No Decrease in Pain Relief With Less Opioids After Surgery

PainRelief.com Interview with:
Ryan Howard, MD
Academic Development Time Year 1
Resident, General Surgery
University of Michigan

PainRelief.com:  What is the background for this study?

Response: Opioids are commonly prescribed to control pain after surgery, but they also carry significant risks such as overdose, long-term dependence, and diversion into the community. While some have advocated for decreasing or eliminating opioids from postoperative pain control regimens, others are concerned that this would lead to uncontrolled pain and dissatisfied patients. To study whether that’s true, we compared two groups of patients undergoing the same surgical procedures. One group received “opioid-sparing” prescriptions after surgery and the other group received “normal-sized” prescriptions.

Conditioned Open-Label Placebos Provide Pain Relief in Some Post-Surgical Patients

PainRelief.com Interview with:
Kristin Schreiber, MD, PhD
Neuroscientist and Clinical Regional Anesthesiologist
Brigham and Women’s Hospital
Assistant Professor of Anesthesia
Harvard Medical School

PainRelief.com:  What is the background for this study?

Response: Traditionally, the placebo effect has involved deceiving patients, where they think they may be taking a real medication. “Open-label placebos” are when placebos are given to patients, and patient are told that they are in fact a placebo. Recent research has suggested that these open-label placebos may actually reduce a number of symptoms in patients, including chronic low back pain. We were interested whether this strategy could be used to help reduce pain and opioid use around the time of surgery. We decided to combine the use of OLP with a conditioning approach, so that anytime a patient took an opioid analgesic, they would take the open-label placebo, so that the OLP pills would be associated with pain relief. That way when patients took them on their own, it would serve to trigger an expectation of pain relief, which is thought to at least partially explain the placebo effect.  

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Understanding Back Pain During Neuroendovascular Procedures

PainRelief.com Interview with:

Adnan Qureshi, MD
Zeenat Qureshi Stroke Institute
Department of Neurology
University of Missouri
Columbia, MO

Dr. Qureshi

PainRelief.com: What is the background for this study? What are the main findings?

ResponseOptimizing of patient experience is a very important goal for any procedure. Neuro Endovascular procedures are unique because most of them are performed awake to perform repeated neurological examinations during the procedure. The angiographic tables have to be made of unique stiff material to ensure X rays can pass through and any movement during procedure can distort images. We believe understanding the factors that can be improved upon given the unique settings remains an important goal of the specialty. 

Our research broadens our understanding of complications of the procedures. Previous studies have look at the risk of stroke or bleeding but not complications like back pain which are far more common.

Recorded Music plus Text During Anesthesia Reduced Need for Pain Medication

PainRelief.com Interview with:
Prof. Dr. Ernil Hansen
Department of Anesthesiology
University Hospital Regensburg
Regensburg, Germany

Prof. Dr. Hansen

PainRelief.com: What is the background for this study? What are the main findings?

Response: It is becoming more and more clear that besides drugs and surgery it is communication that makes therapy effective. A meta-analysis we had conducted recently, suggested some beneficial effects of taped words played during surgery in older studies.

Our current study on 385 patients showed evidence that a text based on hypnotherapeutic principles an reduce postoperative pain and use of opioids. Pain within the first 24h after surgery decreased by 25%, opioid requirement by 34%. Six patients needed to be treated to save one patient from opioid exposure at all. High demand for analgesics was reduced by 41%. 

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Traditional and Battlefield Acupuncture Provide Post-Op Pain Relief and Reduced Need for Opioids

PainRelief.com Interview with:

  • Brinda Krish, D.O., lead author of the study and an anesthesiology resident at Detroit Medical Center.
  • Padmavathi Patel, M.D., principal investigator of the study and Medical Director, Northstar Anesthesia at John D. Dingell Veteran Hospital.

PainRelief.com:  What is the background for this study?  What are the main findings?

Dr. Padmavathi Patel: Pain is a major contributor to health care costs and a common cause of long-term disability (about  $61.2 billion/year) in lost productivity due to pain.

acupuncture

76.2 million Americans (one in four) have suffered from pain that lasts longer than 24 hours (2013).

Numerous literature such as:

1. “Use of prescription opioids in the treatment of pain has increased notably over recent decades.”

2. “Rates of death from prescribed opioids increased four fold between 2000 and 2014.”

3. “16,651 opioid related deaths in 2010.”

4. “The problem of opioid overuse and dependence is seen in the military as well as in civilian.”

-Opioid-related side effects could lead to a delay in recovery.
-Pain control is more challenging for military population.
-More extensive injuries and greater pain severity is seen in survivors of combat- related blast injuries compared to those of non-blast civilians and also they require larger opioid doses.
-Pain is a very common patient complaint, both in veteran and non-veteran populations.
-Among the 5.7 million unique patients seen annually with in the Department of Veterans Affairs (DVA), more than half of these patients experience chronic pain.

In 2017, The DVA and the United States Department of Defense (DoD) published an updated guidelines on opioid therapy for chronic pain that strongly recommends against initiation of long-term opioid use and recommends alternatives, including non-pharmacologic therapy, such as Acupuncture, which has been shown to be effective for treating a variety of painful conditions.

Acupuncture techniques have been in existence for centuries, with roots tied to Eastern Asia. Traditional acupuncture involves the insertion of very thin needles at specific trigger points around the body to relieve pain. Battlefield acupuncture (BFA), developed by a U.S. Air Force doctor uses needles that are inserted at various trigger points in the ear. In 2013, $5.4 million was awarded to the Departments of Defense and Veterans Affairs to teach BFA to healthcare providers in both the military and the Department of Veterans Affairs and assess it.  In light of the opioid epidemic, there is a strong need to decrease perioperative opioid use. Opioid use due to postoperative pain along with perioperative anxiety has been linked to increased length of hospital stay, increased morbidity and mortality, and ultimately higher healthcare costs.

Battlefield acupuncture was introduced into Veterans Health Administration (VHA) in the last few years and in VHA, clinicians of various disciplines (MDs, DOs, PAs, nurse-practitioners), can currently obtain clinical privilege to provide it.

I received the Battlefield acupuncture training at John D. Dingell VA medical Center, Detroit and I was surprised with the outcomes of chronic pain patients. As an anesthesiologist I know pain after the surgery is common, often severe and largely unnecessary. I discussed these concerns with the surgeons and created the protocol to use BFA for general surgical patients and traditional acupuncture for hip replacement patients as an adjuvant to the standard protocol for acute post-surgical pain control.

Effective relief of postoperative pain is vital. Such pain probably prolongs hospital stay, as it can affect all the organ systems with side effects. Post op pain remains grossly under treated, with up to 70% of patients reporting moderate to severe pain following surgery.

Multimodal pain control not only can result in earlier discharge from hospital, but it may also reduce the onset of chronic pain syndromes.

2 studies performed TA (n=21), Controls given sham acupuncture (n=21).  BFA (n=28), Controls given sham acupuncture (n=36). Measured variables included post-operative opioid requirements, postoperative pain, the incidence of PONV, and patient satisfaction scores

Key conclusions use of Battlefield acupuncture and Traditional acupuncture reduced post-operative opioid requirements, post-operative pain scores (pain intensity) and increased patient satisfaction scores.  BFA also reduced PONV in patients.  

Are Invasive Procedures Effective for Chronic Pain Relief? A Systematic Review

PainRelief.com Interview with:
Wayne B. Jonas, MD
Executive Director
Samueli Integrative Health Programs, H&S Ventures,
Alexandria, VA

PainRelief.com:  What is the background for this study?

Response: The search for non-drug approaches to chronic pain is a major recommendation in many recent guidelines for both pain management and reduction in the use of opioids. Surgical and invasive procedures are non-drug approaches often used for pain conditions like back pain and arthritis, so good evidence is needed to determine the safety and efficacy of these procedures. Properly done randomized, placebo-controlled trials are the best way (the gold standard) to get that evidence, so we did a thorough evaluation of such research, using standard systematic review and meta-analysis methods.

Wide Variation in Opioid Prescribing for Pain Relief Following Knee Arthroscopy

PainRelief.com Interview with:
Benjamin Ukert PhD
Assistant Professor
Department of Health Policy and Management
Texas A&M

Mucio Kit Delgado, MD, MS
Department of Emergency Medicine
Perelman School of Medicine
University of Pennsylvania

PainRelief.com:  What is the background for this study?

Response: The opioid epidemic has received a lot of attention and many state policies have been passed to address excessive opioid prescribing and highlight the dangers of opioid use initiation for those who have never been exposed to opioids. We also now know that most patients prescribed opioids for post-operative pain have significant quantities of pills leftover. One study showed that after knee arthroscopy, 50% of patients took no opioids, and 90% took less than 5 pills (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7190545/).

We thought to investigate whether overprescribing is still common, and asked the question whether we now observe low levels of prescribing following knee arthroscopy and whether there are differences in prescribing practices across states.

Total Hip Replacement Can Be Safely Performed with Minimal Opioids for Pain Relief

MedicalResearch.com Interview with:
Andrew Wickline MD FAAOS
New Hartford, NY 13413

MedicalResearch.com:  What is the background for this study?  What are the main findings?

Response: Joint replacement has long been synonymous with pain relief–but not until 6-12 weeks after surgery.  Many patients put off joint replacement due to fear and anxiety–particularly about the possible pain after surgery often seen in the first several months.  Opioids have long been the mainstay of controlling pain after surgery but are associated with significant side effects and risk for addiction and injury. 

Our study shows that with our comprehensive protocol, 97% of patients can have successful surgical recovery with little to no opioids being necessary to stay comfortable.  Additionally, it shows that 94% of patients can go home within 24 hours and 95% will likely need no post-operative therapy to recover.

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Business Model Can Help With Pain Relief Decisions After Surgery

Dr. Schug

PainRelief.com Interview with:
Professor Stephan A Schug MD FANZCA FFPMANZCA EDPZ 
Emeritus Professor and Honorary Senior Research Fellow
Anaesthesiology and Pain Medicine
Medical School  University of Western Australia

PainRelief.com:  What is the background for this study?

Response: This paper is the result of applying a widely used tool in operations research, Multi-Criteria Decision Analysis (MCDA), to a medical problem, namely the use of parenteral analgesics in postoperative pain management. MCDA is a modelling approach which is aimed at achieving evidence-based decisions in settings of multiple conflicting criteria. It is commonly applied to decisions in politics and business; one of our co-authors is Lawrence D Phillips from the London School of Economics and Political Sciences, where he uses this methodology in these settings. However, there is increasing use of this methodology in medicine now, in particular in assessment of medicines with obviously conflicting criteria such as efficacy, adverse effects, safety and even price. The methodology has been applied to a number of medicine (eg psychoactive drugs) and considered by the European Medicines Agency (EMA).

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