Current Topics: Opioid Focus
Journal CME - 2016 March
Background: N-methyl-d-aspartate receptor antagonists have been shown to reduce perioperative pain and opioid use. Theauthors performed a meta-analysis to determine whether the use of perioperative dextromethorphan lowers opioid consumption or pain scores. Methods: PubMed, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Pubget, and EMBASE were searched. Studies were included if they were randomized, double-blinded, placebo-controlled trials written in English, and performed on patients 12 yr or older. For comparison of opioid use, included studies tracked total consumption of IV or intramuscular opioids over 24 to 48 h. Pain score comparisons were performed at 1, 4 to 6, and 24 h postoperatively. Difference in means (MD) was used for effect size.
Expiration Date: 02/15/2019
Journal CME - 2018 May
Journal CME - 2018 May Background: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive largescale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization. Methods: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into “opioids only” and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported. Results: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to “opioids only”) experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a –18.5% decrease in opioid prescription (95% CI, –19.7% to –17.2%; 205 vs. 300 overall median oral morphine equivalents), and a –12.1% decrease (95% CI, –12.8% to –11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used. Conclusions: While the optimal multimodal regimen is still not known, the authors’ findings encourage the combined use of multiple modalities in perioperative analgesic protocols.
Expiration Date: 04/16/2021
Journal CME - 2018 July
Background: The value of intravenous acetaminophen in postoperative pain management remains debated. The authors tested the hypothesis that intravenous acetaminophen use, in isolation and in comparison to oral, would be associated with decreased opioid utilization (clinically significant reduction defined as 25%) and opioid-related adverse effects in open colectomy patients. Methods: Using national claims data from open colectomy patients (Premier Healthcare Database, Premier Healthcare Solutions, Inc., USA; 2011 to 2016; n = 181,640; 602 hospitals), we separately categorized oral and intravenous acetaminophen use: 1 (1,000 mg) or more than 1 dose on the day of surgery, postoperative day 1, or later. Multilevel models measured associations between intravenous or oral acetaminophen and (1) opioid utilization and (2) opioid-related adverse effects. Percent change and multiplicity-adjusted 99.5% CI are reported. Results: Overall, 25.1% of patients received intravenous acetaminophen, of whom 48.0% (n = 21,878) received 1 dose on the day of surgery. In adjusted analyses, particularly more than 1 dose of intravenous acetaminophen (versus nonuse) on postoperative day 1 was associated with a -12.4% (99.5% CI, -15.2 to -9.4%) change in opioid utilization. In comparison, a stronger reduction was seen in those receiving more than 1 oral acetaminophen dose: -22.6% (99.5% CI, -26.2 to -18.9%). Unadjusted group medians were 550 and 490 oral morphine equivalents, respectively. Intravenous versus oral differences were less pronounced among those receiving more than 1 acetaminophen dose on the day of surgery: -8.0% (99.5% CI, -11.0 to -4.9%) median 499 oral morphine equivalents versus -8.7% (99.5% CI, -14.4 to -2.7%) median 445 oral morphine equivalents, respectively; all statistically significant, but none clinically significant. Comparable outcome patterns existed for opioid-related adverse effects. Conclusions: The demonstrated marginal effects do not support routine use of intravenous acetaminophen given alternative nonopioid analgesic options.
Expiration Date: 06/18/2021
Customizing Pain Management in the Ambulatory Setting
This course helps you improve patient care in the treatment of pain management in four different outpatient settings covering anesthesia: emergency medicine, urology, orthopedics and plastic surgery. Learners will explore multimodal approaches to post-operative analgesia to optimize care with an emphasis on evidence-based recommendations. Links to clinical trial data and guidelines are cited throughout each activity as a resource to reinforce learning. Minimize complications and learn the current techniques for managing acute perioperative pain in these patient settings while earning up to 2 AMA PRA Category 1 Credits™. This activity contributes to the patient safety CME requirement for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program® (MOCA®), known as MOCA 2.0™. Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Through the American Board of Medical Specialties (“ABMS”) and Association of American Medical Colleges’ (“AAMC”) joint initiative (ABMS MOC Directory) to create a wide array of Maintenance of Certification (“MOC”) Activities, Customizing Pain Management in the Ambulatory Setting has met the MOC requirements as a MOC Part II CME Activity (apply toward general CME requirement) by the following ABMS Member Boards:
Expiration Date: 04/30/2019
Patient Safety Highlights 2015 - Perioperative Pathways for Obstructive Sleep Apnea: Avoiding Complications After Ambulatory Surgery
Screening tools have become more accurate in prediction of postoperative complications based on disease-entity (sleep apnea and comorbidities) and procedure-specific aspects. Through a review of key elements of preoperative polysomnography and CPAP testing, learners will be able to develop a process for fast-track sleep apnea testing process. The effectiveness of preoperative CPAP on avoiding complications will be reviewed. The effectiveness of opioid sparing techniques, specific anesthetic agents, neuromuscular monitoring and reversal agents will be reviewed. In summary, the learner will be able to identify the SLEEP APNEA PERIOPERATIVE PATHWAYS that take into account the preoperative screening or polysomnography results as well as the respiratory consequences of intraoperative interventions. Additionally, the clinician will review the limitations and effectiveness of postoperative monitoring and CPAP therapy in reducing complications in sleep apnea patients.
Expiration Date: 11/17/2018