Tag: Pain

Opioid prescribing after surgery remains the same for seniors, but doses are lower, study shows

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Newswise — NEW ORLEANS — Although there has been no decrease in the number of opioid prescriptions seniors receive after surgery, the doses of those prescriptions are lower, according to a study of more than a quarter million Canadian patients being presented at the ANESTHESIOLOGY® 2022 annual meeting.

“While it’s good news that the doses in opioid prescriptions are being reduced, the fact that the actual number of opioid prescriptions filled has remained the same shows there is still an opportunity for improvement,” said Naheed Jivraj, MBBS, MS, FRCPC, lead author of the study and a critical care medicine fellow at the University of Toronto, Ontario. “That’s particularly true for procedures associated with low postoperative pain that can be effectively controlled with non-opioid medications such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs).”

While opioids can be an important part of pain management after surgery, limiting their use, including by lowering the dose, is important since they can cause major side effects and lead to addiction, as well as a potentially deadly overdose.

To assess trends in filling pain prescriptions in the week after surgery, the researchers studied the records of 278,366 patients representing all adults in Ontario older than 65 who had one of 14 surgical procedures between 2013 and 2019. The surgical procedures in the study included: thyroid removal, appendix removal, hernia repair, laparoscopic or open removal of the gallbladder, removal of the prostate, open-heart surgery, laparoscopic or open colon removal, laparoscopic vaginal or abdominal hysterectomy, removal of the breast, hip replacement and knee replacement.

They identified an increase in patients filling non-opioid prescriptions (e.g., acetaminophen or NSAID) from 9% in 2013 to 28% in 2019. They found most patients also continued to receive a prescription that contained an opioid — 76% in 2013 and 75% in 2019. However, the dose of the opioid prescriptions decreased, from an average of 317 MME (morphine milligram equivalent) in 2013 to an average of 260 MME in 2019.

Most patients undergoing procedures such as removal of the appendix or thyroid can get pain relief from acetaminophen or an NSAID; however, few patients who had these procedures filled prescriptions for those non-opioid alternatives, researchers noted.

“Our study highlights how pain management practices are changing after surgery,” said Dr. Jivraj. “The increase in seniors filling non-opioid prescriptions and the lower opioid dose may reflect the development of surgery-specific prescribing guidelines and the increasing use of anesthesiologist-championed Enhanced Recovery After Surgery protocols and other programs that focus on improving patient outcomes.”

THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves.

For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

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American Society of Anesthesiologists (ASA)

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October 22, 2022
Both Types of THC Get You High–So Why Is Only One Illegal?

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Newswise — One is an illegal drug found in marijuana while the other is marketed as a safe herbal alternative. But the claimed differences between them aren’t backed by science, a group of UConn researchers report on Nov. 1 in Drug and Alcohol Dependence.

Tetrahydrocannabinol, or THC, is the psychoactive compound produced by cannabis plants. The federal government lists Δ9 -THC (pronounced delta-9-THC) on the Schedule 1 list of dangerous drugs with no accepted medical use. But other versions of THC that differ only by the location of a double bond, such as Δ8-THC, remain quietly quasi-legal on the federal level.

The legality differences between the various versions of THC are causing conflict between the hemp and cannabis industries. There is also potential for harm to consumers. Although Δ8-THC is viewed as an herbal extract of hemp, many manufacturers use solvents and chemical processes that can leave harmful residues in the product, and there are no standards for purity or safety. Because there are no limits, some products contain ridiculously high levels of ∆8 and other THC variants that could potentially cause harm due to the sheer dosage. And states do not agree on its safety or legality. Some states, such as Connecticut, have made Δ8-THC as controlled as Δ9-THC, while in others it remains legal. Cannabis producers allege the distinction is giving rise to unfair competition between the hemp and marijuana markets.

If regulating Δ9-THC as an illegal drug is based on the fact that it has physical and psychoactive effects, then the first step to rational regulation of Δ8-THC would look at whether it, too, has those effects. And people who have experience with both say it does; most agree the effects of Δ8 are similar to Δ9.

UConn School of Nursing professor and Center for Advancement in Managing Pain director Steve Kinsey, graduate student Olivia Vanegas, and their colleagues in UConn Chemistry and local startup 3BC Inc decided to test that in mice. Research done in Japan in the 1980s had shown that Δ8-THC produced the same effects in mice as Δ9-THC. Kinsey and Vanegas reproduced that work and found it to be true: the mice given Δ8 became lethargic, their body temperature dropped, and they became cataleptic, meaning the researchers could put the mice in unusual positions and they’d stay like that for several seconds, which is common in THC-treated mice, but not normal mice.

Then the researchers took it a step farther, blocking the mice’s THC receptors. Blocked mice had no reaction to Δ8-THC, making it clear that Δ8 interacts with the same receptors as Δ9-THC.

Then the researchers took a group of mice and gave them Δ8-THC twice a day for five days. Over time, the mice became desensitized to it. And when they were then given the THC blocker, the mice acted like they were in withdrawal.

Finally collaborators at RTI International ran an experiment “asking” the mice how the drug felt. First they trained the mice to go to a specific spot for a reward if they were dosed with Δ9-THC. After the training, the mice were dosed with Δ8-THC. Unsurprisingly, they went to the same reward spot as when they were dosed with Δ9.

“So they’re telling us the same thing people buying the stuff in gas stations tell us: Δ8 feels like THC,” Kinsey says.

Chemically, it’s unsurprising. Molecules as similar as Δ8- and Δ9-THC usually (though not always) act the same in the body. But legally it causes a lot of complications.

The distinction between Δ8- and Δ9- originally came about from the congressional Farm Bill covering hemp growing and sales. Hemp is defined as a cannabis plant that has less than 0.3% Δ9-THC by dry weight. Anything that has more concentrated Δ9-THC than that is considered marijuana. Additionally, the Farm Bill said anything else naturally present in the hemp plant is legal. That includes Δ8-THC.

“It’s creating a fight between marijuana and hemp” growers, says John Harloe, an attorney on Colorado’s THC taskforce. Products classified as marijuana “must be sold through dispensaries and pay high taxes, while hemp producers can sell essentially the same product but without the same regulations, due to the ambiguity in the Farm Bill,” Harloe says.

Harloe is bringing Kinsey and Vanegas’s paper to the Colorado taskforce to inform the discussion. The taskforce is trying to create appropriate regulation that will address the different chemical variations of THC and guard public safety without crippling the hemp industry. The paper is particularly valuable because there is so little research done on THC and its intoxicating effects, due to federal rules.

“Any bit of science is going to be influential,” Harloe says.

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University of Connecticut

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October 21, 2022
Is ‘frozen shoulder’ a genetic condition? Study finds links to specific genes

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Newswise — October 14, 2022 – Frozen shoulder, or adhesive capsulitis, is a common cause of shoulder pain and immobility. New findings point to specific genes associated with an increased risk of this condition, reports The Journal of Bone & Joint Surgery. The journal is published in the Lippincott portfolio in partnership with Wolters Kluwer.

The risk genes are associated with nearly a sixfold increase in the odds of developing frozen shoulder – a stronger association for most known clinical risk factors, according to the new research by Mark T. Langhans, MD, PhD, of Hospital for Specialty Surgery, New York. The authors believe their findings may lend new insights into the causes, prevention, and treatment of adhesive capsulitis.

Genome-wide association study finds ‘significant loci’ affecting frozen shoulder risk

Patients with adhesive capsulitis develop painful and progressive loss of shoulder motion with associated pain. Frozen shoulder is one of the most common shoulder conditions, occurring in up to 10% of people at some time in their lives. Although the exact cause is unclear, frozen shoulder sometimes occurs after an injury, surgery, or other condition that reduces shoulder mobility. Loss of motion results from fibrosis (scarring or thickening) of the capsule around the shoulder joint.

Certain clinical factors are associated with an increased risk of frozen shoulder, including diabetes, thyroid disease, and smoking. Recent studies have suggested that risk is also higher in people with affected relatives – suggesting a possible genetic predisposition. Dr. Langhans and colleagues performed a genome-wide association study to identify specific genes that might be related to the risk of frozen shoulder.

Data studied from large British database

The study used data from a large British database, the UK Biobank, which includes genetic and health data on approximately 500,000 patients. The analysis focused on 2,142 patients with adhesive capsulitis compared to those without this diagnosis. Possible genetic associations were adjusted for other factors, including sex, diabetes, thyroid disease, history of shoulder dislocation, and smoking.

The study identified three significant loci for frozen shoulder. The strongest association was found for gene variants located at a site called WNT7B. This finding was consistent with previous studies that reported a possible link between WNT7B and frozen shoulder, along with several other orthopaedic-related conditions. Weaker associations were also found for two previously unreported genetic loci located near genes for POU1F1 and MAU2.

All three associations remained significant after adjustment for other factors. Together, the three variants carried nearly a sixfold increase in the odds of developing frozen shoulder. That was greater than the risk associated with diabetes (about four-fold) or thyroid disease (less than two-fold), and second only to smoking (about 11-fold).

New insights could lead to a new development

The findings may lend new insights into the development of adhesive capsulitis. In particular, genes located at WNT7B have been shown to be expressed in bone-forming cells (osteoblasts) and to be involved in regulating fibrosis, along with a wide range of other functions. The two newly reported loci, POU1F1 and MAU2, are involved with cell division, which might lend clues into the cellular mechanism by which frozen shoulder develops.

The researchers note some key limitations of their analysis, including the need for further studies of genetic associations in groups other than the white, British population that predominates in the UK Biobank.

Meanwhile, the new study identifies several gene loci with the ability to predict a clinically relevant risk of frozen shoulder. Dr. Langhans and colleagues conclude: “Refining the genetic risk metric and including it in a larger clinical model could allow patients at risk for future adhesive capsulitis to be identified, leading to efforts at prevention, early diagnosis, and ultimately improved outcomes.”

Click here to read “Genome-Wide Association Study of Adhesive Capsulitis Suggests Significant Genetic Risk Factors“

DOI: 10.2106/JBJS.21.01407

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About The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, The Journal publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal.

About Wolters Kluwer

Wolters Kluwer (WKL) is a global leader in professional information, software solutions, and services for the clinicians, nurses, accountants, lawyers, and tax, finance, audit, risk, compliance, and regulatory sectors. We help our customers make critical decisions every day by providing expert solutions that combine deep domain knowledge with advanced technology and services.

Wolters Kluwer reported 2021 annual revenues of €4.8 billion. The group serves customers in over 180 countries, maintains operations in over 40 countries, and employs approximately 19,800 people worldwide. The company is headquartered in Alphen aan den Rijn, the Netherlands.

Wolters Kluwer provides trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers and students in effective decision-making and outcomes across healthcare. We support clinical effectiveness, learning and research, clinical surveillance and compliance, as well as data solutions. For more information about our solutions, visit https://www.wolterskluwer.com/en/health and follow us on LinkedIn and Twitter @WKHealth.

For more information, visit www.wolterskluwer.com, follow us on Twitter, Facebook, LinkedIn, and YouTube.

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Wolters Kluwer Health: Lippincott

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October 14, 2022
Study casts doubt on routine use of anesthesiologists in cataract surgery

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Newswise — Ophthalmologists may be able to safely cut back on having anesthesiologists or nurse anesthetists routinely at bedside during cataract surgery, which accounts for more than two million surgeries per year in the U.S., according to a study publishing Oct. 3 in JAMA Internal Medicine.

A team of researchers from UC San Francisco examined Medicare claims for 36,652 patients who had cataract surgery in 2017 and found the use of anesthesia care was substantially higher for cataract surgery when compared to patients undergoing other elective, low-risk outpatient procedures—such as cardiac catheterization or screening colonoscopy. However, they found that these patients experienced fewer systemic complications—such as myocardial infarction or stroke—than did patients undergoing the other low-risk procedures. These results held true even in cases where anesthesia experts were not present for the cataract surgery, suggesting that for many cataract patients, it may be reasonable to consider doing the procedure without routine anesthesia support.

“It’s important to note we only looked at systemic complications and not ophthalmologic outcomes from the procedure,” noted senior study author Catherine Chen, MD, MPH, UCSF associate professor in Anesthesia and Perioperative Care and researcher at the Philip R. Lee Institute for Health Policy Studies. “We are evaluating those next, but it would be premature to say we should change practice now based on this study. Hopefully we can get a conversation going, though.”

Some type of anesthetic and possibly sedation is needed for cataract surgery, Chen noted, but the question is who should be present for administration and intraoperative monitoring of these patients. In the past, cataract surgery carried a much higher risk of complications, which helps explain the historic and legacy use of anesthesiologists and/or certified registered nurse anesthetists (CRNA).

“The risk of the procedure itself used to require general anesthesia with paralysis and inpatient admission. Over time, ophthalmologists improved their technique so it [cataract surgery] is much safer and can be done on an outpatient basis,” said Chen. “Often the patient just needs a topical anesthetic such as numbing drops in the eyeball, and, at UCSF anyway, a little fentanyl and midazolam, which are agents a sedation nurse can administer safely.”

A Question of Resources

The study found that, for cataract surgery, 90% of U.S. Medicare patients have an anesthesia provider at the bedside compared to a range of <1% to 70% at bedside for other low-risk elective procedures. In contrast, fewer cataract surgery patients experienced systemic complications within seven days (7.7%) than patients undergoing other low-risk procedures (range, 13% to 52%).

Approximately 6% of ophthalmologists never used anesthesia providers, 77% always used anesthesia providers, and 17% used them for only a subset of patients. Patients of those ophthalmologists who never used anesthesia providers had a 7.4% rate of systemic complications.

There is no specific guidance from professional associations on whether to include an anesthesia expert during cataract surgery, but other countries do not routinely use them, to no ill effect, Chen noted.

With U.S. anesthesiologists being asked to staff an increasing number of non-OR procedures, such as endoscopic or interventional radiology procedures where patients tend to be much sicker and the procedure potentially more invasive, there often aren’t enough of these specialists go around, Chen said.

“Add to this a general shortage of anesthesiologists since COVID, and it’s clear we need to ensure staff resources are used efficiently,” said Chen.

In an upcoming study, Chen and her colleagues will look at both systemic and ophthalmologic outcomes stratified by whether patients received care from an anesthesia provider during cataract surgery. While the current study used a sample of 5% of Medicare claims, the upcoming study will use 20% of claims.

“It’s certainly possible that by having an anesthesiologist there, the patients are calmer and possibly less likely to move, and so the ophthalmologic outcomes could be better—so we are working on those studies now,” Chen said. “Where I think where we could end up, when the results are in, is that instead of automatically defaulting to include an anesthesiologist, we stratify patients by risk so that their level of sedation and anesthesia support matches their likelihood of complications.”

Co-authors and funding: Please see paper for additional co-authors and funding disclosures.

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University of California, San Francisco (UCSF)

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October 3, 2022