Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study.

Gabapentin and postoperative pain and opioid consumption: A double-blind randomized controlled trial of perioperative pain management for sinus surgery

appears neither logical nor beneficial to patients.

Trapeziectomy alone or in combination with a suspensionplasty technique is a common surgical treatment for symptomatic thumb basal joint arthritis. The authors undertook a prospective comparative study to test the hypothesis that peripheral nerve blocks would provide better pain control than local anesthesia with bupivacaine or liposomal bupivacaine regarding pain scores and opioid pill consumption. Patients who elected to undergo basal joint arthroplasty were allocated to 1 of 3 postoperative pain management groups: (1) peripheral nerve block, (2) local anesthesia with bupivacaine, or (3) local anesthesia with liposomal bupivacaine. Total opioid pill consumption and visual analog scale pain scores were reported for the first 5 postoperative days (PODs). Seventy-eight patients were enrolled, with 27, 23, and 28 patients in the peripheral nerve block, bupivacaine, and liposomal bupivacaine groups, respectively. All groups experienced an increase in opioid pill consumption and visual analog scale pain scores from POD 0 to POD 1. Postoperative visual analog scale pain scores were lowest in group 3 from POD 0 to POD 2. Average visual analog scale pain scores were highest in group 1, except for on POD 0. After POD 2, visual analog scale pain scores normalized between all groups and decreased uniformly thereafter. Total opioid consumption was lowest in group 3 (average, 11 pills) compared with group 1 (average, 17 pills) and group 2 (average, 19 pills). Overall, these findings did not support the authors' hypothesis that peripheral nerve blocks are superior in terms of postoperative pain control and opioid consumption. Although there were advantages regarding opioid consumption and pain control with liposomal bupivacaine, these were limited to the first POD. The effectiveness of each modality, as well as potential risks and costs, should be considered when determining the optimal strategy. [Orthopedics. 2018; 41(3):e410-e415.].

ObjectiveTo compare efficacy of oral versus intravenous (IV) methadone on postoperative pain and opioid requirements after spine surgery.MethodsThis was a retrospective, single-academic center cohort study evaluating 1010 patients who underwent >3 level spine surgery from January 2017 to May 2020 and received a one-time dose of oral or intravenous methadone prior to surgery. The primary outcome measured was postoperative opioid use in oral morphine equivalents (ME) and verbal response scale (VRS) pain scores up to postoperative day (POD) three. Secondary outcomes were time to first bowel movement and adverse effects (reintubation, myocardial infarction, and QTc prolongation) up to POD 3.ResultsA total of 687 patients received oral and 317 received IV methadone, six patients were excluded. The IV group received a significantly greater methadone morphine equivalent (ME) dose preoperatively (112.4 ± 83.0 mg ME versus 59.3 ± 60.9 mg ME, p < 0.001) and greater total (methadone and non-methadone) opioid dose (119.1 ± 81.4 mg ME versus 63.9 ± 62.5 mg ME, p < 0.001), intraoperatively. Although pain scores for the oral group were non-inferior to the IV group for all postoperative days (POD), non-inferiority for postoperative opioid requirements was demonstrated only on POD 3. Based on the joint hypothesis for the co-primary outcomes, oral methadone was non-inferior to IV methadone on POD 3 only. No differences in secondary outcomes, including QTc prolongation and arrhythmias, were noted between the groups.ConclusionsOral methadone is a feasible alternative to IV methadone for patients undergoing spine surgery regarding both pain scores and postoperative opioid consumption.

Previous studies have sought to determine the effect of inpatient ketamine therapy on postoperative pain in a variety of surgical specialties. To determine the effects of postoperative ketamine analgesia after periacetabular osteotomy (PAO) and/or derotational femoral osteotomy (DFO) on opioid requirements, pain, and discharge time. Cohort study; Level of evidence, 3. Prospective data were collected on 145 patients who underwent PAO and/or DFO by the senior author between January 2021 and December 2022. Hip arthroscopy was performed 3 to 10 days before addressing any intra-articular pathology. In 2021, patients (n = 91 procedures; control group) received a traditional postoperative multimodal pain regimen. In 2022, postoperative low-dose ketamine (0.1-1 mg/kg/h) was added to the multimodal analgesic approach until 24 hours before discharge (n = 81 procedures; ketamine group). The ketamine and control groups were matched based on procedure type. Total opioid consumption was collected using milligram morphine equivalents (MMEs) for both groups. Postoperative pain was measured using the Defense and Veterans Pain Rating Scale (DVPRS), which was analyzed as the mean score per day. Data on the mean MME and DVPRS were analyzed for up to 7 days postoperatively. Linear mixed statistical analysis was performed to determine the significance of low-dose postoperative ketamine on postoperative pain and opioid utilization. Patients who did not receive ketamine after PAO and/or DFO utilized a mean of 181 ± 335 MMEs and had a mean DVPRS score of 4.18 ± 1.63. Patients who received postoperative ketamine required a mean of 119 ± 291 MMEs and had a mean DVPRS score of 4.34 ± 1.61. The ketamine group was found to consume a significantly lower total MME dose per day (P < .001). No significant difference was found in the mean DVPRS score between the ketamine and control groups (P = .42). Also, no significant difference was found on the day of discharge (P = .79). Patients who received postoperative ketamine after PAO and/or DFO had a significant decrease in MME dose when compared with a control group of patients who did not receive ketamine. Surgeons should consider adding ketamine to their postoperative multimodal pain control protocol to decrease opioid consumption while adequately addressing postoperative pain.

ESRA19-0716 Pain rebound in day surgery: how can we avoid it?

Association between higher BMI and postoperative pain and opioid consumption in pediatric inpatients – A retrospective cohort study

There is increased interest in nonpharmacological treatments to reduce pain after total knee arthroplasty. Yet, little consensus supports the effectiveness of these interventions. To systematically review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty. Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and ClinicalTrials.gov for the period between January 1946 and April 2016. Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included. Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses. Postoperative pain and consumption of opioids and analgesics. Of 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, -3.50; 95% CI, -5.90 to -1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, -1.14; 95% CI, -1.90 to -0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, -0.13; 95% CI, -0.26 to -0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, -0.51; 95% CI, -1.00 to -0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were -0.05 (95% CI, -0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, -6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was -0.14 (95% CI, -1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%). In this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption.

OBJECTIVES/GOALS: The current opioid epidemic has placed post-operative pain management under scrutiny. Limiting post-operative pain can decrease overall opioid usage in the recovery period, especially after orthognathic surgery. Several studies have illustrated the efficacy of pregabalin in decreasing postoperative pain and opioid usage in adults undergoing orthognathic surgery. We aim to study the effects of a single dose of preoperative pregabalin on postoperative pain and total opioid consumption after orthognathic surgery in individuals with cleft lip and palate. METHODS/STUDY POPULATION: This was a retrospective cohort study of consecutive patients who received Le Fort I midface advancement between June 2012 and July 2019 by one of two surgeons at a single institution. We took advantage of our institution’s implementation, beginning in 2016, of a one-time dose of preoperative pregabalin for LeFort I midface advancement. All patients had diagnosed cleft lip and palate. The treatment group received a one-time preoperative dose of pregabalin. The control group did not receive pregabalin. Total morphine milligram equivalents (MME) consumption was calculated by adding intraoperative opioid administration and postoperative opioid consumption during admission. Postoperative pain control during admission consisted of oral oxycodone and intravenous (IV) hydromorphone or morphine. Duration of hospitalization and pain intensity assessed with the numeric pain rating scale (0-10) were also recorded. The mean postoperative pain assessment scores during admission was calculated for each patient. The median of these individual mean pain assessment scores for each group was subsequently computed. RESULTS/ANTICIPATED RESULTS: Twenty-three patients (14 males, 9 females) were included in this study; 12 patients received pregabalin (median dose: 150mg, range: 100-200mg). Mean age (years) at operation of the pregabalin (18.3 ± 1.9) and control groups (17.8 ± 1.9) were also equivalent (p = 0.571). Median hospital stay for both groups was 1.0 day. The pregabalin group had significantly lower consumption of total opioids during admission (total MME 70.95 MME; IQR: 24.65-150.17) compared to the control group (138.00 MME; IQR: 105.00-232.48) (MU = 31.00, p = 0.031). Although pain scores in the treatment group (3.21 ± 2.03) were lower than in the control group (3.71 ± 2.95), the difference was not statistically significant (p = 0.651, 95% Cl [−1.75, 2.75]). DISCUSSION/SIGNIFICANCE OF IMPACT: Based on the results, a one-time preoperative oral dose of pregabalin before orthognathic surgery in patients with cleft lip and palate reduced total opioid consumption during admission. However, there was no difference in length of stay or pain scores within the two groups. A single preemptive oral dose of pregabalin should be considered an effective adjunct to pain management protocols in patients undergoing orthognathic surgery.

Bupivacaine Extended-Release Liposomal Injection Versus Bupivacaine HCl for Early Postoperative Pain Control Following Wrist Operations: A Prospective, Randomized Control Trial

The purpose of this study is to identify patterns of postoperative narcotic use and determine the impact of psychosocial and perioperative factors on postoperative opioid consumption following arthroscopic knee surgery. Fifty consecutive patients undergoing arthroscopic knee surgery were prospectively enrolled. Patients were contacted via telephone at 1 week postoperatively to report their pain level and opioid consumption. The patient was contacted again at 2 weeks, 4 weeks, and 90 days as necessary until opioid cessation, at which time the patient's plan for unused pills was inquired. Opioid consumption was compared using t-tests and one-way analysis of variance for demographic and surgical factors. Linear regression was used to determine whether the Pain Catastrophizing Scale (PCS), Resilience Scale (RS-11), International Knee Documentation Committee questionnaire, or patient-reported pain at 1 week predicted higher opioid consumption. The average morphine equivalent dose of opioid consumption was 142 mg. Sixty-four percent consumed less than 100 mg, and 68% discontinued opioid use by 1 week postoperatively. Seventy-four percent reported surplus pills, and 49% of those patients plans for pill disposal. Factors associated with higher consumption included undergoing a major procedure, having a regional anesthesia block, and higher area deprivation index score (p < 0.05). Higher PCS scores and reported average pain level at 1 week were predictive of higher opioid consumption (p < 0.05). In conclusion, a majority of patients undergoing outpatient knee surgery did not require the entirety of their narcotic prescription. The majority of patients consumed less than 100 mg of morphine equivalents and discontinued opioid use by 1 week postoperatively. Ligament reconstruction, living in an area with a higher index of deprivation, and higher score on the PCS were associated with greater opioid consumption. Overall, patient knowledge regarding opioid disposal was poor, and patients would likely benefit from additional education prior to surgery.

To identify characteristics associated with high inpatient daily opioid consumption after cesarean delivery. This is a retrospective cohort study of all cesarean deliveries performed under neuraxial anesthesia with neuraxial morphine, at a single institution from January 1, 2015, to December 31, 2015. Women with preoperative opioid use disorder or chronic opioid use were excluded. Sociodemographic data, medical comorbidities, use of anxiolytics or antidepressants, smoking history, nonopioid substance use, intrapartum and cesarean delivery characteristics, and opioid consumption data (converted to morphine milligram equivalents) were abstracted. We defined high opioid use as a mean daily opioid consumption, standardized to the postoperative length of stay (excluding the first 24 postoperative hours to account for neuraxial morphine), greater than the 75th percentile of all opioid consumption. We used multivariable Poisson regression, stratified by whether or not cesarean delivery was scheduled, to identify characteristics associated with high opioid consumption. Among 949 women who underwent cesarean delivery, the mean (SD) and median (interquartile range) daily opioid consumption was 48.6 (22.8) and 44.6 (36.6-66.6) morphine milligram equivalents, respectively. Among those women with high opioid consumption, the mean (SD) and median (interquartile range) daily opioid consumption was 78.8 (8.5) and 78.3 (72.9-83.5) morphine milligram equivalents, respectively. Daily opioid consumption among those with high consumption was similar among women with scheduled compared with unscheduled cesarean delivery. Sociodemographic characteristics were similar among women with and without high opioid consumption. No sociodemographic, antepartum, or intrapartum characteristics were associated with high opioid consumption for either women having unscheduled or scheduled cesarean deliveries. For a quarter of women undergoing cesarean delivery, daily consumption of opioids is equivalent to 10 tablets of oxycodone 5 mg daily. No characteristics were associated with high opioid use for women having a scheduled or unscheduled cesarean delivery. Understanding opioid consumption after cesarean delivery is critical to managing women's postoperative pain while decreasing opioid exposure and risks of long-term opioid use disorder.

The present study is a scoping review of the literature from Medline, PubMed, and Scopus databases from 2000 to 2025. Studies were selected based on predefined criteria, including the intraoperative administration of methadone during orthopedic surgery and the reporting of outcomes such as pain scores, opioid consumption, or adverse effects. A qualitative synthesis of the findings from 13 selected studies was performed to evaluate the existing literature on the efficacy and safety of perioperative methadone for postoperative pain management in orthopedic surgery. Studies were selected based on predefined criteria, including the intraoperative administration of methadone during orthopedic surgery and the reporting of outcomes such as pain scores, opioid consumption, or adverse effects. A qualitative synthesis of the findings from 13 selected studies was performed. Randomized controlled trials in adult spine surgery consistently showed that intraoperative methadone (0.2 mg/kg) significantly reduced postoperative opioid consumption by up to 50% and lowered pain scores for up to 72 h compared to other opioids. Similar benefits were observed in pediatric spine surgery, particularly with multimodal regimens including methadone, which reduced total opioid use by as much as 76%. However, for arthroscopic knee surgery, morphine provided superior analgesia compared to methadone. The safety profile of perioperative methadone appears acceptable, with no major adverse events reported when dosed appropriately. Perioperative methadone is an effective analgesic adjunct that reduces postoperative pain and opioid requirements, especially in major spine surgery when integrated into a multimodal strategy. Its efficacy varies by surgical context, and further high-quality research is needed to define optimal dosing and its role in other orthopedic procedures.

Background:There continues to be focus on the value of regional and neuraxial anesthetic techniques when combined with general anesthesia to improve postoperative analgesia. The reported advantages include decreased postoperative opioid requirements, decreased medication-related adverse effects, decreased hospital length of stay, and increased patient satisfaction. Orthopedic procedures of the hip may be amenable to such techniques as there is significant postoperative pain with the requirement for hospital admission and the administration of parenteral opioids. Given the surgical site, various regional anesthetic techniques may be used to provide analgesia including caudal epidural anesthesia (CEA) or lumbar plexus blockade (LPB).Purpose: The objective of this study was to assess the effectiveness of LPB versus CEA as an analgesic thechnique for patients undergoing elective hip surgery from the opioid consumption and pain scores perspective.Patients and methods: The current study retrospectively reviews our experience with CEA and LPB for postoperative analgesia after hip surgery in the pediatric population. Regional anesthesia technique was reviewed as well as opioid requirements and pain scores.Results: The study cohort included 61 patients, 29 who received an LPB and 32 who received CEA. No difference was noted in the demographics between the two groups. Intraoperative opioid use was 0.7 (IQR: 0.5, 1.1) mg/kg of oral morphine equivalents (MEs) in the LPB group compared to 0.6 (IQR: 0.5, 0.9) in the CEA group (p=0.479). Postoperative opioid use over the first 48 hrs was 4 (IQR: 1, 6) mg/kg of oral ME in the LPB group, compared to 2 (interquartile range [IQR]: 1, 3) in the CEA group (p=0.103). Over the first 24 hrs after surgery, the median pain score in the LPB group was 5 (IQR: 1–6), compared to 3 (IQR: 0, 5) in the CEA group (p=0.014).Conclusion: These retrospective data suggest a modest postoperative benefit of CEA when compared to LPB following hip surgery in the pediatric population. Postoperative pain scores were lower in patients receiving CEA; however, no difference in the intraoperative or postoperative opioid requirements was noted between the two groups.

Major lumbar spine surgery causes severe pain in the postoperative period. There are few studies regarding the effect oferector spinae plane block (ESPB)effect on lumbar surgery and its effect is still controversial. Therefore, the study aimed to investigate the effect of ultrasound-guided low thoracic ESPB on opioid consumption and postoperative pain score. Seventy-eight patients undergoing elective open lumbar spine surgery were randomized into two groups. In ESPB group (n = 35) received ultrasound-guided ESPB and in the control group (n = 35), there was no block. Postoperative opioid consumption as morphine equivalent dose, numerical rating scale, mobilization time, discharge time and side effects, bolus deliveries, rescue analgesia doses were evaluated. Total opioid consumption as morphine equivalent was higher in the control group than the ESPB group (p = 0.000). Compare with the control group, the numeric rating scale scores were lower in the ESPB group at the 6th, 12th, and 24th hours (p < 0.05). The patient-controlled analgesia button pressing number in the postoperative 24-h period was lower in the ESPB group (p = 0.000). In the postoperative 24-h period, the need for paracetamol in the ESPB group was lower and the difference between the groups was statistically significant (p = 0.008). Rescue analgesia (diclofenac) doses were higher in the control group (p < 0.05). There was no statistically significant difference in terms of side effects and mobilization times. ESPB is adequate for postoperative analgesia in patients undergoing lumbar spine surgery and can reduce opioid consumption compared with standard analgesia.