Caring for Our Patients With Opioid Use Disorder in the Perioperative Period: A Guide for the Anesthesiologist.

Opioid use disorder (OUD) is a rising public health crisis, impacting millions of individuals and families worldwide. Anesthesiologists can play a key role in improving morbidity and mortality around the time of surgery by informing perioperative teams and guiding evidence-based care and access to life-saving treatment for patients with active OUD or in recovery. This article serves as an educational resource for the anesthesiologist caring for patients with OUD and is the second in a series of articles published in Anesthesia & Analgesia on the anesthetic and analgesic management of patients with substance use disorders. The article is divided into 4 sections: (1) background to OUD, treatment principles, and the anesthesiologist; (2) perioperative considerations for patients prescribed medications for OUD (MOUD); (3) perioperative considerations for patients with active, untreated OUD; and (4) nonopioid and nonpharmacologic principles of multimodal perioperative pain management for patients with untreated, active OUD, or in recovery. The article concludes with a stepwise approach for the anesthesiologist to support OUD treatment and recovery. The anesthesiologist is an important leader of the perioperative team to promote these suggested best practices and help save lives.

New-Onset Tinnitus After Dorsal Root Ganglion Stimulator Implantation: A Case Report.

Dorsal column (dcSCS) and dorsal root ganglion stimulation (DRG-S) complications are similar, typically related to placement and device failure. We present the first case of tinnitus after DRG-S implantation. The patient presented with complex regional pain syndrome (CRPS) type 2. After previous failed treatments, she had a lumbosacral DRG-S trial, which provided relief; however, she briefly noted ringing in her ears. After permanent implantation, she reported persistent, intolerable left-sided tinnitus. Tinnitus can be modulated by secondary somatosensory inputs to the cochlear nucleus from the dcSCS. Therefore, lumbosacral DRG-S stimulating distal sensory neurons leading to tinnitus is a feasible complication.

Radiofrequency ablation of the hip: review.

Radiofrequency ablation (RFA) of the articular branches of the femoral and obturator nerves (the innervation of the anterior capsule of the hip) is an emerging treatment for chronic hip pain. Body mass index (BMI) greater than 30, older age, large acetabular/femoral head bone marrow lesions, chronic widespread pain, depression, and female sex increase the risk of developing hip pain. Chronic hip pain is a common condition with a wide range of etiologies, including hip osteoarthritis (OA), labral tears, osteonecrosis, post total hip arthroplasty (THA), post-operative dislocation/fracture, and cancer. The most common and well studied is hip OA. Management of chronic hip pain includes conservative measures (pharmacotherapy and exercise), surgery, and percutaneous procedures such as RFA. While surgery is effective, those whose medical comorbidities preclude surgery, those who do not wish to have surgery, and those whose pain persists after surgery (11-36% of patients) could benefit from RFA. Because of the aforementioned circumstances, hip RFA is often a palliative intervention. Hip RFA is an effective treatment, one recent retrospective study of 138 patients found 69% had >50% pain relief at 6 months. The most frequent adverse event reported for hip RFA is pain from needle placement. No serious bleeding events have been reported, despite the valid concern of the procedure's proximity to vasculature. This descriptive review details the pathophysiology of hip pain, its etiologies, its clinical presentation, conservative management, the anatomy/technique of hip RFA, hip RFA efficacy, and RFA adverse events.

Needs-based novel digital curriculum for the neuromodulation training deficit: Pain Rounds.

This study reports the needs-based development, effectiveness and feasibility of a novel, comprehensive spinal cord stimulation (SCS) digital curriculum designed for pain medicine trainees. The curriculum aims to address the documented systematic variability in SCS education and empower physicians with SCS expertise, which has been linked to utilization patterns and patient outcomes. Following a needs assessment, the authors developed a three-part SCS e-learning video curriculum with baseline and postcourse knowledge tests. Best practices were used for educational video production and test-question development. The study period was from 1 February 2020 to 31 December 2020. A total of 202 US-based pain fellows across two cohorts (early-fellowship and late-fellowship) completed the baseline knowledge assessment, while 122, 96 and 88 participants completed all available post-tests for Part I (Fundamentals), Part II (Cadaver Lab) and Part III (Decision Making, The Literature and Critical Applications), respectively. Both cohorts significantly increased knowledge scores from baseline to immediate post-test in all curriculum parts (p<0.001). The early-fellowship cohort experienced a higher rate of knowledge gain for Parts I and II (p=0.045 and p=0.027, respectively). On average, participants viewed 6.4 out of 9.6 hours (67%) of video content. Self-reported prior SCS experience had low to moderate positive correlations with Part I and Part III pretest scores (r=0.25, p=0.006; r=0.37, p<0.001, respectively). Initial evidence suggests that Pain Rounds provides an innovative and effective solution to the SCS curriculum deficit. A future controlled study should examine this digital curriculum's long-term impact on SCS practice and treatment outcomes.

A Survey on the Choice of Spinal Cord Stimulation Parameters and Implantable Pulse Generators and on Reasons for Explantation.

Objective: Spinal Cord Stimulation (SCS) is a vital treatment for chronic intractable pain. In the last few years, the field has undergone dramatic changes in new waveform and frequency introduction as well as device miniaturization. It is important to understand contemporary practice patterns regarding these parameters. Methods: We surveyed the active membership of Spine Intervention Society (SIS), and American Society of Regional Anesthesia (ASRA) on their practices regarding various aspects of Spinal Cord Stimulation therapy. Here we report on SCS waveform usage, battery types, and causes of explant in this cohort of providers. Results: There was similar degree of usage of tonic, burst, and 10 kHz usage at 71.5%, 74.1% and 61.7% respectively. Dorsal root ganglion stimulation was used by 32.6% and other modes of stimulation by 13.5%. Rechargeable systems were often or always used by 67.2% whereas 10% never used a rechargeable system. Most common cause of explant was loss of effectiveness, reported by 53.7%. Conclusion: There has been significant adoption of new waveforms in daily practice of spinal cord stimulation therapy and there is robust mixed usage of new waveforms and frequencies. Rechargeable systems are the most commonly used but primary cell is also used in significant numbers. Loss of efficacy remains the most common cause of explant for the majority of practitioners. This survey establishes practice patterns of SCS usage regarding these important variables against which future changes can be gauged.

Presence of opioid safety initiatives, prescribing patterns for opioid and naloxone, and perceived barriers to prescribing naloxone: Cross-sectional survey results based on practice type, scope, and location.

BACKGROUND AND OBJECTIVES: The opioid epidemic is a public health crisis in the United States (US) and is associated with devastating consequences, including opioid misuse and related overdose. In response to the opioid crisis, the US Department of Health and Human Services is advancing improved practices in pain management. Strategies to help mitigate opioid risks include physician safety programs, hospital- or practice-based initiatives, patient education, and harm reduction campaigns that include the use of naloxone. To date, little information is available regarding the use of these strategies among healthcare providers. A survey was conducted to identify the presence of opioid safety initiatives, prescribing patterns of opioids and naloxone, and perceived barriers to prescribing naloxone. The presence of these strategies was compared between different practice types (hospital-based/academic vs. private practice), practice scope (chronic pain vs. "other"), and practice location (in the US vs. outside the US) Regarding "outside the US," the actual geographical distribution of those countries was not captured by respondents. METHODS: A 13-question web-based anonymous cross-sectional survey was sent to members of the American Society of Regional Anesthesia and Pain Medicine and the Women in Pain Medicine online community via email and social media (Twitter and Facebook). Survey questions were designed to ascertain the presence of opioid safety initiatives, opioid and naloxone prescribing patterns, and perceived barriers to prescribing naloxone based on practice type (hospital-based/academic vs. private practice), scope (chronic pain vs. "other"), and location (in the US vs. outside the US). RESULTS: Opioid safety initiatives: The presence of physician safety initiatives was found to be statistically higher among hospital-based/academic practices. No statistical difference was found for hospital- or practice-based, patient education, or harm reduction initiatives for different practice types (hospital-based/academic vs. private practice). The presence of patient education initiatives is statistically higher for chronic pain providers versus others. No statistical difference was found for physician safety, hospital- or practice-based, or harm reduction initiatives among the different practice scopes (chronic pain vs. others). The presence of opioid safety initiatives is statistically higher in the US compared with outside the US Prescribing patterns for opioids: Hospital-based/academic practices are more likely to prescribe opioids to patients suspected of the following: illicit or nonmedical drug use, recently released from prison or correctional facility, in opioid detoxification, a mandatory medication treatment program, and/or a current methadone maintenance program, and those having difficulty accessing emergency medical services. Chronic pain providers are more likely to prescribe opioids to patients taking antidepressants compared with "other" providers. Other providers are more likely to prescribe opioids to patients suspected of the following: illicit or nonmedical drug use, recently released from prison or correctional facility, in opioid detoxification, in mandatory medication treatment programs, in current methadone maintenance programs, and patients having difficulty accessing emergency medical services. There is no difference in opioid prescribing patterns based on practice location. Prescribing pattern for naloxone: Chronic pain providers and providers in the US are more likely to prescribe/recommend naloxone and are more aware of a state's medical board guidelines on naloxone prescribing. There is no statistical difference between practice types. Most providers, regardless of practice type, scope, or location, will coprescribe naloxone at a morphine milligram equivalent per day threshold of >50. Hospital-based/academic practices are more likely to prescribe naloxone to patients with opioid prescriptions and coexisting respiratory disease. Chronic pain providers are more likely to prescribe naloxone for patients with methadone prescriptions in opioid-naïve populations, coexisting respiratory, hepatic and/or renal dysfunction, known or suspected alcohol use, coprescribed benzodiazepine or antidepressants, and those having difficulty accessing emergency medical services. Based on practice location, providers in the US are more likely to prescribe naloxone for patients with opioid prescriptions and coexisting hepatic and/or renal dysfunction, known or suspected alcohol use, coprescribed benzodiazepine or antidepressants, recently released from a correctional facility, opioid detoxification program or mandatory abstinence program, and those having difficulty accessing emergency medical services. Perceived barriers to prescribing naloxone: We found no statistical difference regarding obstacles to prescribing naloxone based on practice type. The cost of the medication and lack of interest from patients are perceived barriers encountered by chronic pain providers versus other providers who do not have enough knowledge regarding when and how to prescribe for a patient. Based on practice location, perceived barriers for providers in the US are related to medication costs and lack of interest from patients. CONCLUSION: While some improvements have been achieved in the fight against the opioid epidemic, our survey results indicate that further knowledge is needed to determine the potential obstacles to implementing opioid safety initiatives, understanding prescribing practices for opioids and naloxone, and lowering the barriers to prescribing naloxone based on practice type, scope, and location.

Telemedicine and current clinical practice trends in the COVID-19 pandemic.

Telemedicine is the medical practice of caring for and treating patients remotely. With the spread of the coronavirus disease-2019 (COVID-19) pandemic, telemedicine has become increasingly prevalent. Although telemedicine was already in practice before the 2020 pandemic, the internet, smartphones, computers, and video-conferencing tools have made telemedicine easily accessible and available to almost everyone. However, there are also new challenges that health care providers may not be prepared for, including treating and diagnosing patients without physical contact. Physician adoption also depends upon reimbursement and education to improve the telemedicine visits. We review current trends involving telemedicine, how pandemics such as COVID-19 affect the remote treatment of patients, and key concepts important to healthcare providers who practice telemedicine.

Spinal Cord Stimulator Placement in Patient With von Willebrand Disease: A Case Report.

Complex regional pain syndrome (CRPS) is a regional neuropathic pain syndrome. Excruciating pain often interferes with patients' ability to function normally. Spinal cord stimulators (SCS) have been effective in treating pain along with signs of sympathetic overactivity in patients with CRPS. Implantation of SCS is a high-risk interventional procedure with the potential for serious bleeding and neurological consequences in the spine. Meticulous evaluation and careful optimization are needed in patients with bleeding disorders.

Substantial Elevation of Liver Enzymes During Ketamine Infusion: A Case Report.

Intravenous infusion of a subanesthetic dose of ketamine has been shown to improve neuropathic pain. However, ketamine-induced liver injury can occur. Reported here are 2 cases with substantial liver enzyme elevations less than 2 days after initiation of repeat ketamine infusion at least 7 months after the last infusion. Although their liver enzymes normalized within a few weeks, it is unclear what the long-term consequences are. Furthermore, drug-induced liver injury can cause acute liver failure. Therefore, we recommend close monitoring of liver enzymes every 1 to 2 days during ketamine infusions.

Low-Dose Intrathecal Ziconotide for Spasticity From Primary Lateral Sclerosis: A Case Report.

Spasticity can be very debilitating and painful. We present a case of severe spasticity from primary lateral sclerosis refractory to intrathecal baclofen in doses up to 1100 µg/d. Baclofen was weaned down and switched to intrathecal ziconotide at 0.6 µg/d. The dose was then titrated up to 3 µg/d with excellent control of spasticity. This case suggests that low-dose intrathecal ziconotide should be considered in patients with lower extremity spasticity refractory to intrathecal baclofen.

Sphenopalatine Ganglion Blocks in the Management of Head and Neck Cancer-Related Pain: A Case Series.

Head and neck cancer can be painful, debilitating, and refractory to oral medications. Due to the association of the sphenopalatine ganglion (SPG) with maxillary nerve sensory fibers, SPG blocks may be used to treat the pain of the hard and soft palate, tonsils, nasal cavity, paranasal sinuses, oral gingiva, premaxillary soft tissue, maxilla, and orbital floor. We present the first case series of performing SPG blocks utilizing TX360 nasal atomizers or angiocatheters to treat head and neck cancer-related pain. Pain scores were reduced by 38% to 80% with an average pain relief duration of 23 days.

Sympathetic blocks for complex regional pain syndrome: a survey of pain physicians.

BACKGROUND: Sympathetic blocks (SB) are commonly used to treat pain from complex regional pain syndrome (CRPS). However, there are currently no guidelines to assist pain physicians in determining the best practices when using and performing these procedures. METHODS: A 32-question survey was developed on how SBs are used and performed to treat CRPS. The survey was conducted online via SurveyMonkey. The responses were statistically analyzed using descriptive statistics, and comparing academic versus non-academic, and fellowship versus non-fellowship-trained physicians. RESULTS: A total of 248 pain physicians responded with a response rate of 37%. Forty-four percent of respondents schedule the first SB at the first clinic visit; 73% perform one to three consecutive blocks; over 50% will repeat the block if a patient receives at least 50% pain relief from the previous one lasting 1-7 days.Fifty-four percent of respondents perform stellate ganglion blocks (SGB) at the C6 vertebral level, 41% at C7; 53% perform lumbar sympathetic blocks (LSB) at L3 level, 39% at L2; 50% use fluoroscopy to guide SGB, 47% use ultrasound. More respondents from academic than non-academic centers use ultrasound for SGB. About 75% of respondents use a total volume of 5-10 mL for SGB and 10-20 mL for LSB. The most commonly used local anesthetic is 0.25% bupivacaine. About 50% of respondents add other medications, mostly steroids, for these blocks. CONCLUSION: Our study showed a wide variation in current practice among pain physicians in treating CRPS with SBs. There is a clear need for evidence-based guidelines on when and how to perform SBs for CRPS.

Postoperative oxycodone toxicity in a patient with chronic pain and end-stage renal disease.

We present this case to review the metabolism of oxycodone and the effects of end-stage renal disease on the elimination of oxycodone and its metabolites. A 42-year-old female with end-stage renal disease who was dependent on hemodialysis presented for left hamstring posterior capsule release. She had been receiving methadone for 2 years for chronic leg pain. On postoperative day 1, the patient's medication was changed from IV hydromorphone to oral oxycodone to treat breakthrough pain. By the next day, the patient was unarousable with notable respiratory depression. She did not fully recover after urgent hemodialysis but did have full recovery after receiving an IV naloxone infusion for 22 hours. Further study of the safety of oxycodone in hemodialysis patients is warranted.