Green Light-Based Analgesia - Novel Nonpharmacological Approach to Fibromyalgia Pain: A Pilot Study.

BACKGROUND: There continues to be significant reliance on pharmacological modalities for the management of chronic pain, with a particular focus on opioid analgesics as a singular option for pain management. Fibromyalgia is a prototypical central pain disorder, which is often used as a model to study chronic pain disorders. It has an estimated prevalence of approximately 1.1% to 5.4% in the general population. The widespread use of opioids in patients with fibromyalgia has been well demonstrated in several health claims database studies, with rates of use ranging from 11.3% to 69%. Minimizing opioid exposures reduces misuse risk, but requires adequate opioid-sparing multimodal analgesic strategies, particularly nonopioid analgesic adjuncts, to ensure effective treatment of pain, particularly high-impact pain. We chose fibromyalgia as our study population. Given that it is a disordered sensory processing condition, it may be particularly amenable to the beneficial effects of green-light therapy. OBJECTIVES: Most studies have evaluated exposure to light-emitting diode lights as a mode of green-light delivery; our study used green-light filtering eyeglasses, which would allow the wearer to move about with minimal interference. STUDY DESIGN: We conducted a randomized controlled trial to test the feasibility of green-light filtering eyeglasses in the treatment of chronic pain. SETTING: This study was conducted at Duke University Health System. METHODS: We recruited and randomized adult patients with a known diagnosis of fibromyalgia patients and excluded patients who were unable to wear eyeglasses for at least 4 hours per day or were colorblind according to the Ishihara Colorblindness Test. Patients were assigned to 1 of 3 arms: clear eyeglasses (control), green eyeglasses, or blue eyeglasses. We initially recruited 45 patients and randomly assigned 15 patients per group. RESULTS: To evaluate clinical significance, we determined the rate of >= 10% decline in oral morphine equivalents and found that 33%, 11%, and 8% of the green, blue, and clear eyeglass groups, respectively, achieved this clinically meaningful outcome. LIMITATIONS: This study was powered to detect feasibility of the intervention, rather than conclusive analgesic effects. CONCLUSIONS: Our study demonstrated the feasibility of this treatment approach and study design and supports a future study to determine the efficacy of green light-based analgesia on opioid use, pain, and anxiety. While the reduction of opioid use was not of statistical significance, we believe it to be of clinical significance as there was no increase of patient-reported pain. This warrants further investigation in a large-scale trial of the use of green-light filtration of ambient light to mitigate opioid use and possible mediation of psychological impacts of pain with the use of green-lensed eyeglasses.

Opioids after a cesarean section: Prescribing, patient use, storage, and disposal practices.

Cesarean sections (C-sections) are commonly performed procedures, accounting for approximately one-third of births in the United States. This is often one of the first medical encounters for women which require prescription medications to manage post-operative pain. Our observational study looked at opioids prescribed and consumed for post-surgical C-section pain. We interviewed patients to examine handling practices of those who had excess opioids, including storage and disposal. Patients underwent a C-section at Duke University Health System from January 2017 through July 2018 and were pre-scribed opioids post-operatively. In this study, we observed 154 women who met inclusion criteria. Sixty women declined participation, and 15 could not recall the details of their opioid use. Of the 77 women who participated, most (97 percent) received oxycodone 5 mg tablets. About one-third of the women did not use any opioids, about one-third used all of their opioids, and the remainder used only a fraction of the pills prescribed. After sharing preliminary results with providers, they began prescribing fewer pills. Even then, only a fraction or none of the pills were used, and patients rarely required a renewal of pain prescriptions. We found only 1 percent of women stored their opioids in a secure location. These findings suggest an individualized approach to opioid prescribing along with nonopioid analgesics use may mitigate the consequences of excess opioid prescribing, which include lack of proper disposal and excess opioids in the community.

Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder.

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.

Pain Trajectories After Valve Surgeries Performed via Midline Sternotomy Versus Mini-Thoracotomy.

OBJECTIVES: Controlling moderate-to-severe pain remains a major challenge after cardiothoracic surgery. Several outcomes have been compared extensively after valve surgery performed via midline sternotomy versus mini-thoracotomy, but postoperative pain (POP) was not adequately examined. Therefore, the authors tested the hypothesis that there is no difference in POP trajectories in patients undergoing valve surgery via midline sternotomy versus mini-thoracotomy. DESIGN: An Institutional Review Board-approved retrospective study. SETTING: At a single, large academic medical center. PARTICIPANTS: Adult patients who underwent mitral or aortic valve surgeries over a 5-year period. INTERVENTIONS: The authors compared the characteristics of pain between valve surgery patients receiving either midline sternotomy or mini-thoracotomy. To identify pain score trajectories, the authors employed latent class linear mixed models and then used multinomial regression models to study the association between incision type and pain trajectory class. MEASUREMENTS AND MAIN RESULTS: The authors' cohort consisted of 1,660 surgical patients-544 (33%) received a midline sternotomy, and 1,116 (66%) received a mini-thoracotomy. The authors identified the following 4 pain trajectory classes: stationary, rapidly improving, slowly improving, and acute worsening pain. Compared to the rapidly improving class, the odds of belonging to the stationary (adjusted odds ratio [aOR] [95% CI] 1.45 [1.01- 2.08]; p = 0.04) or the acute worsening class (aOR [95% CI] 1.71 [1.10-2.67] p = 0.02) were significantly higher for sternotomy patients compared to mini-thoracotomy. CONCLUSIONS: Midline sternotomies are associated with higher odds of having an acute worsening or stationary versus a rapidly improving pain trajectory compared to mini-thoracotomies. Therefore, the choice of incision may play an important role in determining POP trajectory after valve surgery.

Pro-Con Debate: Anesthesiologist- Versus Hospitalist- Run Preoperative Clinics and Perioperative Care.

In this Pro-Con commentary article, we discuss the models, value propositions, and opportunities of preoperative clinics run by anesthesiologists versus hospitalists and their role in perioperative care. The medical and anesthesia evaluation before surgery has pivoted from the model of "clearance" to the model of risk assessment, preparation, and optimization of medical and psychosocial risk factors. Assessment of these risk factors, optimization, and care coordination in the preoperative period has expanded the roles of anesthesiologists and hospitalists as members of the perioperative care team. There is ongoing debate regarding which model of preoperative assessment provides the most optimal preparation for the patient undergoing surgery. This article hopes to shed light on this debate with the data and perspectives on these care models.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management.

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

Making a business plan for starting a transitional pain service within the US healthcare system.

Chronic pain imposes a tremendous economic burden of up to US$635 billion per year in terms of direct costs (such as the costs of treatment) and indirect costs (such as lost productivity and time away from work). In addition, the initiation of opioids for pain is associated with a more than doubling of pharmacy and all-cause medical costs. The high costs of chronic pain are particularly relevant for anesthesiologists because surgery represents an inciting event that can lead to chronic pain and long-term opioid use. While the presence of risk factors and an individual patient's postoperative pain trajectory may predict who is at high risk for chronic pain and opioid use after surgery, to date, there are few interventions proven to reduce these risks. One promising approach is the transitional pain service. Programs like this attempt to bridge the gap between acute and chronic pain management, provide continuity of care for complicated acute pain patients after discharge from the hospital, and offer interventions for patients who are on abnormal trajectories of pain resolution and/or opioid use. Despite awareness of chronic pain after surgery and the ongoing opioid epidemic, there are few examples of successful transitional pain service implementation in the USA. Key issues and concerns include financial incentives and the required investment from the hospital or healthcare system. We present an economic analysis and discussion of important considerations when developing a business plan for a transitional pain service.

Geospatial Variations and Neighborhood Deprivation in Drug-Related Admissions and Overdoses.

Drug overdoses are a national and global epidemic. However, while overdoses are inextricably linked to social, demographic, and geographical determinants, geospatial patterns of drug-related admissions and overdoses at the neighborhood level remain poorly studied. The objective of this paper is to investigate spatial distributions of patients admitted for drug-related admissions and overdoses from a large, urban, tertiary care center using electronic health record data. Additionally, these spatial distributions were adjusted for a validated socioeconomic index called the Area Deprivation Index (ADI). We showed spatial heterogeneity in patients admitted for opioid, amphetamine, and psychostimulant-related diagnoses and overdoses. While ADI was associated with drug-related admissions, it did not correct for spatial variations and could not account alone for this spatial heterogeneity.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain.

BACKGROUND CONTEXT: The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN: This is a guideline summary review. METHODS: This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. RESULTS: Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

Demographic Factors Associated with Patient-Reported Outcome Measures in Pain Management.

BACKGROUND: Pain control is strongly correlated with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) quality-of-care domains and overall hospital experience. Prior research implicates several factors in the variability of patients' pain management satisfaction scores, including but not limited to racial diversity, ethnic diversity, gender, socioeconomic status, and other cultural factors. OBJECTIVE: In this study, we examined responses to the HCAHPS survey in order to assess factors associated with patient-reported experiences of pain management. STUDY DESIGN: The study design involved a retrospective analysis of patient survey responses. SETTING: The research took place at a university-affiliated tertiary hospital. METHODS: The study was conducted in a university-affiliated tertiary hospital. Records for adult patients discharged between October 2015 and June 2017 were included. We obtained all patient responses to the HCAHPS pain management questions. We then performed a systematic statistical analysis to evaluate interactions between demographic factor variables and responses to the HCAHPS pain management questions. RESULTS: Between October 2015 and June 2017, 107,287 patients were discharged from the hospital. Of these, 13,026 of the respondents answered at least one of the HCAHPS pain management questions. Among HCAHPS pain-domain respondents, "Hispanic" and "Black or African American" respondents are more likely to report successful Pain Control when compared to "Not Hispanic" and "Caucasian/White," respectively (odds ratios [ORs] 1.60, 1.22). Additionally, among women, "Black or African American" respondents are more likely to report positive Staff Helpfulness than "Caucasian/White" respondents (OR 1.38).However, we also identified corresponding associations among HCAHPS pain-question responding and patient race/ethnicity: "Hispanic" and "Black/African American" patients were each less likely to respond to the HCAHPS pain questions (ORs 2.03, 2.74). LIMITATIONS: The primary limitation to this study was nonresponse bias; nevertheless, this is likely to be similar to bias experienced at other institutions. Additionally, this is a single institution study; however, given that the institution has a very large catchment area, we believe the results could be generalized to other settings. CONCLUSION: Response rates and responses to HCAHPS pain questions vary by race/ethnicity and sex. It appears likely that Hispanic and Black/African American patients underreport negative experiences. As HCAHPS surveys are used to inform decision-making within the US health care system, demographic biases in the survey data could lead to biases in care and resource allocation. KEY WORDS: Pain, HCAHPS, patient reported outcome measures, patient satisfaction, ethnicity, race.

The Opioid-Tolerant Patient: Opioid Optimization.

Chronic opioid use and abuse continue to plague our country despite efforts to curtail their use. Patients on chronic opioids (opioids tolerant) who undergo total joint arthroplasty have been clearly shown to have higher rates of complications, infection, and early revision compared to the opioid-naïve patients. The ability to successfully wean patients off of narcotics before surgery remains challenging and fragmented at best. The utilization of a multidisciplinary team that assists with not only preoperative opioids reduction but also postoperative opioids management is critical to the successful management of these patients. This symposium focuses on the opioid-tolerant patients and a comprehensive approach to opioids optimization.

Persistent postoperative pain: mechanisms and modulators.

PURPOSE OF REVIEW: Persistent postoperative pain (PPP) is a significant source of morbidity in our population. An excellent opportunity to understand the transition from acute to chronic pain states. Understanding the mechanisms that drive this and modulators that influence this transition is essential to both prevent and manage this condition. RECENT FINDINGS: Although the exact mechanism for the development of PPP is still poorly understood, hypotheses abound. Basic science research with animal models implicates nociceptive and neuropathic pain signals leading to pain sensitization due to persistent noxious signaling. Effects on the inhibitory modulation of noxious signaling in medullary-spinal pathways and descending modulation have also been implicated. SUMMARY: Persistent maladaptive neuroplastic changes secondary to neurotrophic factors and interactions between neurons and microglia may well explain the phenomenon. This article reviews the current thought processes on mechanisms and modulators from a basic science and epidemiological perspective.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy.

Enhanced recovery pathways have quickly become part of the standard of care for patients undergoing elective surgery, especially in North America and Europe. One of the central tenets of this multidisciplinary approach is the use of multimodal analgesia with opioid-sparing and even opioid-free anesthesia and analgesia. However, the current state is a historically high use of opioids for both appropriate and inappropriate reasons, and patients with chronic opioid use before their surgery represent a common, often difficult-to-manage population for the enhanced recovery providers and health care team at large. Furthermore, limited evidence and few proven successful protocols exist to guide providers caring for these at-risk patients throughout their elective surgical experience. Therefore, the fourth Perioperative Quality Initiative brought together an international team of multidisciplinary experts, including anesthesiologists, nurse anesthetists, surgeons, pain specialists, neurologists, nurses, and other experts with the objective of providing consensus recommendations. Specifically, the goal of this consensus document is to minimize opioid-related complications by providing expert-based consensus recommendations that reflect the strength of the medical evidence regarding: (1) the definition, categorization, and risk stratification of patients receiving opioids before surgery; (2) optimal perioperative treatment strategies for patients receiving preoperative opioids; and (3) optimal discharge and continuity of care management practices for patients receiving opioids preoperatively. The overarching theme of this document is to provide health care providers with guidance to reduce potentially avoidable opioid-related complications including opioid dependence (both physical and behavioral), disability, and death. Enhanced recovery programs attempt to incorporate best practices into pathways of care. By presenting the available evidence for perioperative management of patients on opioids, this consensus panel hopes to encourage further development of pathways specific to this high-risk group to mitigate the often unintentional iatrogenic and untoward effects of opioids and to improve perioperative outcomes.

A Perioperative Medicine Model for Population Health: An Integrated Approach for an Evolving Clinical Science.

Health care delivery in the United States continues to balance on the tight rope that connects its transition from volume to value. Value in economic terms can be defined as the amount something exceeds its commodity price and is determined by extraordinary reputation, quality, and/or service, whereas its destruction can be a consequence of poor management, unfavorable policy, decreased demand, and/or increased competition. Going forward, payment for health care delivery will increasingly be based on services that contribute to improvements in individual and/or population health value, and funds to pay for health care delivery will become increasingly vulnerable to competitive market forces. Therefore, a sustainable population health strategy needs to be comprehensive and thus include perioperative medicine as an essential component of the complete cycle of patient-centered care. We describe a multidisciplinary integrated program to support perioperative medicine services that are integral to a comprehensive population health strategy.

Postoperative Pain Management in Children of Hispanic Origin: A Descriptive Cohort Study.

BACKGROUND: It has been established that pain is frequently undertreated in children following outpatient surgery. Very few studies, however, have investigated this phenomenon in ethnically diverse populations. METHODS: This study included 105 families of children aged 2 to 15 years of Hispanic origin and low income undergoing outpatient tonsillectomy and adenoidectomy surgery. Participating parents completed baseline and demographic packets. Recorded postoperative pain ratings and administration of analgesics at home for 1 week were collected during home visits. RESULTS: Despite the high (70%; 99% confidence interval [CI], 57%-82%) incidence of significant pain in the first 24 hours home, 32% (95% CI, 20%-45%) of the children received 0 to 1 dose of analgesia. Overall, 21% children (99% CI, 11%-35%) received 4 or less total doses of pain medication over the entire week after surgery. Of the total analgesic doses administered to children in the week after surgery, only 44% (99% CI, 40%-47%) were in accepted ranges. CONCLUSIONS: Despite experiencing significant postoperative pain, Hispanic children assessed in this study received suboptimal analgesic therapy at home.

Morphine versus Hydromorphone: Does Choice of Opioid Influence Outcomes?

Morphine has traditionally been considered the first line agent for analgesia in hospitals; however, in the last few years there has been a shift towards the use of hydromorphone as a first line agent. We conducted a hospital population based observational study to evaluate the increasing use of hydromorphone over morphine in both medical and surgical populations. Additionally, we assessed the effect of this trend on three key outcomes, including adverse events, length of stay, and readmission rates. We evaluated data from the University Health Systems Consortium. Data from 38 hospitals from October 2010 to September 2013 was analyzed for patients treated with either hydromorphone or morphine. The use of morphine steadily decreased while use of hydromorphone increased in both medical and surgical groups. Rescue drugs were used more frequently in patients treated with hydromorphone in comparison to patients treated with morphine (p < 0.01). Patients receiving morphine tended to stay in the hospital for almost one day longer than patients receiving hydromorphone. However, 30-day all cause readmission rates were significantly higher in patients treated with hydromorphone (p < 0.01). Our study highlights that the choice of hydromorphone versus morphine may influence outcomes. There are implications related to resource utilization and these outcomes.

Pain Management in Pregnancy: Multimodal Approaches.

Nonobstetrical causes of pain during pregnancy are very common and can be incapacitating if not treated appropriately. Recent reports in the literature show that a significant percentage of pregnant women are treated with opioids during pregnancy. To address common pain conditions that present during pregnancy and the available pharmacological and nonpharmacological treatment options, for each of the pain conditions identified, a search using MEDLINE, PubMed, Embase, and Cochrane databases was performed. The quality of the evidence was evaluated in the context of study design. This paper is a narrative summary of the results obtained from individual reviews. There were significant disparities in the studies in terms of design, research and methodology, and outcomes analyzed. There is reasonable evidence available for pharmacological approaches; however, these are also associated with adverse events. Evidence for nonpharmacological approaches is limited and hence their efficacy is unclear, although they do appear to be primarily safe. A multimodal approach using a combination of nonpharmacological and pharmacological options to treat these pain conditions is likely to have the most benefit while limiting risk. Research trials with sound methodology and analysis of outcome data are needed.

Incidence of serotonin syndrome in patients treated with fentanyl on serotonergic agents.

BACKGROUND: There has been a recent surge in the literature highlighting the association of fentanyl as precipitating serotonin syndrome in patients on a serotonergic agent. OBJECTIVE: The purpose of our study was to understand the incidence of serotonin syndrome in patients who receive fentanyl while on serotonergic agents. STUDY DESIGN: This retrospective analysis was conducted from 2012 to 2013 after approval from the Institutional Review Board. We searched for all patients that had received a serotonergic agent and were admitted to the hospital during the study period. Next, we split these patients into 2 groups by placing all patients who had received fentanyl and a serotonergic agent into one group. We then searched for any of the Hunter Serotonin Toxicity Criteria in the records of patients that had received both fentanyl and a serotonergic agent. Further, we searched for all patients with serotonin syndrome mentioned in their records. SETTING: This study was conducted at a 900 bed tertiary care academic center. RESULTS: Over the 2 year study period, 112,045 patients were on a serotonergic agent, and 4,538 of these patients were treated with both fentanyl and a serotonergic agent. A search for Hunter's Criteria through the records of the patients receiving both fentanyl and a serotonergic agent revealed 23 patients had been documented with some of these symptoms. On detailed chart review, only 4 [95% CI 1 - 10] of these patients truly met Hunter's Criteria for serotonin syndrome. We then searched all admissions for a diagnosis code of serotonin syndrome during the study period. Five additional cases of serotonin syndrome were found, but none of these patients were treated with fentanyl. LIMITATIONS: Some of the limitations of our study include that it represents a single institution, although it is a large academic center. An inherent limitation may be the under diagnosis of serotonin syndrome. CONCLUSION: The incidence of serotonin syndrome in patients who receive both fentanyl and a serotonergic agent is low.