Preoperative Analgesic Regimens Did Not Improve Recovery After Spine Surgery
Recently, several multimodal approaches to pain relief have been suggested to decrease opioid use and improve recovery after surgery.
In a study by Mahwari et al, the authors evaluated the effect of using a combination of 4 nonopioid analgesics, versus placebo, on the quality of recovery, postoperative opioid consumption, and pain scores. The study participants were adults undergoing multilevel spine surgery, a procedure associated with severe postoperative pain.
In a double-blind randomized trial, patients were assigned to placebo therapy or to a multimodal regimen that consisted of:
1. A single preoperative oral dose of acetaminophen 1000 mg;
2. A single preoperative dose of gabapentin 600 mg;
3. An infusion of ketamine 5 [micro]g/kg/min throughout surgery; and
4. An infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery.
Placebo management was determined by the routine use of the practitioner. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome, quality of recovery, was assessed by a 15-item questionnaire (0-150 points, with 15% considered to be a clinically important difference) on the third postoperative day.
Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0-10, with a 1-point change considered important) over the initial 48 postoperative hours.
As no differences could be found, the trial was stopped early. The average duration +/- SD of surgery was 5.4 +/- 2.1 hours. The mean +/- SD quality of recovery score was 109 +/- 25 in the pathway patients (n = 150) versus 109 +/- 23 in the placebo group (n = 149).
There was no estimated difference in means (P = 0.920).
Pain management within the initial 48 postoperative hours was not superior in the multimodal analgesic group. The opioid consumption median at 48 hours was 72 mg in the study group and 75 mg in the placebo group. Mean 48-hour pain scores were 4.8 +/- 1.8 in the analgesic pathway group versus 5.2 +/- 1.9 in the placebo group (P = 0.094).
The researchers concluded that a multimodal, perioperative analgesic pathway, as was used, did not improve recovery in patients who had multilevel spine surgery. (See Mahwari K, Avitsian R, Sessler D, et al. Multimodal analgesic regimen for spine surgery: a randomized placebo-controlled trial. Anesthesiology. 2020;132:992-1002. doi:10.1097/ALN.0000000000003143.)
Smaller Package Size Reduces the Quantity of Opioids Administered
In considering the question whether and how the unit dose of a drug might relate to opioid administration, Ershoff et al devised a study to use alternating sizes of hydromorphone vials. They hypothesized that the unit dose of hydromorphone is an independent determinant of the quantity of hydromorphone administered to patients intraoperatively.
This observational cohort study included 15,010 patients who received intraoperative hydromorphone as part of an anesthetic.
From March 2016 to July 2017, hydromorphone was available as a 2-mg unit dose.
From July 1, 2017, to November 20, 2017, hydromorphone was only available in a 1-mg unit dose. Thereafter, hydromorphone was reintroduced in the 2-mg unit dose.
An interrupted time series analysis was performed using segmented Poisson regression with 2 change points, the first representing the switch from a 2-mg to 1-mg unit dose, and the second representing the reintroduction of the 2-mg dose.
The authors determined that the 2-mg to 1-mg unit dose change was associated with a 49% relative decrease in the probability of receiving a hydromorphone dose greater than 1 mg (P < 0.0001). The reintroduction of a 2-mg unit dose was associated with a 48% relative increase in the probability of administering a dose greater than 1 mg (P = 0.008).
The conclusion drawn was that, using an interrupted time series analysis, unit dose of hydromorphone (2 mg vs 1 mg) is an independent determinant of the quantity of hydromorphone administered to patients intraoperatively. (See Ershoff BD, Grogan T, Hin JC, et al. Hydromorphone unit dose affects intraoperative dosing: an observational study. Anesthesiology. 2020;132(5):981-991. doi:10.1097/ALN.0000000000003176.)
Adding a Tolerability Question to the Numeric Rating Scale Improves the Accuracy of Pain Assessment
Limiting pain assessment only to the numeric rating scale (NRS) reduces the expression of chronic pain to a single dimension, thus minimizing the complex effects of chronic pain on quality of life and other factors involved in analgesic decision-making.
Asking patients simply to rate their pain on a scale anchored by a pain-free state (ie, 0 on a scale of 0-10 points) suggests that a pain-free state is a readily attainable treatment goal, thus perhaps contributing to unrealistic expectations.
In this study, the authors hypothesized that the incorporation of a standardized pain tolerability question (PTQ) (ie, "Is your pain tolerable?") would augment the information gleaned from the NRS.
Between December 2016 and March 2017, 537 participants were recruited (after exclusions) electronically, after a primary care encounter at 1 of 157 participating primary practices. Median age was 62 years, and 38% were male. Patients had an active prescription for an analgesic medication or an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) visit diagnosis associated with chronic pain.
More than 50% of patients had musculoskeletal disease and more than 1 pain site (eg, osteoarthritis or soft-tissue disorder).
Patients were asked, "Is your pain tolerable?" (Answer choices were "yes," "no," or "not in pain.") and asked to rate average pain intensity (on a scale of 0-10 points) during the previous 24 hours. Responses to the PTQ were compared with responses on the NRS scale using logistic regression.
A pain rating of "intolerable" was associated with the higher NRS (P = 0.01). In the moderate range of the NRS (ie, 4-6), 40 of 211 patients (19.0%) characterized their pain as intolerable, whereas in the severe range of the NRS (ie, 7-10), 72 of 137 patients (52.6%) considered it intolerable.
The researchers conclude that the findings confirmed the intuitive assumption that most patients with low pain intensity (ie, NRS score 1-3) find their pain tolerable. However, the tolerability of pain rated between 4 and 6 varies substantially among patients, such that if a patient describes pain as tolerable, the clinician's inclination to initiate higher-risk treatments might decrease.
Also, a subgroup of patients with severe pain reported their symptoms as tolerable. This discordance between tolerability and pain intensity may be an opening for a clinician to explore mood, sleep disruption, or the curtailing of activities to control pain. Patient satisfaction regarding communication, treatment goal setting, and treatment effects could perhaps be improved. (See Markman JD, Gewandter JS, Frazer ME. Comparison of a pain tolerability question with the numeric rating scale for assessment of self-reported chronic pain. JAMA Netw Open. 2020;3(4):e203155. doi:10.1001/jamanerkopen.2020.3155.)