No place for routine use of modified-release opioids in postoperative pain management.

Modified-release opioid tablets were introduced into surgical practice in the belief that they provided superior pain relief and reduced nursing workload, and they rapidly became embedded into many perioperative pathways. Although national and international guidelines for the management of postoperative pain now advise against the use of modified-release opioids, they continue to be prescribed in many centres. Recognition that modified-release opioids show lack of benefit and increased risk of harm compared with immediate-release opioids in the acute, postoperative setting has become clear. Their slow onset and offset make rapid and safe titration of these opioids impossible, including down-titration as the patient recovers; pain relief may be less effective; they have been associated with an increased incidence of opioid-related adverse drug events, increased length of hospital stay, and higher readmission rates; and they lead to higher rates of opioid-induced ventilatory impairment and persistent postoperative opioid use. Evidence indicates that modified-release opioids should not be used routinely in the postoperative period.

Prescription of analgesia in emergency medicine (POEM) secondary analysis: an observational multicentre comparison of pain relief provided to adults and children with an isolated limb fracture and/or dislocation.

BACKGROUND: Acute pain is a common reason for emergency department (ED) attendance. Royal College of Emergency Medicine (RCEM) pain management audits have shown national variation and room for improvement. Previous evidence suggests that children receive less satisfactory pain management than adults. METHODS: Prescription of analgesia in emergency medicine is a cross-sectional observational study of consecutive patients presenting to 12 National Health Service EDs with an isolated long bone fracture and/or dislocation, and was carried out between 2015 and 2017. Using the recommendations in the RCEM Best Practice Guidelines, pain management in ED was assessed for differences of age (adults vs children) and hospital type (children's vs all patients). RESULTS: From the total 8346 patients, 38% were children (median age 8 years). There was better adherence to the RCEM guidance for children than adults (24% (766/3196) vs 11% (579/5123)) for the combined outcome of timely assessment, pain score and appropriate analgesia. In addition, children were significantly more likely than adults to receive analgesia appropriate to the pain score (of those with a recorded pain score 67% (1168/1744) vs 52% (1238/2361)). Children's hospitals performed much better across all reported outcomes compared with general hospitals. CONCLUSIONS: In contrast to previous studies, children with a limb fracture/dislocation are more likely than adults to have a pain score documented and to receive appropriate analgesia. Unexpectedly, children's EDs performed better than general EDs in relation to timely and appropriate analgesia but the reasons for this are not apparent from the present study.

Topical lidocaine for neuropathic pain in adults.

BACKGROUND: Lidocaine is a local anaesthetic that is sometimes used on the skin to treat neuropathic pain. OBJECTIVES: To assess the analgesic efficacy of topical lidocaine for chronic neuropathic pain in adults, and to assess the associated adverse events. SEARCH METHODS: We searched CENTRAL, MEDLINE, and EMBASE from inception to 1 July 2014, together with the reference lists of retrieved papers and other reviews. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal to identify additional published or unpublished data. SELECTION CRITERIA: We included randomised, double-blind studies of at least two weeks' duration comparing any formulation of topical lidocaine with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 and over. We included only full journal publication articles. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention-to-treat analysis without imputation for dropouts; at least 200 participants in the comparison, 8 to 12 weeks' duration, parallel design); second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison; and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. MAIN RESULTS: We included 12 studies (508 participants) in comparisons with placebo or an active control. Six studies enrolled participants with moderate or severe postherpetic neuralgia, and the remaining studies enrolled different, or mixed, neuropathic pain conditions, including trigeminal neuralgia and postsurgical or post-traumatic neuralgia. Four different formulations were used: 5% medicated patch, 5% cream, 5% gel, and 8% spray. Most studies used a cross-over design, and two used a parallel-group design. Two studies used enriched enrolment with randomised withdrawal. Seven studies used multiple doses, with one to four-week treatment periods, and five used single applications. We judged all of the studies at high risk of bias because of small size or incomplete outcome assessment, or both.There was no first or second tier evidence, and no pooling of data was possible for efficacy outcomes. Only one multiple-dose study reported our primary outcome of participants with ≥ 50% or ≥ 30% pain intensity reduction. Three single-dose studies reported participants who were pain-free at a particular time point, or had a 2-point (of 10) reduction in pain intensity. The two enriched enrolment, randomised withdrawal studies reported time to loss of efficacy. In all but one study, third tier (very low quality) evidence indicated that lidocaine was better than placebo for some measure of pain relief. Pooling multiple-dose studies across conditions demonstrated no clear evidence of an effect of lidocaine on the incidence of adverse events or withdrawals, but there were few events and the withdrawal phase of enriched enrolment designs is not suitable to assess the true impact of adverse events (very low quality evidence). AUTHORS' CONCLUSIONS: This review found no evidence from good quality randomised controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain. Clinical experience also supports efficacy in some patients. Several large ongoing studies, of adequate duration, with clinically useful outcomes should provide more robust conclusions about both efficacy and harm.

Changes in opioid prescribing during the COVID-19 pandemic in England: an interrupted time-series analysis in the OpenSAFELY-TTP cohort.

BACKGROUND: The COVID-19 pandemic disrupted health-care delivery, including difficulty accessing in-person care, which could have increased the need for strong pharmacological pain relief. Due to the risks associated with overprescribing of opioids, especially to vulnerable populations, we aimed to quantify changes to measures during the COVID-19 pandemic, overall, and by key subgroups. METHODS: For this interrupted time-series analysis study conducted in England, with National Health Service England approval, we used routine clinical data from more than 20 million general practice adult patients in OpenSAFELY-TPP, which is a a secure software platform for analysis of electronic health records. We included all adults registered with a primary care practice using TPP-SystmOne software. Using interrupted time-series analysis, we quantified prevalent and new opioid prescribing before the COVID-19 pandemic (January, 2018-February, 2020), during the lockdown (March, 2020-March, 2021), and recovery periods (April, 2021-June, 2022), overall and stratified by demographics (age, sex, deprivation, ethnicity, and geographical region) and in people in care homes identified via an address-matching algorithm. FINDINGS: There was little change in prevalent prescribing during the pandemic, except for a temporary increase in March, 2020. We observed a 9·8% (95% CI -14·5 to -6·5) reduction in new opioid prescribing from March, 2020, with a levelling of the downward trend, and rebounding slightly after April, 2021 (4·1%, 95% CI -0·9 to 9·4). Opioid prescribing rates varied by demographics, but we found a reduction in new prescribing for all subgroups except people aged 80 years or older. Among care home residents, in April, 2020, parenteral opioid prescribing increased by 186·3% (153·1 to 223·9). INTERPRETATION: Opioid prescribing increased temporarily among older people and care home residents, likely reflecting use to treat end-of-life COVID-19 symptoms. Despite vulnerable populations being more affected by health-care disruptions, disparities in opioid prescribing by most demographic subgroups did not widen during the pandemic. Further research is needed to understand what is driving the changes in new opioid prescribing and its relation to changes to health-care provision during the pandemic. FUNDING: The Wellcome Trust, Medical Research Council, The National Institute for Health and Care Research, UK Research and Innovation, and Health Data Research UK.

Current Issues in the Use of Opioids for the Management of Postoperative Pain: A Review.

Importance: Uncontrolled and indiscriminate prescribing of opioids has led to an opioid crisis that started in North America and spread throughout high-income countries. The aim of this narrative review was to explore some of the current issues surrounding the use of opioids in the perioperative period, focusing on drivers that led to escalation of use, patient harms, the move away from using self-reported pain scores alone to assess adequacy of analgesia, concerns about the routine use of controlled-release opioids for the management of acute pain, opioid-free anesthesia and analgesia, and prescription of opioids on discharge from hospital. Observations: The origins of the opioid crisis are multifactorial and may include good intentions to keep patients pain free in the postoperative period. Assessment of patient function may be better than unidimensional numerical pain scores to help guide postoperative analgesia. Immediate-release opioids can be titrated more easily to match analgesic requirements. There is currently no good evidence to show that opioid-free anesthesia and analgesia affects opioid prescribing practices or the risk of persistent postoperative opioid use. Attention should be paid to discharge opioid prescribing as repeat and refill prescriptions are risk-factors for persistent postoperative opioid use. Opioid stewardship is paramount, and many governments are passing legislation, while statutory bodies and professional societies are providing advice and guidance to help mitigate the harm caused by opioids. Conclusions and Relevance: Opioids remain a crucial part of many patients' journey from surgery to full recovery. The last few decades have shown that unfettered opioid use puts patients and societies at risk, so caution is needed to mitigate those dangers. Opioid stewardship provides a multilayered structure to allow continued safe use of opioids as part of broad pain management strategies for those patients who benefit from them most.

Hopes and fears before opioid tapering: a quantitative and qualitative study of patients with chronic pain and long-term opioids.

BACKGROUND: It is clear that the risks of opioids in chronic pain outweigh the benefits, creating a drive for clinicians to support patients taper and stop long-term opioids. However, it is not known how patients who have been taking these medicines for months or years feel about reducing them. Using quantitative and qualitative data, this study describes the psychological complexity of these patients and examines their hopes and fears before opioid reduction. METHODS: Sixty patients attending the opioid clinic completed psychological and pain questionnaires, providing quantitative data, just before they commenced opioid tapering. They scored the severity of opioid side effects and completed a free text framework to express their beliefs about stopping or continuing opioids. A phenomenological approach was used to identify common qualitative themes. RESULTS: Most patients were taking opioid doses above the UK recommended maximum dose and reported severe pain with high pain interference. Over 80% of patients described significant depression and 60% significant anxiety. Negative themes around stopping opioids were more common than positive ones, with 63% patients fearing increased pain. A quarter of patients referred to addiction and 16% feared withdrawal. Five patients hoped for a better quality of life; seven feared a worse one. Opioid side effects were common and severe. CONCLUSION: Patients with chronic pain taking long-term opioids demonstrate high psychological distress and low self-efficacy. Their concerns around opioid tapering relate to pain, quality of life and withdrawal. Identifying and addressing patients' individual concerns should increase the likelihood of successful opioid tapering.

Prescription Of analgesia in Emergency Medicine (POEM): a multicentre observational survey of pain relief in patients presenting with an isolated limb fracture and/or dislocation.

BACKGROUND: Acute pain is one of the most commonly cited reasons for attendance to the emergency department (ED), and the Royal College of Emergency Medicine (RCEM) Best Practice Guideline (2014) acknowledged that the current management of acute pain in UK EDs is inadequate and has a poor evidence base. METHODS: The Prescription Of analgesia in Emergency Medicine (POEM) survey is a cross-sectional observational survey of consecutive patients presenting to 12 National Health Service (NHS) EDs with limb fracture and/or dislocation in England and Scotland and was carried out between 2015 and 2017. The primary outcome was to assess the adequacy of pain management in the ED against the recommendations in the RCEM Best Practice Guidelines. RESULTS: In all, 8346 patients were identified as attending the ED with a limb fracture and/or dislocation but adherence to RCEM guidelines could only be evaluated for the 4160 (49.8%) patients with a recorded pain score. Of these, 2409/4160 (57.9%) patients received appropriate pain relief, but only 1347 patients were also assessed within 20 minutes of their arrival in the ED. Therefore, according to the RCEM guidelines, only 16.1% (1347/8346) of all patients were assessed and had satisfactory pain management in the ED. CONCLUSIONS: The POEM survey has identified that pain relief for patients with an isolated limb fracture remains inadequate when strictly compared to the RCEM Best Practice Guidelines. However, we have found that some patients receive analgesia despite having no pain score recorded, while other analgesic modalities are provided that are not currently encompassed by the Best Practice Guidelines. Future iterations of these guidelines may wish to encompass the breadth of available modalities of pain relief and the whole patient journey. In addition, more work is needed to improve timely and repeated assessment of pain and its recording, which has been better achieved in some EDs than others.

Caesarean delivery: Bringing more than just a bundle of joy.

Background: Chronic postsurgical pain (CPSP) is a potential complication of all surgical procedures, including caesarean delivery (CD). Psychological factors such as anxiety and depression with negative coping strategies are known to increase the risk of the development of CPSP. Aim: This short review will appraise some additional features that are unique to CD and assess the interplay between them and persisting pain. Methods: This is a narrative review with a focus on describing relevant features associated with the development of CPSP after CD. Results: Hormone changes, postpartum depression, breastfeeding, and sleep disturbance each may affect the mother's pain in the short and long term. Together they have the potential to negatively impact the mother-infant bond. Conclusions: In the weeks after delivery, pain, depression, and poor sleep negatively impact the mother's quality of life and her ability to care for, and bond with, her baby. This represents a critical time for the emotional, social, and behavioral development of the infant. Far-reaching benefits for the whole family may be realized by the early identification and management of persisting postoperative pain and postpartum depression.

Contexte: La douleur chronique postopératoire est une complication possible de toutes les interventions chirurgicales, y compris l'accouchement par césarienne. Il est bien connu que certains facteurs psychologiques comme l'anxiété et la dépression, assortis de stratégies d'adaptation négatives, augmentent le risque de souffrir de douleur chronique postopératoire.But: Ce bref examen porte sur certaines caractéristiques particulières de l'accouchement par césarienne et évalue l'interaction entre celles-ci et la douleur persistante.Méthodes: Un examen narratif mettant l'accent sur la description des caractéristiques pertinentes associées au développement de la douleur chronique post-chirurgicale après un accouchement par césarienne.Résultats: Les changements hormonaux, la dépression postpartum, l'allaitement et les perturbations du sommeil peuvent tous affecter la douleur de la mère à court terme et à long terme. Ensemble, ils peuvent avoir un effet négatif sur le lien entre la mère et le nourrisson.Conclusions: Dans les semaines suivant l'accouchement, la douleur, la dépression et les problèmes de sommeil peuvent avoir des répercussions négatives sur la qualité de vie de la mère, ainsi que sur sa capacité à s'occuper de son bébé et à créer un lien avec lui. Il s'agit d'un moment de première importance pour le développement émotionnel, social et comportemental de l'enfant. La détection précoce et la prise en charge de la douleur postopératoire persistante ainsi que de la dépression postpartum peuvent avoir des bienfaits de grande portée pour toute la famille.

Perioperative opioid use and misuse.

Prescribed opioid misuse in North America is a public health crisis, with huge social, medical and economic repercussions. Surgery is an identified driver for persistent opioid use and misuse. The UK has also seen a surge in opioid consumption per capita and it is now necessary for primary and secondary care to work together to mitigate the problem of perioperative prescribed opioid misuse.This review discusses the identified drivers for persistent opioid use following surgery and discusses the remedial actions that must be taken by all stakeholders to mitigate the UK developing its own perioperative prescribed opioid crisis.

Opioid prescribing trends and geographical variation in England, 1998-2018: a retrospective database study.

BACKGROUND: There is a call for greater monitoring of opioid prescribing in the UK, particularly of strong opioids in chronic pain, for which there is little evidence of clinical benefit. We aimed to comprehensively assess trends and variation in opioid prescribing in primary care in England, from 1998 to 2018, and to assess factors associated with high-dose opioid prescribing behaviour in general practices. METHODS: We did a retrospective database study using open data sources on prescribing for all general practices in England. For all standard opioids we calculated the number of items prescribed, costs, and oral morphine equivalency to account for variation in strength. We assessed long-term prescribing trends from 1998 to 2017, patterns of geographical variation for 2018, and investigated practice factors associated with higher opioid prescribing. We also analysed prescriptions for long-acting opioids at high doses. FINDINGS: Between 1998 and 2016, opioid prescriptions increased by 34% in England (from 568 per 1000 patients to 761 per 1000). After correcting for total oral morphine equivalency, the increase was 127% (from 190 000 mg to 431 000 mg per 1000 population). There was a decline in prescriptions from 2016 to 2017. If every practice prescribed high-dose opioids at the lowest decile rate, 543 000 fewer high-dose prescriptions could have been issued over a period of 6 months. Larger practice list size, ruralness, and deprivation were associated with greater high-dose prescribing rates. The clinical commissioning group to which a practice belongs accounted for 11·7% of the variation in high-dose prescribing. We have developed a publicly available interactive online tool, OpenPrescribing.net, which displays all primary care opioid prescribing data in England down to the individual practice level. INTERPRETATION: Failing to account for opioid strength would substantially underestimate the true increase in opioid prescribing in the National Health Service (NHS) in England. Our findings support calls for greater action to promote best practice in chronic pain prescribing and to reduce geographical variation. This study provides a model for routine monitoring of opioid prescribing to aid targeting of interventions to reduce high-dose prescribing. FUNDING: National Institute for Health Research (NIHR) School of Primary Care Research, NIHR Biomedical Research Centre Oxford, NHS England.

Acute pain management in patients with drug dependence syndrome.

Managing patients with dependence requires knowledge of pharmacology; an understanding of the diagnosis of dependence and recognition of withdrawal; skills in communication and collaborative working; and a nonjudgmental, empathic attitude.

A self-report-based study of the incidence and associations of sexual dysfunction in survivors of intensive care treatment.

OBJECTIVES: To determine the incidence and associations of sexual dysfunction in survivors of intensive care unit treatment in their first year after hospital discharge using a self-report measure. DESIGN: A prospective observational study. SETTING: ICU Follow-up Clinic, The Royal Berkshire Hospital, Reading. SUBJECTS: One hundred and twenty-seven patients aged 18 years and over who spent 3 days or more in the intensive care unit. MAIN OUTCOME MEASURES: Demographic data; reported incidence of sexual dysfunction and post-traumatic stress disorder symptomatology; association between reported sexual dysfunction and age, gender, post-traumatic stress disorder symptomatology and length of intensive care unit stay; patient and partner satisfaction with current sex life. RESULTS: Fifty-two patients (43.6%) reported symptoms of sexual dysfunction. There was a significant association between sexual dysfunction and post-traumatic stress disorder symptomatology (p = 0.019). There was no association between reported sexual dysfunction and gender (p = 0.33), age (p = 0.8) or intensive care unit length of stay (p = 0.41). Forty-five per cent of patients and 40% of partners were not satisfied with their current sex life. No other medical practitioner had sought symptoms of sexual dysfunction during the study period. CONCLUSIONS: Symptoms of sexual dysfunction are common in patients recovering from critical illness and appear to be significantly associated with the presence of post-traumatic stress disorder symptomatology. The intensive care unit follow-up clinic is a suitable forum for the screening and referral of patients with sexual dysfunction.