Novel Protocol Reduced Use of Opioid Pain Relievers After Knee and Shoulder Surgeries

PainRelief.com Interview with:
Nicole Simunovic, MSc
On behalf of the NO PAin Principal Investigators

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

Response: Orthopaedic surgeons prescribe more opioids than any other type of surgeon in North America. Opioids have the potential to be highly addictive and can cause serious harm or even death if taken in excess. The goal of our clinical study was to determine if an opioid sparing approach to postoperative pain management was safe and effective in patients undergoing arthroscopic knee and shoulder surgery.

Policymakers Can Mitigate Prescription Opioid Misuse Associated with Delayed Dispensing for Pain Relief after Procedures

PainRelief.com Interview with:
Kao
Ping ChuaMD, PhD
Department of Pediatrics
Susan B. Meister Child Health Evaluation and Research Center
University of Michigan Medical School
Department of Health Management and Policy
University of Michigan School of Public Health, Ann Arbor

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

Response: Opioid prescriptions written by dentists and surgeons are almost always written for the immediate relief of acute pain after procedures. However, current federal and state laws allow these prescriptions to be dispensed well after the time that they are written. When this occurs, that could be a potential sign that the prescription was used in a time frame or for a reason other than intended by the prescriber, both of which are forms of prescription opioid misuse.

Study Evaluates Long-Acting Bupivacaine for Pain Relief During Knee Replacement

PainRelief.com Interview with:
Prof. Hemant G. Pandit, DPhil
Leeds Institute of Rheumatic and Musculoskeletal Medicine
Chapel Allerton Hospital, University of Leeds
Leeds, United Kingdom

Prof. Pandit

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

Response:  Knee replacement is highly successful for treating severe arthritis. There are 100,000 people who undergo knee replacement surgery every year in the UK, with numbers set to rise significantly in future. It remains however a painful procedure with nearly half of patients reporting severe pain post-operatively. Currently pain control is provided by injecting a local anaesthetic of bupivacaine hydrochloride around the knee during surgery providing good pain relief for 12 to 24 hours. However, patients typically experienced the worst pain the next morning when they are encouraged to bend their knee and get out of bed. 

Liposomal bupivacaine is a local anaesthetic preparation which can provide sustained release of pain relief medication over a longer period of time (up to 72 hours). The drug is costly and is used in routine clinical practice in the USA with previous studies showing varying results with the use of LB. We therefore (researchers at the Universities of Oxford and Leeds) developed the SPAARK (Study of Peri-Articular Anaesthetic for Replacement of the Knee) Trial, to test whether liposomal bupivacaine would be more effective at managing the pain compared to current treatments in patients undergoing a knee replacement. 

Total Knee Replacement: Outcomes by Age vs Co-Morbidities

PainRelief.com Interview with:
Juan Ignacio, Teves
Agustin, Garcia-Mansilla

Italian Hospital of Buenos Aires

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

Response: It is well known that the increased life expectancy of the general population leads to an increase in the number of prosthetic replacement surgeries in the years to come. A concern of patients who consult for this type of procedure is whether age alone is a risk factor for this surgery and the literature is not conclusive about whether age or comorbidities are more important in postoperative results.

For this reason, we decided to compare two series of patients, some older than 80 years and others younger, to determine whether or not age influences the result of total knee replacement.

Continue reading

Minimally Invasive Spinal Surgery for Leg or Back Pain Linked to Improved Pain Relief and Function

PainRelief.com Interview with:
Dr. Mohamad Bydon MD
Professor of Neurosurgery
Mayo Clinic
Rochester, Minnesota

:Dr. Bydon MD

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

Response: Patients presenting with back or leg pain due to degenerative lumbar spine disease often undergo spinal fusion to mitigate the symptoms and halt the progression of the disease.

PainRelief.com: What are the main findings?

Minimally invasive surgery (MIS) in the lumbar spine encompasses a variety of techniques, such as percutaneous screw placement and operation via tubular retractors, and aims to limit the distortion of patients’ anatomy as much as possible. Eventually, compared to open fusion, MIS fusion is associated with decreased muscle destruction, incision size, and time-to-mobilization.

Continue reading

Physical Therapy After Knee Replacement Linked to Less Long Term Opioids for Pain Relief

PainRelief.com Interview with:
Deepak Kumar, PT, PhD
Assistant Professor, Physical Therapy
Assistant Professor, BU School of Medicine
Director, Movement & Applied Imaging Lab

Dr. Kumar

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

Response: We investigated the association of physical therapy interventions with long-term opioid use in people who undergo total knee replacement surgery.   For people with advanced osteoarthritis, total knee replacement is the only option. The number of total knee replacement surgeries has been increasing and is expected to rise exponentially over the next few years with an aging population and rising rates of obesity. However, up to a third of patients continue to experience knee pain after this surgery. Also, a significant proportion of people become long-term opioid users after total knee replacement. Reliance on opioids may reflect a failure of pain management in these patients. Given that physical therapy interventions are known to be effective at managing pain due to knee osteoarthritis, we wanted to study whether physical therapy before or after surgery may reduce the likelihood of long-term opioid use.

We used real-world data from insurance claims for this study. In our cohort of about 67,000 patients who underwent knee replacement between 2001-2016, we observed that, receiving physical therapy within 90 days before surgery or outpatient physical therapy within 90 days after surgery were both related to lower likelihood of long-term opioid use later. We also observed that initiating outpatient physical therapy within 30 days and 6 or more sessions of physical therapy were associated with reduced likelihood of long-term opioid use compared to later initiation or fewer PT sessions, respectively. However, we did not see an association between type of physical therapy. i.e., active (e.g., exercsise) vs. passive (e.g., TENS) and long-term opioid use.

Importantly, most of our findings were consistent for people who had or had not used opioids previously. We also were able to account of a larger number of potential factors that could confound these associations because of the large sample size. However, there are limitations to our work. Since we only had access to insurance claims data but not to health records, we are unable to make any inferences about association of physical therapy with pain or quality of life, etc.

Continue reading

Caution Should Be Taken with Hip Steroid Injections For Arthritis Pain Relief

PainRelief.com Interview with:
Kanu M. Okike, MD
Orthopedic Surgeon
The Hawaii Permanente Medical Group

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

Response: Hip corticosteroid injections are a common treatment for osteoarthritis and other hip conditions.  Recently, isolated case reports have raised the question of whether hip corticosteroid injections could be associated with rapid progression of the arthritis process – a condition known as rapidly destructive hip disease (RDHD).

Continue reading

Multimodal Analgesia For Pain Relief After Joint Replacement

PainRelief.com Interview with:

Joseph Albert Karam, MD
Assistant Professor of Clinical Orthopaedic Surgery
Associate Program Director, Orthopaedic Surgery Residency
The University of Illinois at Chicago

Joseph-Karam
Dr. Karam

PainRelief.com:  What is the background for this study?Would you describe the multimodal pain plan?

Response: Pain after joint replacement surgery has been historically managed by protocols centered on opioid medication. Given the side effects associated with these medications, the risk for long term addiction and evidence showing that opioids are not necessarily the best at treating pain perioperatively in joint replacement, multimodal pain management protocols have been established. These protocols utilize different families of medications that target pain at different steps in the pain pathway.

The exact protocol varies from one institution to the other but typically include systemic agents such as acetaminophen, non-steroidal anti-inflammatories/COX-2 inhibitors, gabapentinoids, corticosteroids, as well as loco-regional interventions such as local infiltration analgesia and regional nerve blocks. ‘Pre-emptive analgesia’ which most commonly uses a nonsteroidal anti-inflammatory, acetaminophen and/or a gabapentinoid has also been demonstrated to play a key role. Additional measures such as NMDA antagonists and epidural catheters can also be used in select cases. Non-pharmacological treatments such as cryotherapy, cryoneurolysis and electrical nerve stimulation have also been described. Our preferred institutional protocol is detailed in the paper.

Continue reading

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.  

Continue reading