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INTRODUCTION: We hypothesized that patients with complex regional pain syndrome (CRPS) would describe a more negative pain phenotype including higher pain severity, more neuropathic pain descriptors, more centralized pain symptoms, poorer physical function, and more affective distress when compared with patients with neuropathic pain of the extremities not meeting CRPS criteria. MATERIALS AND METHODS: This was a retrospective cross-sectional study conducted at a tertiary pain center. The sample included 212 patients who met Budapest Criteria for CRPS and 175 patients with neuropathic pain of the extremities who did not meet criteria. All patients completed a packet of questionnaires before their initial visit containing validated outcome measures assessing pain severity, pain interference, physical functioning, depression, anxiety, and catastrophizing. RESULTS: Patients with CRPS reported higher physical disability (p=0.022) and more neuropathic pain symptoms (p=0.002) than patients not meeting CRPS criteria, but the groups did not otherwise differ significantly. There were no significant differences in pain severity or affective distress, despite power analyses suggesting the ability to detect small to medium effect sizes (d=0.29; w=0.14). Subanalyses of differences in neuropathic pain symptoms revealed that patients with CRPS, compared with patients not meeting CRPS criteria, were more likely to report pain with light touch (p=0.003), sudden pain attacks (p=0.003), pain with cold or heat (p=0.002), sensation of numbness (p=0.042), and pain with slight pressure (p=0.018). DISCUSSION: Counter to our hypothesis, the present study suggests that patients with CRPS do not have a worse clinical phenotype compared with patients not meeting CRPS criteria, with the exception of higher physical disability and more neuropathic pain symptoms. This corresponds to recent evidence that patients with CRPS are similar to other patient populations with chronic pain.
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Importance: Patterns of preoperative opioid use are not well characterized across different surgical services, and studies in this patient population have lacked important self-reported data of pain and affect. Objectives: To assess the prevalence of preoperative opioid use and the characteristics of these patients in a broadly representative surgical cohort. Design, Setting, and Participants: Cross-sectional, observational study of patients undergoing surgery at a tertiary care academic medical center. Data were collected as a part of large prospective institutional research registries from March 1, 2010, through April 30, 2016. Exposures: Preoperative patient and procedural characteristics, including prospectively assessed self-reported pain and functional measures. Main Outcomes and Measures: Patient-reported opioid use before surgery. Results: Of the total 34â¯186 patients recruited (54.2% women; mean [SD] age, 53.1 [16.1] years), preoperative opioid use was reported in 7894 (23.1%). The most common opioids used were hydrocodone bitartrate (4685 [59.4%]), tramadol hydrochloride (1677 [21.2%]), and oxycodone hydrochloride (1442 [18.3%]). Age of 31 to 40 years (adjusted odds ratio [aOR], 1.26; 95% CI, 1.10-1.45), tobacco use (former use aOR, 1.32 [95% CI, 1.22-1.42]; current use aOR, 1.62 [95% CI, 1.48-1.78]), illicit drug use (aOR, 1.74; 95% CI, 1.16-2.60), higher pain severity (aOR, 1.33; 95% CI, 1.31-1.35), depression (aOR, 1.22; 95% CI, 1.12-1.33), higher Fibromyalgia Survey scores (aOR, 1.06, 95% CI, 1.05-1.07), lower life satisfaction (aOR, 0.95, 95% CI, 0.93-0.96), and more medical comorbidities (American Society of Anesthesiology score aOR, 1.47 [95% CI, 1.37-1.58]; Charlson Comorbidity Index aOR, 1.29 [95% CI, 1.18-1.41]) were all independently associated with preoperative opioid use. Preoperative opioid use was most commonly reported by patients undergoing orthopedic (226 [65.1%]) and neurosurgical spinal (596 [55.1%]) procedures and least common among patients undergoing thoracic procedures (244 [15.7%]). After adjusting for patient characteristics, the patients undergoing lower extremity procedures were most likely to report preoperative opioid use (aOR, 3.61; 95% CI, 2.81-4.64), as well as those undergoing pelvic (excluding hip) (aOR, 3.09; 95% CI, 1.88-5.08), upper extremity (aOR, 3.07; 95% CI, 2.12-4.45), and spinal or spinal cord (aOR, 2.68; 95% CI, 2.15-3.32) procedures, with the group undergoing intrathoracic surgery as the reference group. Conclusions and Relevance: In this large study of preoperative opioid use that includes patient-reported outcome measures, more than 1 in 4 patients presenting for surgery reported opioid use. These data provide important insights into this complicated patient population that would appear to help guide future preoperative optimization and perioperative opioid-weaning interventions.
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Analgésicos Opioides/uso terapéutico , Dolor/prevención & control , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Procedimientos Ortopédicos/estadística & datos numéricos , Medición de Resultados Informados por el Paciente , Cuidados Preoperatorios , Estudios Prospectivos , Centros de Atención Terciaria , Procedimientos Quirúrgicos Torácicos/estadística & datos numéricosRESUMEN
OBJECTIVE: To explore the clinical and financial implications of preoperative opioid use in major abdominal surgery. BACKGROUND: Opioids are increasingly used to manage chronic pain, and chronic opioid users are challenging to care for perioperatively. Given the epidemic of opioid-related morbidity and mortality, it is critical to understand how preoperative opioid use impacts surgical outcomes. METHODS: This was an analysis of nonemergent, abdominopelvic surgeries from 2008 to 2014 from a single center within the Michigan Surgical Quality Collaborative clinical registry database. Preoperative opioid use (binary exposure variable) was retrospectively queried from the home medication list of the preoperative evaluation. Our primary outcome was 90-day total hospital costs. Secondary outcomes included hospital length of stay, 30-day major complication rates, discharge destination, and 30-day hospital readmission rates. Analyses were risk-adjusted for case complexity and patient-specific risk factors such as demographics, insurance, smoking, comorbidities, and concurrent medication use. RESULTS: In all, 2413 patients met the inclusion criteria. Among them, 502 patients (21%) used opioids preoperatively. After covariate adjustment, opioid users (compared with those who were opioid-naïve) had 9.2% higher costs [95% confidence interval (CI) 2.8%-15.6%; adjusted means $26,604 vs $24,263; P = 0.005), 12.4% longer length of stay (95% CI 2.3%-23.5%; adjusted means 5.9 vs 5.2 days; P = 0.015), more complications (odds ratio 1.36; 95% CI 1.04-1.78; adjusted rates 20% vs 16%; P = 0.023), more readmissions (odds ratio 1.57; 95% CI 1.08-2.29; adjusted rates 10% vs 6%; P = 0.018), and no difference in discharge destination (P = 0.11). CONCLUSIONS: Opioid use is common before abdominopelvic surgery, and is independently associated with increased postoperative healthcare utilization and morbidity. Preoperative opioids represent a potentially modifiable risk factor and a novel target to improve quality and value of surgical care.
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Abdomen/cirugía , Analgésicos Opioides/efectos adversos , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Costos de Hospital , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Abdomen/fisiopatología , Anciano , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/economía , Estudios de Cohortes , Procedimientos Quirúrgicos del Sistema Digestivo/economía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Michigan , Persona de Mediana Edad , Análisis Multivariante , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/etiología , Periodo Preoperatorio , Sistema de Registros , Análisis de Regresión , Estudios Retrospectivos , Medición de Riesgo , Estadísticas no Paramétricas , Procedimientos Quirúrgicos Operativos/métodos , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVES: Effective use of postoperative incentive spirometry improves patient outcomes but is limited by pain after thoracic and upper abdominal surgery. Thoracic epidurals are frequently used to provide analgesia and attenuate postoperative pulmonary dysfunction. We hypothesized that, in patients with thoracic epidurals for thoracic and abdominal surgery, high pain scores would be associated with poorer incentive spirometry performance, even when accounting for other variables. METHODS: Retrospective study of 468 patients who underwent upper abdominal or thoracic surgery using postoperative thoracic epidural analgesia between June 1, 2009, and August 31, 2013, at a single tertiary academic center. The association between incentive spirometry performance and pain was assessed as the primary outcome. Other independent predictors of incentive spirometry performance were also identified. RESULTS: Postoperative incentive spirometry performance was found to be inversely proportional to pain score, which correlated significantly stronger with deep breathing pain compared with pain at rest (-0.33 vs -0.14 on postoperative day 1; -0.23 vs -0.12 on postoperative day 2). Pain with deep breathing was independently associated with poorer incentive spirometry performance in the multivariable linear regression model (P < 0.0001), as was increasing age, female sex, thoracic surgery, and higher American Society of Anesthesiologists (ASA) physical status score. CONCLUSIONS: The present study suggests that pain with deep breathing is more indicative of thoracic epidural efficacy than is pain at rest. Furthermore, incentive spirometry performance could be used as another indicator of thoracic epidural efficacy. This may be particularly useful in patients reporting high pain scores postoperatively.
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Analgesia Epidural , Dolor Postoperatorio/fisiopatología , Complicaciones Posoperatorias/fisiopatología , Abdomen/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Espirometría/estadística & datos numéricos , Toracotomía , Resultado del TratamientoRESUMEN
Over the past two decades, the prescription of high dose opiate therapy has continued to accelerate in an attempt to treat patients with chronic pain. This presents a substantial challenge when patients on high dose opiate therapy require surgery, as opiate pain relief is a cornerstone of postoperative pain management. These patients have exceptionally challenging pain to control. This is likely due to downregulation of existing opiate receptors and the reluctance of clinicians to increase doses of opiates to exceptionally high levels to facilitate pain relief. We hypothesize that using the method of ultra-rapid opiate detoxification (UROD), it would be possible to rapidly increase the number of opiate receptors and return patients to a more naive state, which would be susceptible to exogenous opiate administration. Validation of this hypothesis is supported by two mechanisms, the first of which are reports of patients that underwent UROD for opiate addition that subsequently suffer respiratory arrests when beginning to rapidly abuse opiates shortly after treatment. Additionally there are data demonstrating the tapering of opiate therapy prior to elective surgery results in better pain control. In conclusion, we hypothesize that patients on chronic high dose opiates could obtain substantially better pain relief if they underwent UROD prior to surgery. This technique could be administered shortly before surgery and may dramatically improve the patients' recoveries.
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Analgésicos Opioides/uso terapéutico , Naltrexona/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Dolor Postoperatorio/tratamiento farmacológico , Cuidados Preoperatorios/métodos , Humanos , Modelos Biológicos , Receptores Opioides/metabolismoRESUMEN
SUMMARY: Regional and neuraxial analgesic techniques are components of a concerted effort to better manage perioperative pain in the surgical patient. These techniques are routinely used in a host of surgical specialties and are now beginning to gain traction in plastic surgery. An improved understanding of the utility and limitations of available analgesic techniques in perioperative pain management is crucial for effective patient care. The purpose of this article is to provide an overview of regional and neuraxial analgesic techniques relevant to plastic surgery procedures of the trunk.
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UNLABELLED: Although chronic pain in childhood can last into adulthood, few studies have evaluated the characteristics of adults with chronic pain who report childhood chronic pain. Thus, 1,045 new patients (mean age, 49.5 ± 15.4) at an academic tertiary care pain clinic were prospectively evaluated using validated self-report questionnaires. Patients also responded to questions about childhood pain. We found that almost 17% (n = 176) of adult chronic pain patients reported a history of chronic pain in childhood or adolescence, with close to 80% indicating that the pain in childhood continues today. Adults reporting childhood chronic pain were predominantly female (68%), commonly reported widespread pain (85%), and had almost 3 times the odds of meeting survey criteria for fibromyalgia (odds ratio [OR] = 2.94, 95% confidence interval [CI] = 2.04-4.23) than those denying childhood chronic pain. Similarly, those with childhood pain had twice the odds of having biological relatives with chronic pain (OR = 2.03, 95% CI = 1.39-2.96) and almost 3 times the odds of having relatives with psychiatric illness (OR = 2.85, 95% CI = 1.97-4.11). Lastly, compared to patients who did not report childhood chronic pain, those who did were more likely to use neuropathic descriptors for their pain (OR = 1.82, 95% CI = 1.26-2.64), have slightly worse functional status (B = -2.12, t = -3.10, P = .002), and have increased anxiety (OR = 1.77, 95% CI = 1.24-2.52). PERSPECTIVE: Our study revealed that 1 in 6 adult pain patients reported pain that dated back to childhood or adolescence. In such patients, evidence suggested that their pain was more likely to be widespread, neuropathic in nature, and accompanied by psychological comorbidities and decreased functional status.