scholarly journals Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

2020 ◽  
Vol 10 (1) ◽  
pp. 7
Author(s):  
Eran Bornstein ◽  
Gregg Husk ◽  
Erez Lenchner ◽  
Amos Grunebaum ◽  
Therese Gadomski ◽  
...  
Keyword(s):  
Pain Management ◽  
Combination Therapy ◽  
Cesarean Delivery ◽  
Severe Pain ◽  
Large Scale ◽  
Immediate Release ◽  
Opioid Use ◽  
Opioid Dose ◽  
Analgesic Therapy ◽  
Order Set

Background: Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Methods: Our health system’s post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as p < 0.05. Results: A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; p < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; p < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; p < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, p < 0.0001). Conclusions: Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.

170: Outpatient opioid use after multimodal pain management for cesarean delivery: A randomized control trial

2018 ◽  
Vol 218 (1) ◽  
pp. S117
Author(s):  
Emily E. Hadley ◽  
Luis Monsivais ◽  
Lucia Pacheco ◽  
Yara Ramirez ◽  
Viviana Ellis ◽  
...  
Keyword(s):  
Pain Management ◽  
Cesarean Delivery ◽  
Randomized Control Trial ◽  
Opioid Use ◽  
Multimodal Pain Management ◽  
Randomized Control

Implications of uninterrupted preoperative transdermal buprenorphine use on postoperative pain management

2019 ◽  
Vol 44 (3) ◽  
pp. 342-347 ◽  
Author(s):  
Yvette N Martin ◽  
Amy C S Pearson ◽  
John R Tranchida ◽  
Toby N Weingarten ◽  
Phillip J Schulte ◽  
...  
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Pain Score ◽  
Recovery Room ◽  
Severe Pain ◽  
Receptor Agonist ◽  
Postoperative Pain Management ◽  
Opioid Use ◽  
Intravenous Morphine ◽  
Matched Study

Background and objectivesBuprenorphine is a partial µ-receptor agonist resistant to displacement from receptors by conventional opioids, which can block the effect of conventional opioids and may interfere with postoperative pain management. We aimed to quantify perioperative opioid use in patients receiving transdermal buprenorphine (TdBUP).MethodsWe identified patients receiving TdBUP who underwent surgery between 2004 and 2016. To compare opioid requirements (intravenous morphine equivalents (IV-MEq)), we constructed a matched study, matching each TdBUP patient with two opioid-naive patients by sex, age, and type of anesthesia and procedure.ResultsNineteen unique patients underwent 22 procedures while receiving TdBUP. Total (IQR) amounts of IV-MEq (intraoperative, recovery room, and 24 hours after recovery-room discharge) were 98 (63, 145) and 46 (30, 65) mg IV-MEq for TdBUP and opioid-naive patients, respectively (p<0.001). Postoperative IV-MEq requirements were 54 (38, 90) and 15 (3, 35) mg for TdBUP and opioid-naive patients, respectively (p<0.001). Among TdBUP patients, higher preoperative doses of TdBUP were associated with greater postoperative opioid requirements (p=0.02). Specifically, patients with a 20 µg/hour TdBUP patch required 133.8 mg IV-MEq more postoperatively than patients with a 5 µg/hour patch (p=0.002). Following discharge from the recovery room, 17 (77%) TdBUP patients and 15 (34%) opioid-naive patients reported severe pain (OR 6.6 (95% CI 2.0 to 21.3); p<0.001; adjusting for baseline pain score, 5.0 (95% CI, 1.4 to 17.8); p=0.01).ConclusionsAnalgesic management for patients receiving TdBUP therapy must account for increased opioid needs, and greater preoperative doses of TdBUP were associated with greater postoperative opioid requirements.

scholarly journals Pain and Opioid Use: Evidence for Integrating Acupuncture Into Treatment Planning

2021 ◽  
Vol 10 ◽  
pp. 216495612110425
Author(s):  
Elizabeth Sommers ◽  
Sivarama Prasad Vinjamury ◽  
Jennifer Noborikawa
Keyword(s):  
Pain Management ◽  
Large Scale ◽  
Opioid Use Disorder ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Related Factors ◽  
Treatment Protocols ◽  
Meta Analyses

The epidemics of pain and opioid use pose unique challenges. Comprehensive approaches are required to address minds, bodies and spirits of individuals who live with pain and/or opioid use. The lack of an effective “quick fix” for either condition necessitates developing effective, innovative and multi-disciplinary avenues for treatment. This analytic article reviews epidemiological and demographic factors associated with pain and with opioid use and additional challenges posed by the Covid-19 epidemic. Several large-scale studies and meta-analyses have examined the role of acupuncture as a nonpharmacological approach to pain management as well as a component of comprehensive strategies to address opioid use disorder. We review and describe these in the context of safety, effectiveness, access and cost-related factors. With one in four U.S. hospitals as well as 88% of Veterans Health Administration facilities incorporating acupuncture, the feasibility of mobilizing and scaling up these treatment resources is being developed and demonstrated. We also identify potential facilitators and barriers to implementing acupuncture treatment. As part of a multi-disciplinary approach to pain management and/or opioid use disorder, we suggest that integrating acupuncture into treatment protocols may represent a viable strategy that is based on and consistent with public health principles.

Is Pain Intensity a Predictor of the Complexity of Cancer Pain Management?

2009 ◽  
Vol 27 (4) ◽  
pp. 585-590 ◽  
Author(s):  
Robin L. Fainsinger ◽  
Alysa Fairchild ◽  
Cheryl Nekolaichuk ◽  
Peter Lawlor ◽  
Sonya Lowe ◽  
...  
Keyword(s):  
Pain Management ◽  
Cancer Pain ◽  
Pain Intensity ◽  
Classification System ◽  
Pain Control ◽  
Severe Pain ◽  
Cox Regression ◽  
Secondary Analysis ◽  
Initial Assessment ◽  
Opioid Dose

Purpose The lack of a standardized cancer pain (CP) classification system prompted the development of the Edmonton Classification System for Cancer Pain (ECS-CP). Its five features have demonstrated value in predicting pain management complexity. Pain intensity (PI) at initial assessment has been proposed as having additional predictive value. We hypothesized that patients with moderate to severe CP would take longer to achieve stable pain control, use higher opioid doses, and require more complicated analgesic regimens than would patients with mild CP at initial assessment. Methods A secondary analysis of a multicenter ECS-CP validation study involving patients with advanced cancer was conducted (n = 591). Associations between PI and length of time to stable pain control (Cox regression), final opioid dose (Kruskal-Wallis one-way analysis of variance), and number of adjuvant modalities (χ2) were calculated. PI at initial assessment was defined using a numerical scale as mild (0 to 3), moderate (4 to 6), or severe (7 to 10). Results Patients with moderate and severe pain required a significantly longer time to achieve stable pain control (P < .0001). PI was a significant predictor of length of time to stable pain control in the univariate regression analysis. The four significant predictors in the multivariate model were moderate and severe PI (P < .0001), age (P = .001), and neuropathic pain (P = .002). Patients with moderate to severe pain required significantly higher final opioid doses (P < .0001) and more adjuvant modalities (P = .015). Conclusion PI at initial assessment is a significant predictor of pain management complexity and length of time to stable pain control. Incorporation of this feature into the ECS-CP needs additional consideration.

scholarly journals Acute Pain Burden and Opioid Dose Requirements after Cesarean Delivery in Parturients with Preexisting Chronic Back Pain and Migraine

2021 ◽  
Vol 2021 ◽  
pp. 1-6
Author(s):  
Ryu Komatsu ◽  
Michael G. Nash ◽  
Kenneth C. Ruth ◽  
William Harbour ◽  
Taylor M. Ziga ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Back Pain ◽  
Postoperative Pain ◽  
Pain Score ◽  
Cesarean Delivery ◽  
Chronic Back Pain ◽  
Weighted Average ◽  
Opioid Use ◽  
Opioid Dose ◽  
Chronic Pain Conditions

Introduction. Preexisting chronic pain has been reported to be a consistent risk factor for severe acute postoperative pain. However, each specific chronic pain condition has unique pathophysiology, and it is possible that the effect of each condition on postoperative pain is different. Methods. This is a retrospective cohort study of pregnant women with preexisting chronic pain conditions (i.e., migraine, chronic back pain, and the combination of migraine + chronic back pain), who underwent cesarean delivery. The effects of the three chronic pain conditions on time-weighted average (TWA) pain score (primary outcome) and opioid dose requirements in morphine milligram equivalents (MME) during postoperative 48 hours were compared. Results. The TWA pain score was similar in preexisting migraine and chronic back pain. Chronic back pain was associated with significantly greater opioid dose requirements than migraine (12.92 MME, 95% CI: 0.41 to 25.43, P = 0.041 ). Preoperative opioid use ( P < 0.001 ) was associated with a greater TWA pain score. Preoperative opioid use ( P < 0.001 ), smoking ( P = 0.004 ), and lower postoperative ibuprofen dose ( P = 0.002 ) were associated with greater opioid dose requirements. Conclusions. Findings suggest women with chronic back pain and migraine do not report different postpartum pain intensities; however, women with preexisting chronic back pain required 13 MME greater opioid dose than those with migraine during 48 hours after cesarean delivery.

Trends in pancreatic cancer chemotherapy treatment in the United States from 2008 through 2016.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e15734-e15734
Author(s):  
Shirley Hui ◽  
David Bernstein ◽  
Vinod P. Balachandran ◽  
Henry J. Henk
Keyword(s):  
United States ◽  
Pancreatic Cancer ◽  
Combination Therapy ◽  
Combined Therapy ◽  
Advanced Pancreatic Cancer ◽  
Disease Status ◽  
The United States ◽  
Opioid Use ◽  
First Line ◽  
Opioid Dose

e15734 Background: Pancreatic cancer is the third leading cause of cancer death in the United States. 55% of patients present with advanced disease at diagnosis and are treated with chemotherapy, with gemcitabine and 5FU-backbone based therapies both demonstrating efficacy. However, data on the adoption of these of therapies in academic and non-academic centers is scarce. The goal of this study is to examine the aggregate adoption of these therapeutic regimens in widespread clinical practice from 2008 through 2016 using health plan claims data. Methods: Privately insured and Medicare patients with advanced pancreatic cancer treated with chemotherapy from 2008 through 2016 were identified from the OptumLabs Data Warehouse. First-line treatment regimen and duration were correlated with age, sex, race, Charlson Comorbidiy Index (CCI) score, and opioid use measured by morphine milligram equivalents (MME) (as a proxy for pain) in the 6 months prior to starting chemotherapy. Disease status was classified as advanced, adjuvant or neo-adjuvant. Results: For 14,301 patients treated with chemotherapy primarily, the use of monotherapy has significantly decreased from 73% to 27% (p < 0.001) between 2008 and 2016, while combination therapy using two antineoplastic agents (20% to 41%; p < 0.001) and three or more agents (6% to 32%; p < 0.001) increased. Since 2013, patients receiving combination therapy vs. monotherapy are significantly younger (mean 66 vs. 70; p < 0.001), have higher CCI (6.3 vs. 6.1; p = 0.002), and have similar daily opioid dose prior to chemotherapy (5.2 vs. 3.8 MMEs; p = 0.086). Duration on first-line regimen was greater in patients receiving combined therapy, compared to those on gemcitabine monotherapy (median 130 vs. 119 days; p < 0.001) after adjusting for CCI, disease status, and demographics. Conclusions: The use of combined therapy for the treatment of pancreatic cancer has increased over time, with patients on combined therapy appearing to be younger. [Table: see text]

scholarly journals The use of oral opioids to control children’s pain in the post-codeine era

2021 ◽  
Vol 26 (2) ◽  
pp. 120-123
Author(s):  
Michael J Rieder ◽  
Geert ’t Jong
Keyword(s):  
Pain Management ◽  
Severe Pain ◽  
Oral Morphine ◽  
Evidence Based ◽  
Efficacy And Safety ◽  
Limited Data ◽  
Safety And Efficacy ◽  
Safety Concerns ◽  
Analgesic Therapy ◽  
Children's Pain

Abstract Pain is a common problem for children, and pain management comprises both pharmacologic and nonpharmacologic measures. For moderate to severe pain, oral opioids have been a popular choice for the last few decades. Codeine has historically been the best-known oral opioid for use in children. However, availability and use of codeine have sharply declined due to safety concerns. A variety of other opioids have been used in place of codeine, but data are limited regarding their efficacy and safety in children. While the same pathways metabolize oral oxycodone as codeine, oxycodone’s pharmacokinetics varies widely. There are also limited data on the safety and efficacy of oral hydromorphone and tramadol use for children. Oral morphine is the opiate alternative to codeine for which there is the most evidence of safety and efficacy in children. Research is needed to investigate both other opioids and non-opioid approaches to guide evidence-based analgesic therapy and treatment for moderate-to-severe pain in children.

scholarly journals The use of bilateral transversus abdominis plane blocks with liposomal bupivacaine on postoperative cesarean delivery patients during COVID-19 pandemic is associated with reduced narcotics use and reduced length of stay

2021 ◽  
Vol 17 ◽  
pp. 174550652110580
Author(s):  
Dennis E Feierman ◽  
Jason Kim ◽  
Aden Bronstein ◽  
Agnes Miller ◽  
Christein Dgheim ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Length Of Stay ◽  
Cesarean Delivery ◽  
Large Scale ◽  
Medical Center ◽  
Transversus Abdominis ◽  
Opioid Use ◽  
Transversus Abdominis Plane ◽  
Liposomal Bupivacaine ◽  
Number Of Patients

Background: The use of transversus abdominis plane blocks has been previously shown in both large-scale studies and our own institution to significantly reduce postoperative pain and opioid use. In addition, the use of bilateral transversus abdominis plane blocks using liposomal bupivacaine in combination with neuraxial morphine significantly reduced post-cesarean-delivery pain and opioid use. During the COVID-19 crisis, our anesthesia department in a collaborative effort with our obstetric colleagues thought that the use of bilateral transversus abdominis plane blocks with liposomal bupivacaine could reduce the use of opioids to treat postoperative pain and might result in decreased length of stay. Methods: After institutional review board approval, a retrospective study of 288 patients who underwent cesarean delivery under spinal or epidural (neuraxial) anesthesia at Maimonides Medical Center in Brooklyn, NY was conducted. Historical controls were from 142 consecutive patients from 1 January 2012 through 12 May 2012. An additional set of controls consisted of 30 consecutive patients from 10 March 2020 through 13 April 2020. The primary outcome data analyzed were the use of opioids and length of stay. Results: Post cesarean delivery, patients who received both bilateral transversus abdominis plane blocks with liposomal bupivacaine and neuraxial morphine was associated with a significant decrease in the number of patients using post operative opioids, 54%–60% decreased to 18% ( p < 0.001), and a decreased length of stay; 3.1 days was reduced to 2.39 ( p < 0.001). Conclusion: Neuraxial opioids combined with liposomal bupivacaine transversus abdominis plane blocks provided significant pain relief for patients post cesarean delivery, required less post operative opioids, and facilitated earlier discharge that may aid in reducing patient exposure and hospital burden secondary to COVID-19.

864 Perioperative Multimodal Analgesia Reduces Opioid Use Following Skin Grafting in Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S270-S271
Author(s):  
Angela Gibson ◽  
Richard C Lennertz ◽  
Haley Zimmerman ◽  
Timothy McCormick ◽  
Lee Faucher
Keyword(s):  
Pain Management ◽  
Severe Pain ◽  
Opioid Analgesic ◽  
Oral Morphine ◽  
Skin Grafting ◽  
Multimodal Analgesia ◽  
Burn Patients ◽  
Opioid Use ◽  
Perioperative Analgesia ◽  
Grafting Procedure

Abstract Introduction Burn injuries cause severe pain and patients often require high doses of opioid medications. Pain management is particularly challenging during dressing changes and following skin grafting procedures. Non-opioid analgesic medications and multimodal analgesic strategies have been promoted to improve pain management and decrease opioid use. Methods We performed a retrospective chart review to identify burn patients who underwent autologous skin grafting procedures between January 2011 and June 2018. We included patients who underwent were 18–80 years old and were inpatients for at least 24 hours before and after their procedure. We excluded patients who remained intubated in PACU, had surgery the day prior or had active opioid prescriptions prior to their hospitalization. We evaluated the effect of different non-opioid analgesic medications on opioid use following a skin grafting procedure. The primary outcome measure of this study compared opioid use 24 hours before skin grafting to 24 hours after skin grafting. Results We found that most patients (69%) reported severe pain (NRS ≥7) immediately after autologous skin grafting. On average, patients required an additional 54 mg of oral morphine equivalents (ME) in the 24 hours after the procedure compared to the 24 hours before. The use of perioperative non-opioid analgesia varied between patients (Acetaminophen 29%, gabapentin 29%, ketamine 33% and all three 8%). Patients who received either gabapentin or a combination of acetaminophen, gabapentin and ketamine had a smaller increase in their opioid use than patients who did not receive the medications (-24 ME, CI -46, -3 and -40 ME, CI -75, -5 respectively). Conclusions Burn patients who received perioperative acetaminophen, gabapentin and ketamine required relatively less opioid following their skin grafting procedure. Applicability of Research to Practice These results support the use of multimodal analgesia for perioperative analgesia in burn patients.

Multimodal Pain Management for Cesarean Delivery: A Double-Blinded, Placebo-Controlled, Randomized Clinical Trial

2019 ◽  
Vol 36 (11) ◽  
pp. 1097-1105 ◽  
Author(s):  
Emily E. Hadley ◽  
Luis Monsivais ◽  
Lucia Pacheco ◽  
Rovnat Babazade ◽  
Giuseppe Chiossi ◽  
...  
Keyword(s):  
Pain Management ◽  
Drug Use ◽  
Cesarean Delivery ◽  
Primary Outcome ◽  
Opioid Use ◽  
Multimodal Pain Management ◽  
Significant Difference ◽  
History Of ◽  
Secondary Outcomes ◽  
Double Blinded

Objective Our objective was to evaluate the efficacy of perioperative multimodal pain management in reducing opioid use after elective cesarean delivery (CD). Study Design A single-center, double-blinded, placebo-controlled randomized trial of women undergoing elective CD. Participants were allocated 1:1 to receive the multimodal protocol or matching placebos. The multimodal protocol consisted of a preoperative dose of intravenous acetaminophen, preincision injection of subcutaneous bupivacaine, and intraoperative injection of intramuscular ketorolac. Primary outcome was total opioid intake at 48 hours postoperatively. Secondary outcomes were pain scores, time to first opioid intake, neonatal outcomes, and total outpatient opioid intake on postoperative day (POD) 7. Data were analyzed using parametric and nonparametric tests and quantile regression as appropriate. Results A total of 242 women were screened with 120 randomized, 60 to the multimodal group and 60 to control group. There was no significant difference in the primary outcome of opioid use nor in the secondary outcomes. Smokers and patients with a history of drug use had higher median postoperative opiate use and earlier administration. On POD 7, only 40% of prescribed opioids had been used, and there was no difference between the groups. Conclusion This perioperative multimodal pain regimen did not reduce opioid use in 48 hours after CD. Patients who smoke or with a history of drug use required more opioids in the postoperative period. Providers significantly overprescribed opioids after CD.

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