Analgesic utilization before and after rescheduling of hydrocodone in a large academic level 1 trauma center.

BACKGROUND: Hydrocodone-containing products were recently rescheduled from Drug Enforcement Agency (DEA) schedule III to schedule II due to concerns of abuse and misuse. These changes went into effect on October 6, 2014. OBJECTIVE: This quality improvement project involved a retrospective analysis to determine the effect of the DEA schedule change on prescribing habits of hydrocodone-containing products as well as the remaining schedule III and IV opioids, codeine (schedule III) and tramadol (schedule IV). METHODS: The authors performed a medication use evaluation at our academic level 1 trauma hospital system on outpatient use of hydrocodone-containing products, tramadol, and codeine-containing products for 6 months before and 6 months after the change to schedule II using our electronic record and pharmacy system. RESULTS: A total of 88,428 prescription orders were analyzed. Comparison of prescriptions before and after the DEA schedule changes showed hydrocodone prescriptions reduced from an average of 225.97 per day to 1.20 per day. In addition, tramadol increased from 60.04 per day to 91.85 per day and codeine from 6.81 per day to 98.94 per day. CONCLUSIONS: Our data show a very substantial decrease in utilization of hydrocodone-containing products and concomitant increase in the utilization of tramadol and codeine products at our hospital after the DEA schedule change.

Using pulsed radiofrequency ablation to treat pain associated with a tumor involving the brachial plexus.

Pain associated with cancer is often difficult to treat, even more so when tumors involve peripheral nerves. Therapy is complex and often requires a multimodal approach that can include medications, radiation, and interventional techniques. These components are utilized with variable success, but are also limited by known complications or adverse effects. We present the case of a 53-year-old woman with a metastatic axillary tumor that involved her brachial plexus. Attempts to control her pain with medication were unsuccessful despite escalation and use of adjunct agents. She was not deemed to be a surgical candidate due to the size and location of the tumor. Radiation was discussed but, obviously, would not work immediately. Our team decided to employ a brachial plexus catheter for continuous nerve block, which provided almost complete relief of pain. Since her pain was deemed to be of peripheral etiology, pulsed radiofrequency ablation of her brachial plexus was used for more long-term pain relief. The patient responded very well with minimal pain issues and no apparent complications. On follow-up, the patient had good relief for almost 2 months. Pulsed radiofrequency is a poorly understood technology that has increasing evidence for certain pain conditions; however, for cancer and peripheral nerves the evidence is slim to none. Our case presents a successful use for pain management of a brachial plexopathy due to a tumor. We propose that pulsed radiofrequency may present a non-neurodestructive pain management technique for tumors involving peripheral nerves, though more data is definitely needed.