age and gender were found.Conclusion: Fentanyl products given for BP in doses proportional to background opioid regimen were more effective in older patients without adding risks of adverse effects. Gender did not influence analgesia and adverse effects of fentanyl products. [ABSTRACT FROM AUTHOR]

Opioid tolerance complicates post-surgical analgesia in many patients, with an increased incidence of psychiatric comorbidity often adding complexity. For the management of acute pain in opioid-tolerant patients, a multimodal approach using simple analgesics, adjuvant agents and short-term increased doses of opioids is recommended, with early involvement of specialist pain services. Paradoxical opioid-induced hyperalgesia, as opposed to acute opioid tolerance, requires compensated dose reduction of the precipitating opioid. [ABSTRACT FROM AUTHOR]

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Objective: How implementing diagnostic-related grouping (DRG) payment affected the use of opioids and psychotropics by hip fracture patients following hospitalization remained unknown. Design: A retrospective, pre-post design, cohort study of data excerpted from Taiwan's National Health Insurance Research database (NHIRD). Setting and participants: Adults aged ≥ 65 years first admitted for hip fracture surgery from 2007 to 2012 were identified and divided into two 1:1 propensity-score matched groups: pre-DRG (2007–2009); DRG (2010–2012). Measurements: The outcome measures were use of opioid and/or psychotropic drugs within 30 days, 90 days, 180 days, and 365 days after discharge. Results: Data of 16,522 subjects were excerpted, and 8,261 propensity-score matched subjects each classified into the pre-DRG and DRG groups. After adjustment, the DRG group was significantly more likely than the pre-DRG group to have used antipsychotics after discharge from hip fracture surgery (≤30 days, ≤90 days, ≤180 days and ≤365 days). The DRG group also had significantly higher prescription rates of benzodiazepines and antipsychotics during the observation period. Moreover, the DRG group was less likely to use non-steroidal anti-inflammatory drugs (≤30 days, ≤90 days, ≤180 days and ≤365 days) and more likely to use acetaminophen (≤30 days, ≤180 days, and ≤365 days). Conclusions: In conclusion, DRG implementation in Taiwan substantially increased post-acute prescription of antipsychotic and psychotropic agents for hip fracture patients, and changed use of analgesics, which may result in suboptimal quality and safety for these patients. Further research is needed to evaluate the long-term outcomes of DRG implementation, and the potential benefits of appropriate post-acute care bundled with DRG payment. [ABSTRACT FROM AUTHOR]

Background: Despite exponential growth in pharmacy-dispensed naloxone, little information is available regarding variation in naloxone prescribing pattern across specialty groups, regions, and patient populations.Objective: Explore variation in pharmacy-dispensed naloxone by prescriber specialty and patient characteristics.Design: Cross-sectional analysis of the 2016 national retail pharmacy naloxone prescription claims from the IQVIA Real Longitudinal Prescriptions database.Participants: Naloxone prescribers and individuals filling naloxone prescriptions.Main Measures: Descriptive statistics assess differences across prescriber specialty groups in number of naloxone prescribers, patient and prescription characteristics, and geographic variation in naloxone dispensation and naloxone market share across prescriber specialty groups or formulation.Key Results: In 2016, 100,958 naloxone prescriptions written by 14,026 prescribers were filled by 88,735 patients. Primary care physicians accounted for the largest share of naloxone prescribers (45.9%); pain and anesthesia physicians and non-physicians prescribed to significantly greater numbers of patients (means of 10 and 8, respectively). While responsible for a relatively small share of naloxone dispensed (6.1%), psychiatrists and addiction specialists disproportionately served younger individuals, accounting for 49.5% of all prescriptions for individuals aged 35 and younger. Naloxone fill rates differed greatly across geographic regions, with the highest per capita rates in New England and the most concentrated prescribing in the West South Central and South Atlantic regions, where naloxone prescribers had the highest average numbers of patients (9.7 and 7.9, respectively). The South Atlantic and West South Central also had naloxone markets dominated by the Evzio® auto-injector, responsible for 50.3% and 43.8% of all naloxone dispensed in the regions; in contrast, New England's naloxone market was predominantly comprised of generic formulations (48.8%) and Narcan® nasal spray (45.4%).Conclusions: Our findings reflect a need to better understand barriers to uptake of naloxone prescribing behavior among physicians and other prescribers to ensure individuals have adequate opportunity to receive naloxone from their treating clinicians. [ABSTRACT FROM AUTHOR]

Purpose: Predictors of long-term opioid usage in TLIF patients have not been previously explored in the literature. We examined the effect of pre-operative narcotic use in addition to other predictors of the pattern and duration of post-operative narcotic usage.Methods: We conducted a retrospective cohort study at a single academic institution of patients undergoing a one- or two-level primary TLIF between 2014 and 2017. Total oral morphine milligram equivalents (MMEs) for inpatient use were calculated and used as the common unit of comparison.Results: A multivariate binary logistic regression (R2 = 0.547, specificity 95%, sensitivity 58%) demonstrated that a psychiatric or chronic pain diagnosis (OR 3.95, p = 0.013, 95% CI 1.34-11.6), pre-operative opioid use (OR 8.65, p < 0.001, 95% CI 2.59-29.0), ASA class (OR 2.95, p = 0.025, 95% CI 1.14-7.63), and inpatient total MME (1.002, p < 0.001, 95% CI 1.001-1.003) were positive predictors of prolonged opioid use at 6-month follow-up, while inpatient muscle relaxant use (OR 0.327, p = 0.049, 95% CI 0.108-0.994) decreased the probability of prolonged opioid use. Patients in the pre-operative opioid use group had a significantly higher rate of opioid usage at 6 weeks (79% vs. 46%, p < 0.001), 3 months (51% vs. 14%, p < 0.001), and 6 months (40% vs. 5%, p < 0.001).Conclusions: Pre-operative opioid usage is associated with higher total inpatient opioid use and a significantly higher risk of long-term opiate usage at 6 months. Approximately 40% of pre-operative narcotic users will continue to consume narcotics at 6-month follow-up, compared with 5% of narcotic-naïve patients. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Introduction: To compare all-cause and endometriosis-related healthcare resource utilization (HCRU) and healthcare costs by service categories (outpatient, inpatient, emergency room [ER], pharmacy) among patients with newly diagnosed endometriosis using opioids compared to patients with endometriosis not using opioids.Methods: A retrospective analysis of IBM® MarketScan® Commercial Claims data from 2009 to 2018 was performed for women aged 18-49 with newly diagnosed endometriosis (International Classification of Diseases (ICD)-9 code 617.xx; ICD-10 code N80.xx) over 24 months follow-up. Patients were stratified on the basis of opioid use within 12 months post first endometriosis diagnosis date. Patients with opioid use were 1:1 matched to patients without opioid use using propensity score matching.Results: A total of 85,329 female patients with a new endometriosis diagnosis were identified and 48,470 patients (24,235 opioid and 24,235 non-opioid users) remained after inclusion-exclusion criteria and matching. Opioid patients had an estimated mean 30.33 outpatient visits, 29.59 pharmacy fills, 0.28 inpatient visits, 0.65 ER visits, and total length of stay (LOS) was 1.01 days. Non-opioid patients had an estimated mean 27.94 outpatient visits, 22.06 pharmacy fills, 0.23 inpatient visits, 0.42 ER visits, and total LOS was 0.82 days. On average, opioid patients had significantly greater all-cause HCRU compared to non-opioid patients (all p < 0.0001). Among endometriosis-related healthcare utilization, there were similar ER visits, but lower outpatient visits, inpatient visits, and total LOS and higher pharmacy fills among opioid and non-opioid patients. Estimated mean all-cause costs were higher among opioid ($26,755) vs. non-opioid ($19,302) users (p < 0.0001). A similar trend was observed for estimated mean endometriosis-related costs.Conclusion: This analysis observed significantly higher all-cause HCRU and costs for opioid users compared to non-opioid users among patients with newly diagnosed endometriosis. While observed endometriosis-related costs were significantly higher in opioid users compared to non-opioid users during a 24-month follow-up period, endometriosis-related HCRU varied by service categories for these two populations over this time period. [ABSTRACT FROM AUTHOR]

Background: Headache is a common complication of traumatic brain injury. The International Headache Society defines post-traumatic headache as a secondary headache attributed to trauma or injury to the head that develops within seven days following trauma. Acute post-traumatic headache resolves after 3 months, but persistent post-traumatic headache usually lasts much longer and accounts for 4% of all secondary headache disorders. Main body: The clinical features of post-traumatic headache after traumatic brain injury resemble various types of primary headaches and the most frequent are migraine-like or tension-type-like phenotypes. The neuroimaging studies that have compared persistent post-traumatic headache and migraine found different structural and functional brain changes, although migraine and post-traumatic headache may be clinically similar. Therapy of various clinical phenotypes of post-traumatic headache almost entirely mirrors the therapy of the corresponding primary headache and are currently based on expert opinion rather than scientific evidence. Pharmacologic therapies include both abortive and prophylactic agents with prophylaxis targeting comorbidities, especially impaired sleep and post-traumatic disorder. There are also effective options for non-pharmacologic therapy of post-traumatic headache, including cognitive-behavioral approaches, onabotulinum toxin injections, life-style considerations, etc. Conclusion: Notwithstanding some phenotypic similarities, persistent post-traumatic headache after traumatic brain injury, is considered a separate phenomenon from migraine but available data is inconclusive. High-quality studies are further required to investigate the pathophysiological mechanisms of this secondary headache, in order to identify new targets for treatment and to prevent disability. [ABSTRACT FROM AUTHOR]

Background: Federally qualified health centers (FQHCs) serve diverse communities in the United States (U.S.) and could function as important venues to diagnose and treat hepatitis C virus (HCV) infections.Objective: To determine HCV testing proportion and factors associated with treatment initiation, and treatment outcomes in a large sample of FQHCs around the U.S.Design: Retrospective cohort study using electronic health records of three hundred and forty-one FQHC clinical sites participating in the OCHIN network in 19 U.S. states.Participants: Adult patients (≥ 18 years of age) seen between January 01, 2012, and June 30, 2017.Main Measures: HCV testing proportion, stratified by diagnosis of opioid use disorder (OUD); treatment initiation rates; and sustained virologic response (SVR), defined as undetectable HCV RNA 6 months after treatment initiation.Key Results: Of the 1,508,525 patients meeting inclusion criteria, 88,384 (5.9%) were tested for HCV, and 8694 (9.8%) of individuals tested had reactive results. Of the 6357 with HCV RNA testing, 4092 (64.4%) had detectable RNA. Twelve percent of individuals with chronic HCV and evaluable data initiated treatment. Of those, 87% reached SVR. Having commercial insurance (aOR, 2.11; 95% CI, 1.46-3.05), older age (aOR, 1.07; 95% CI, 1.06-1.09), and being Hispanic/Latino (aOR, 1.87; 95% CI, 1.38-2.53) or Asian/Pacific Islander (aOR, 2.47; 95% CI, 1.46-4.19) were independently associated with higher odds of treatment initiation after multivariable adjustment. In contrast, women (aOR, 0.76; 95% CI, 0.60-0.97) and the uninsured (aOR, 0.15; 95% CI, 0.09-0.25) were less likely to initiate treatment. Only 8% of individuals with chronic HCV were tested for HIV, and 15% of individuals with identified OUD were tested for HCV.Conclusions: Fewer than 20% of individuals with identified OUD were tested for HCV. SVR was lower than findings in other real-world cohorts. Measures to improve outcomes should be considered with the expansion of HCV management into community clinics. [ABSTRACT FROM AUTHOR]

Purpose Of Review: This is a comprehensive review of the literature about the use of bupivacaine hydrochloride for the treatment of post-herpetic neuralgia (PHN). It briefly reviews the background, biology, diagnosis and conventional treatment for PHN, and then introduces and compares the recent evidence for the use of topical bupivacaine.Recent Findings: PHN is defined by pain lasting 90 days or more after the initial presentation of herpes zoster ("Shingles", HZ) rash and is the most common complication of this disease. A product of re-activation of the Varicella-Zoster virus (VZV), HZ is diagnosed more than 1 million times annually in the United States. Approximately 20% of patients with HZ will experience PHN and will continue to suffer intermittent neuropathic symptoms, including itching and pain, that is sharp, stabbing, throbbing or burning, with the pain localized to the site of their original rash. This long-lasting pain compares with the severity of long-standing rheumatics and osteo-arthritis and is accompanied by severe allodynia causing significant suffering, and a financial burden that is manifested in both healthcare costs and loss of quality-adjusted life years. Prevention of PHN may be achieved with the Zoster vaccine, although there is still a large segment of unvaccinated population. Moreover, the Zoster vaccine is not always effective for prevention. Current treatment includes medical (systemic tricyclic antidepressants, anticonvulsants and opioids, topical lidocaine and capsaicin) and interventional (subcutaneous Botox injections, nerve blocks and nerve stimulation) therapies. These therapies are not always effective, and each carries their own profile of side effects and risks. Moreover, up to 50% of patients with PHN are refractory to management. Recent evidence is emerging to support the use of topical local anesthetics for the treatment of PHN. Two small studies recently found topical lidocaine spray to be effective in treating paroxysmal pain attacks associated with PHN. Bupivacaine is a longer-lasting local anesthetic, and a film-forming formulation allows easy and durable application to the affected skin. Recent studies show that topical film-forming bupivacaine is safe and as effective as lidocaine for the treatment of PHN. PHN is an important though common complication of HZ and can cause long-lasting pain and disability. Current treatment for PNH is limited by efficacy and safety profiles of individual therapies. Recent evidence points to topical local anesthetics as an effective and safe alternative to conventional therapy. Film-forming bupivacaine may offer a durable and safe option for this otherwise difficult to treat syndrome. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine if increased milligram morphine equivalent (MME) requirements are a predictor of adult compartment syndrome in patients with tibia fractures.Methods: A retrospective case-control study at a level-1 trauma center was performed over a five year period. Patients with tibia fractures who had acute compartment syndrome (ACS) requiring fasciotomy (n = 26) were matched with controls (n = 25). MME and pain scores were assessed within the 24 hour period preceding fasciotomy (cases) or fixation (controls). The presence or absence of the "6 Ps" and other clinical signs (diastolic blood pressure [DBP]) were also analyzed.Results: Mean MMEs two hours before surgery was 25.5 ± 39.2 for ACS patients versus 8.6 ± 11.1 in controls (P = 0.043), while the mean pain scores were 8.8 ± 1.8 and 7.0 ± 2.5 (P = 0.049), respectively. Multivariable regression showed patients with ACS consumed 16.9 MME more than controls within two hours of surgery (P = 0.043) and scored 1.8 points higher on the numeric pain rating scale (P = 0.049). The mean number of clinical signs of compartment syndrome in the ACS patients was 3.4 ± 1.3 compared to 0.84 ± 0.85 in controls (P < 0.001). DBP was significantly higher in ACS patients within two to four hours of surgery (P = 0.005).Conclusion: Increased MME requirements and pain scores within two hours of surgery were significant predictors of ACS following tibia fracture. Increased narcotic requirements, pain scores, and DBP may be useful objective indicators of evolving ACS, in addition to the traditional signs, and should be closely monitored in the at-risk patient. [ABSTRACT FROM AUTHOR]

It is unclear if anxiety sensitivity may serve as mechanism underlying the relation between posttraumatic stress symptom severity and opioid misuse and dependence among trauma-exposed persons with chronic pain. Therefore, the current study evaluated the explanatory role of anxiety sensitivity in the relations between posttraumatic stress symptom severity and opioid misuse and dependence. Participants included 294 trauma-exposed adults with chronic pain (71.4% female, Mage = 37.79 years, SD = 10.85, Mpain rating = 7.32/10) that reported current moderate to severe chronic pain and prescription opioid use. Participants were recruited via an online national survey in the United States of America. There were statistically significant indirect effects of posttraumatic stress symptom severity via anxiety sensitivity in relation to opioid misuse and dependence. The indirect effects of the reverse models for opioid misuse and dependence also were significant and suggest the potential for bi-directional relations; however, the magnitude of the effect was smaller in the tests of specificity than in the original models. The present findings provide initial empirical evidence that greater posttraumatic stress symptom severity is related to anxiety sensitivity, which in turn, is associated with increased opioid misuse and dependence among trauma-exposed individuals with chronic pain. [ABSTRACT FROM AUTHOR]

Background: National guidelines advise decreasing opioids for chronic pain, but there is no guidance on implementation.Objective: To evaluate the effectiveness of an Integrated Pain Team (IPT) clinic in decreasing opioid dose and mitigating opioid risk.Design: This study prospectively compared two matched cohorts receiving chronic pain care through IPT (N = 147) versus usual primary care (UPC, N = 147) over 6 months. Patients were matched on age, sex, psychiatric diagnoses, and baseline opioid dose.Patients: Veterans receiving care at a VA medical center or VA community-based clinics.Intervention: Interdisciplinary IPT, consisting of a collocated medical provider, psychologist, and pharmacist embedded in VA primary care providing short-term biopsychosocial management of veterans with chronic pain and problematic opioid use.Main Measures: Change in opioid dose expressed as morphine equivalent daily dose (MEDD) and opioid risk mitigation evaluated at baseline, 3 months, and 6 months.Key Results: Compared with veterans receiving UPC, those followed by IPT had a greater mean MEDD decrease of 42 mg versus 8 mg after 3 months and 56 mg versus 17 mg after 6 months. In adjusted analysis, compared with UPC, veterans in IPT achieved a 34-mg greater mean reduction at 3 months (p = 0.002) and 38-mg greater mean reduction at 6 months (p = 0.003). Nearly twice as many patients receiving care through IPT versus UPC reduced their daily opioid dose by ≥50%, representing more than a two-fold improvement at 3 months, which was sustained at 6 months [odds ratio = 2.03; 95% CI = 1.04-3.95, p = 0.04]. Significant improvements were also demonstrated in opioid risk mitigation by 6 months, including increased urine drug screen monitoring, naloxone kit distribution, and decreased co-prescription of opioids and benzodiazepines (all p values < 0.001).Conclusions: Interdisciplinary biopsychosocial models of pain care can be embedded in primary care and lead to significant improvements in opioid dose and risk mitigation. [ABSTRACT FROM AUTHOR]

Background: Opioid-induced constipation (OIC), the most common side effect of opioid treatment, is under-recognized and undertreated in older patients. Naldemedine, an oral, peripherally acting μ-opioid receptor antagonist (PAMORA), is approved in Japan, the United States, and the European Union for treatment of OIC in adult patients. Objective: This integrated analysis of three phase 3 trials (COMPOSE-1, COMPOSE-2, and COMPOSE-3) evaluated the safety and efficacy of naldemedine for up to 12 weeks in a subgroup of patients aged ≥ 65 years. Methods: Patients aged 18–80 years with chronic non-cancer pain for ≥ 3 months (treated with opioids for ≥ 3 months in COMPOSE-1 and COMPOSE-2) and OIC received oral naldemedine 0.2 mg or placebo once daily. Safety assessments included overall incidence of treatment-emergent adverse events (TEAEs), TEAEs in the gastrointestinal disorders System Organ Class, and TEAEs of opioid withdrawal or possible opioid withdrawal. Efficacy was based on the proportion of responders in COMPOSE-1 and COMPOSE-2, defined as having ≥ 3 spontaneous bowel movements/week and a ≥ 1-spontaneous bowel movement/week increase from baseline for ≥ 9 of 12 weeks and ≥ 3 of the last 4 weeks. Results: A total of 14.8% (344/2328) of patients were aged ≥ 65 years in all studies. The incidence of TEAEs in naldemedine-treated patients aged ≥ 65 years (45.9%) was comparable to that in patients aged ≥ 65 years receiving placebo (51.6%) and in the overall naldemedine group (47.1%). The incidence of gastrointestinal disorders System Organ Class TEAEs in naldemedine-treated patients aged ≥ 65 years (20.2%) was also comparable to that in patients aged ≥ 65 years receiving placebo (16.1%) and in the overall naldemedine group (21.8%). The incidence of TEAEs of opioid withdrawal with naldemedine was 1.1% in patients aged ≥ 65 years and 1.0% overall, and the incidence of TEAEs of possible opioid withdrawal was 1.1% in patients aged ≥ 65 years and 1.7% overall. The proportion of responders was higher in naldemedine-treated patients versus placebo, both overall (50.1% vs 34.1%; p < 0.0001) and in those aged ≥ 65 years (51.8% vs 37.6%). Conclusions: This integrated analysis confirmed that OIC treatment with naldemedine 0.2 mg was generally well tolerated and effective in patients aged ≥ 65 years with chronic non-cancer pain. Safety and efficacy results were consistent with the overall patient population. ClinicalTrials.gov registration: NCT01965158, NCT01993940, NCT01965652. [ABSTRACT FROM AUTHOR]