Opioid Prescribing for Chronic Pain — Achieving the Right Balance through Education

Daniel P. Alford. New England Journal of Medicine 2016; 374:301-303

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Image source: Eric Norris

In recent decades, the United States has seen a dramatic increase in opioid prescribing for chronic pain. That growth has been associated with increasing misuse of prescription opioids1 and has led to increases in deaths due to unintentional opioid overdose and in the number of people seeking treatment for opioid-misuse disorders. There’s probably 100% agreement that we, as a profession and society, have become overly opioid-centric in our management of chronic pain. Far more controversial are the role of long-term opioid therapy in managing chronic pain and the best strategy for ending the epidemic of prescription-opioid misuse.

Groups lobbying against prescribing opioids for chronic pain remind us that the effectiveness of long-term opioid therapy has been inadequately studied.2 I believe that this is a case of absence of evidence rather than evidence of absence. As we await scientific evidence, questions remain regarding how best to address the epidemic of prescription-opioid misuse now. Groups advocating quick fixes believe that regulations that limit opioid availability are the best plan. This strategy is well intentioned and will certainly reduce opioid prescribing, but such blunt approaches will also limit access to opioids for patients who are benefiting or may potentially benefit from them.

Read the perspectives article via NEJM

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ANESTHESIOLOGY – FEB 2016 TOC

ON THE COVER: 
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Image source: Anesthesiology

Postoperative cognitive dysfunction is common. It remains uncertain if there are long-term adverse cognitive effects that are attributable to surgery combined with anesthesia. In this issue of Anesthesiology, Dokkedal et al. examined the association between exposure to surgery and level of cognitive function in a sample of 8,503 middle-aged and elderly twins. In an accompanying Editorial View, Avidan and Evers argue based on the existing evidence that persistent postoperative dysfunction is largely a fallacy. Their arguments are highlighted in this month’s infographic.

  • Dokkedal et al.: Cognitive Functioning after Surgery in Middle-aged and Elderly Danish Twins, p. 312

  • Avidan and Evers: The Fallacy of Persistent Postoperative Cognitive Decline, p. 255

  • Infographics in Anesthesiology: Persistent Postoperative Cognitive Decline? A Pyramid of Evidence, p. 21A

 

Podcast: James C. Eisenach – Overview of February issue editorials and original studies.

 

Read the transcript here

Cardiac arrhythmias in the critically ill

Gray, J. et al. Anaesthesia & Intensive Care Medicine. Available online: 25 January 2016

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Image source: Jer5150

Abstract: 

Arrhythmias are a common problem in the critically ill and they can have significant effects on patient outcome. They often require immediate and swift action and it is, therefore, essential that clinicians have a structured approach to the recognition and management of arrhythmias. Here, we provide a framework for the appropriate management of the more frequently encountered cardiac arrhythmias in critical care. We include the algorithms from the 2010 Resuscitation Council Guidelines for reference.

 

Read the abstract here

A comprehensive categorical and bibliometric analysis of published research articles on pediatric pain from 1975 to 2010

Caes, L. et a. Pain: February 2016 – Volume 157 – Issue 2 – p 302–313

Abstract:

The field of pediatric pain research began in the mid-1970s and has undergone significant growth and development in recent years as evidenced by the variety of books, conferences, and journals on the topic and also the number of disciplines engaged in work in this area.

Using categorical and bibliometric meta-trend analysis, this study offers a synthesis of research on pediatric pain published between 1975 and 2010 in peer-reviewed journals. Abstracts from 4256 articles, retrieved from Web of Science, were coded across 4 categories: article type, article topic, type and age of participants, and pain stimulus. The affiliation of the first author and number of citations were also gathered.

The results suggest a significant increase in the number of publications over the time period investigated, with 96% of the included articles published since 1990 and most research being multiauthored publications in pain-focused journals. First authors were most often from the United States and affiliated with a medical department. Most studies were original research articles; the most frequent topics were pain characterization (39.86%), pain intervention (37.49%), and pain assessment (25.00%). Clinical samples were most frequent, with participants most often characterized as children (6-12 years) or adolescents (13-18 years) experiencing chronic or acute pain.

The findings provide a comprehensive overview of contributions in the field of pediatric pain research over 35 years and offers recommendations for future research in the area.

Read the abstract here

Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research

Johnson, R. L. et al. British Journal of Anaesthesia. (2016) 116 (2): 163-176.

Background: This systematic review evaluated the evidence comparing patient-important outcomes in spinal or epidural vs general anaesthesia for total hip and total knee arthroplasty.

Methods: MEDLINE, Ovid EMBASE, EBSCO CINAHL, Thomson Reuters Web of Science, and the Cochrane Central Register of Controlled Trials from inception until March 2015 were searched. Eligible randomized controlled trials or prospective comparative studies investigating mortality, major morbidity, and patient-experience outcomes directly comparing neuraxial (spinal or epidural) with general anaesthesia for total hip arthroplasty, total knee arthroplasty, or both were included. Independent reviewers working in duplicate extracted study characteristics, validity, and outcomes data. Meta-analysis was conducted using the random-effects model.

Results: We included 29 studies involving 10 488 patients. Compared with general anaesthesia, neuraxial anaesthesia significantly reduced length of stay (weighted mean difference −0.40 days; 95% confidence interval −0.76 to −0.03; P=0.03; I2 73%; 12 studies). No statistically significant differences were found between neuraxial and general anaesthesia for mortality, surgical duration, surgical site or chest infections, nerve palsies, postoperative nausea and vomiting, or thromboembolic disease when antithrombotic prophylaxis was used. Subgroup analyses failed to find statistically significant interactions (P>0.05) based on risk of bias, type of surgery, or type of neuraxial anaesthesia.

Conclusion: Neuraxial anaesthesia for total hip or total knee arthroplasty, or both appears equally effective without increased morbidity when compared with general anaesthesia. There is limited quantitative evidence to suggest that neuraxial anaesthesia is associated with improved perioperative outcomes. Future investigations should compare intermediate and long-term outcome differences to better inform anaesthesiologists, surgeons, and patients on importance of anaesthetic selection.

Read the full article here

Cervical epidural analgesia in current anaesthesia practice: systematic review of its clinical utility and rationale, and technical considerations

Shanthanna, H. et al. British Journal of  Anaesthesia (2016) 116 (2): 192-207.

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Image source: Amin Ashaari

Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic changes, it has been used for various surgeries. There have been no previously published systematic reviews aimed at assessing its clinical utility. This systematic review was performed to explore the perioperative benefits of CEA. The review was also aimed at identifying the rationale of its use, reported surgical indications and the method of use.

We performed a literature search involving PubMed and Embase databases, to identify studies using CEA for surgical indications. Out of 467 potentially relevant articles, 73 articles were selected. Two independent investigators extracted data involving 5 randomized controlled trials, 17 observational comparative trials, and 51 case reports (series). The outcomes studied in most comparative studies were on effects of local anaesthetics and other agents, systemic effects, and feasibility of CEA. In one randomized controlled study, CEA was observed to decrease the resting pain scores after pharyngo-laryngeal surgeries. In a retrospective study, CEA was shown to decrease the cancer recurrence after pharyngeal-hypopharyngeal surgeries.

The limited evidence, small studies, and the chosen outcomes do not allow for any specific recommendations based on the relative benefit or harm of CEA. Considering the potential for significant harm, in the face of better alternatives, its use must have a strong rationale mostly supported by unique patient and surgical demands. Future studies must aim to assess analgesic comparator effectiveness for clinically relevant outcomes.

Read the abstract here

Cardiopulmonary resuscitation and post-resuscitation care

Mackenney, J. & Soar, J. Anaesthesia & Intensive Care Medicine. Available online: 18 January 2016

Abstract: 

Survival following cardiac arrest depends on early recognition and effective treatment with high-quality chest compressions with minimal interruption, ventilation, treatment of reversible causes, and defibrillation if appropriate.

Successfully resuscitated patients can develop a ‘SIRS-like’ post-cardiac arrest syndrome.

Post-cardiac arrest care includes coronary reperfusion, control of oxygenation and ventilation, circulatory support, glucose control, treatment of seizures, and therapeutic hypothermia. Prognostication in comatose survivors is challenging.

Approximately one-third of cardiac arrest survivors admitted to intensive care are discharged home.

Read the abstract here