Less-is-More Approach to Pain Relief After Surgery

PainRelief.com Interview with:
Dr Deanne Jenkin PhD
UNSW Australia,
now Research Fellow at The Daffodil Centre
Sydney, Australia

Dr Jenkin

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

Response: At the time, long-term opioid use for chronic non-cancer pain was increasing and there were signs that their benefit was overestimated whilst the harms were underestimated. Our randomized trial found that after going home from fracture surgery, strong opioids were not better for pain relief compared to a milder, potentially safer opioid alternative.

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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.

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Acupuncture for Pain Relief from Chronic Prostatitis and Chronic Pelvic Pain Syndrome

PainRelief.com Interview with:

Zhishun Liu, MD, PhD
Guang’anmen Hospital
China Academy of Chinese Medical Sciences
Beijing, China

acupuncture

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

Response: Pharmacologic therapy has so far failed to reveal universal benefits in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS); the evidence for acupuncture is limited, although it is also recommended in current guidelines.

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“Empowered Relief” Program Equips Patients With Effective Pain Relief Skills

PainRelief.com Interview with:
Beth Darnall, PhD

Director, Stanford Pain Relief Innovations Lab
Associate Professor, Stanford University School of Medicine
Department of Anesthesiology, Perioperative and Pain Medicine
Psychiatry and Behavioral Sciences (by courtesy)
Wu Tsai Neurosciences Institute (affiliate faculty)
Palo Alto, CA 94304

Dr. Darnall

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

Best pain care integrates patient education and tools to help them manage pain and reduce their symptoms1. Multi-session psychological or “behavioral” pain treatment approaches, such as 8-session cognitive behavioral therapy (CBT), are effective for equipping people with pain management skills. However, our prior research showed that patient access to these treatments is often poor, in part due to the costs and time burdens (e.g., up to 16 hours of treatment time).2

Findings from our study suggest that a one-time 2-hour pain relief skills class (“Empowered Relief”) was non-inferior to 8-session CBT for reducing multiple symptoms, including pain catastrophizing, pain intensity, and pain interference at 3 months post-treatment. We also found the single-session pain class imparted substantial reductions for pain bothersome, sleep disturbance, anxiety, fatigue and depression.

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Including a Body Map Can Help Clinicians Manage Chronic Pain

PainRelief.com Interview with:
Ben Alter, MD, PhD
Assistant Professor
Director, Translational Pain Research
Division of Pain Medicine
Department of Anesthesiology and Perioperative Medicine
University of Pittsburgh Medical Center

Dr. Ben Alter

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

Response: In the clinical environment, I am often asking patients where their pain is.  There is a large amount of research establishing that widespread or “all-over” pain is difficult to manage and impacts nearly every aspect of a patient’s life. In fact, a tally of body areas is involved with the diagnosis of fibromyalgia, although this is not the only diagnostic criteria. What wasn’t clear to us was whether patterns of pain across the body also impacted important facets of the pain experience.  

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Migraine: Remote Electrical Neuromodulation For Pain Relief in Adolescents

PainRelief.com Interview with:
Andrew D. Hershey, MD, PhD, FAAN, FAHS
Endowed Chair and Director of Neurology
Professor of Pediatrics and Neurology
Director, Headache Center
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH 45229
University of Cincinnati, College of Medicine

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

Response:  Migraine is a common and debilitating disease, affecting 1 in 10 children and adolescents worldwide. Refractory migraine in adolescents may be associated with poorer academic performance, reduced school attendance, and a negative effect on social interactions. Current acute treatments for adolescents with migraine are mostly pharmacological. These treatments may cause side effects, and their frequent use may potentially lead to medication overuse headache. Additionally, their efficacy may be variable or inadequate. Thus, there is a great unmet need for new safe and effective acute treatments for adolescents with migraine headaches.

Remote Electrical Neuromodulation (REN) is a non-pharmacological, non-invasive neuromodulatory treatment that has been approved by the US FDA for acute treatment of the headache attacks of migraine in patients 12 years of age or older. The REN device (Nerivio®) is a small stimulator controlled by the user via a smartphone application and activates one of the body’s own pain suppression system by inducing weak electrical currents. These currents stimulate nerve fibers in the upper arm to activate an endogenous descending pain inhibition mechanism termed Conditioned Pain Modulation (CPM). Clinical trials of REN have shown efficacy and safety of the treatment in adolescents 12 and older, as well as in adults.

The current study is the first to compare REN and standard-care treatments (over the counter medications and triptans) in adolescents.

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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.

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Runners: Leaning Forward Increases Force on Hip Extensors

PainRelief.com Interview with:
Anna Warrener Ph.D.
Department of Anthropology
University of Colorado Denver
Denver, CO

Dr. Warrener

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

Response: We became interested in looking at trunk position during running because one of us (Daniel Lieberman) had anecdotally observed people running with a variety of trunk positions, and when we went looking for academic literature on the topic, we found it was fairly scarce. We suspected that trunk position could have a major impact on the forces experienced by the lower limbs during running and even affect aspects of gait (stride length and time). So we developed a model predicting how these forces and movements might change as trunk flexion/forward leaning increased.

Our primary predictions were that more forward lean would increase “overstride” which is the distance in side view between the hip and the heel as it contacts the ground (a measure of how far your are extending your leg when you step). This in turn would increase the impact forces experienced by the lower limb at initial contact which have previously been shown to increase the risk of repetitive stress injuries. We also predicted that stride would get longer and take more time because extending the leading leg out farther forward (overstriding) would be necessary to keep the body center of mass within a base of support above the limbs. This more extended limb, we predicted, would change the angles and forces about the ankle, knee and hip joints.

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Pain in U.S. Adult Hispanics Varies by Their Ancestral Country of Origin

PainRelief.com Interview with:
Richard L. Nahin, Ph.D., M.P.H
Lead Epidemiologist
National Center for Complementary and Integrative Health (NCCIH)
National Institutes of Health
Bethesda, Maryland

Dr. Nahin

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

Response: Individuals of Hispanic ancestry living in the U.S. include numerous subpopulations that vary in the prevalence of chronic disabling conditions, as well as exhibit differences in socioeconomic status, health behaviors, global health status, health care utilization, and genetic profiles. 

Despite this evidence, there are few nationally representative studies examining the epidemiology of pain in these Hispanic subpopulations, and none that compared global measures of pain chronicity, severity, nor examined the influence of race on potential associations with pain in Hispanics.

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Prescription Opioids for Pain Relief in Youth Decreased in Recent Years

PainRelief.com Interview with:

Madeline H. Renny, MD
Postdoctoral Fellow, Department of Population Health
Clinical Instructor, Department of Emergency Medicine and Pediatrics
New York University Grossman School of Medicine
New York, New York

Dr. Renny

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

Response: Prescription opioids are involved in over half of opioid overdoses among youth.  Additionally, prescription opioid use is associated with risks of future misuse, adverse events, and unintentional exposures by young children.  While there are several studies on opioid prescribing in adults, few studies have focused on the pediatric and adolescent population.  In the last year, postoperative guidelines for opioid prescribing for children and adolescents were released, but there remain no national guidelines on general opioid prescribing for youth. 

To our knowledge, no prior national studies have examined trends in important opioid prescribing practices, including amount prescribed, duration, high-dosage, and extended-release/long-acting (ER/LA) opioid prescriptions, in this subset of the population; a necessary step in understanding the opioid epidemic and in developing targeted interventions for youth. 

Therefore, we performed a cross-sectional analysis of U.S. opioid prescription data to investigate temporal trends in several key opioid prescribing practices in children, adolescents, and younger adults in the U.S. from 2006-2018.


PainRelief.com: What are the main findings?

Response: We found that opioid dispensing rates declined significantly for children, adolescents, and younger adults since 2013. When examining trends in opioid prescribing practices, there were differences based on age group. For adolescents and young adults, rates of long-duration and high-dosage opioid prescriptions decreased during the study period, whereas there were increases in these rates for younger children.  

PainRelief.com: What should readers take away from your report?

Response: Dispensed opioid prescriptions for youth have significantly decreased in recent years.  These findings are consistent with prior studies in children and adults, suggesting that opioid prescribing practices may be improving. Additionally, the decrease in rates of high-dosage and long-duration prescriptions in adolescents and young adults is encouraging in the context of research showing associations with these prescribing practices and opioid use disorder and overdose. However, opioids remain commonly dispensed to youth and potential high-risk prescribing practices (long-duration, high-dosage, and ER/LA prescriptions) appear to be common, especially in younger children.  

PainRelief.com: What recommendations do you have for future research as a result of this work?

Response: The increase in rates of potential high-risk prescribing practices in young children was an unexpected finding and warrants future study. Due to the limitations of our database (no clinical information, including diagnoses or indications for prescription), we were unable to determine the appropriateness of opioid prescribing practices (e.g., whether a prescription was for a child with cancer or for a child with an acute injury).  Our two sensitivity analyses were performed to try to identify a subset of patients with chronic illness and both showed no differences in trends.  However, it will be important to further investigate these opioid prescribing practices using a database with clinical information to better understand these findings in young children.

Further research investigating specific opioid prescribing practices may inform targeted interventions, including pediatric and adolescent-specific opioid prescribing guidelines, to ensure appropriate opioid prescribing in this population. 

No disclosures

Citation:

Renny MH, Yin HS, Jent V, Hadland SE, Cerdá M. Temporal Trends in Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US From 2006 to 2018. JAMA Pediatr. Published online June 28, 2021. doi:10.1001/jamapediatrics.2021.1832

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