Halena M. Gazelka

The Effects of Depression and Smoking on Pain Severity and Opioid Use in Patients with Chronic Pain

&NA; Depression and smoking are common comorbid conditions among adults with chronic pain. The aim of this study was to determine the independent effects of depression on clinical pain and opioid use among patients with chronic pain according to smoking status. A retrospective design was used to assess baseline levels of depression, clinical pain, opioid dose (calculated as morphine equivalents), and smoking status in a consecutive series of patients admitted to a 3‐week outpatient pain treatment program from September 2003 through February 2007. Depression was assessed using the Centers for Epidemiologic Studies‐Depression scale, and clinical pain was assessed using the pain severity subscale of the Multidimensional Pain Inventory. The study cohort (n = 1241) included 313 current smokers, 294 former smokers, and 634 never smokers. Baseline depression (P = .001) and clinical pain (P = .001) were greater among current smokers compared to former and never smokers, and the daily morphine equivalent dose was greater among smokers compared to never smokers (P = .005). In multivariate linear regression analyses, baseline pain severity was independently associated with greater levels of depression, but not with smoking status. However, status as a current smoker was independently associated with greater opioid use (by 27 mg/d), independent of depression scores. The relationship between depression, smoking status, opioid use, and chronic pain is complex, and both depression and smoking status may be potentially important considerations in the treatment of patients with chronic pain who utilize opioids. This study found that pain severity was associated with greater depression but not smoking; however, smoking was associated with greater opioid use, independent of depression.

Wide Variation and Overprescription of Opioids after Elective Surgery

Objective: We aimed to identify opioid prescribing practices across surgical specialties and institutions. Background: In an effort to minimize the contribution of prescription narcotics to the nationwide opioid epidemic, reductions in postoperative opioid prescribing have been proposed. It has been suggested that a maximum of 7 days, or 200 mg oral morphine equivalents (OME), should be prescribed at discharge in opioid-naïve patients. Methods: Adults undergoing 25 common elective procedures from 2013 to 2015 were identified from American College of Surgeons National Surgical Quality Improvement Program data from 3 academic centers in Minnesota, Arizona, and Florida. Opioids prescribed at discharge were abstracted from pharmacy data and converted into OME. Wilcoxon Rank-Sum and Kruskal-Wallis tests assessed variations. Results: Of 7651 patients, 93.9% received opioid prescriptions at discharge. Of 7181 patients who received opioid prescriptions, a median of 375 OME (interquartile range 225–750) were prescribed. Median OME varied by sex (375 men vs 390 women, P = 0.002) and increased with age (375 age 18–39 to 425 age 80+, P < 0.001). Patients with obesity and patients with non-cancer diagnoses received more opioids (both P < 0.001). Subset analysis of the 5756 (75.2%) opioid-naïve patients showed the majority received >200 OME (80.9%). Significant variations in opioid prescribing practices were seen within each procedure and between the 3 medical centers. Conclusions: The majority of patients were overprescribed opioids. Significant prescribing variation exists that was not explained by patient factors. These data will guide practices to optimize opioid prescribing after surgery.

Incidence of Clinically Significant Percutaneous Spinal Cord Stimulator Lead Migration

To examine the incidence of percutaneous spinal cord stimulator lead migration, given current hardware and surgical technique.

Ultrasound-guided transversus abdominis plane injection with computed tomography correlation: a cadaveric study

Background Ultrasound-guided transversus abdominis plane (TAP) injections are increasingly being used as an alternative to traditional perioperative analgesia in the abdominal region. With the use of a “blind” TAP block technique, these procedures have had variable success in cadaver and in vivo studies. For more accurate injection with the intended medication, ultrasound guidance allows visualization of the correct layer of the abdominal wall planes in which the thoracolumbar nerves reside. Objective To assess the spread of various volumes of contrast placed under live ultrasound guidance into the TAP using computed tomography (CT). Methods Four TAP blocks were performed on 2 fresh frozen cadaver torsos with predetermined contrast volumes of 5, 10, 15, or 20 mL. A CT scan of the cadaver was then performed and interpreted by a musculoskeletal radiologist. This cadaver study was carried out at a tertiary care academic medical center. Results Cranial–caudal spread of injected contrast correlated with increasing injectate volume and was roughly 1 vertebral level (end plate to end plate) for the 5 mL injection and 2 vertebral levels for the 10, 15, and 20 mL injections. However, the degree of injectate spread may be different for live patients than for cadavers. Conclusion This study helps further the understanding of injectate spread following ultrasound-guided TAP injections. Specifically, it suggests that 15 mL provides additional cranial–caudal spread and may be an optimal volume of anesthesia.

Patient Outcomes and Spinal Cord Stimulation: A Retrospective Case Series Evaluating Patient Satisfaction, Pain Scores, and Opioid Requirements.

Spinal cord stimulators (SCS) are used to treat various chronic pain states. Establishing patient outcomes in terms of pain control, opioid medication use, and overall satisfaction is vital in maintaining SCSs role in clinical practice.

Incidence of neuropathic pain after radiofrequency denervation of the third occipital nerve

The purpose of this study was to identify the incidence of neuropathic pain occurring after radiofrequency neurotomy of the third occipital nerve (TON). This study was conducted at a teaching hospital from January 1, 2008, to March 31, 2010. With institutional review board approval, Current Procedural Terminology codes were used to identify patients who received radiofrequency ablation (RFA) of the nerves supplying the C2-3 facet joint and the TON. The C3 dorsal ramus provides innervation to the C2-3 facet joint and the suboccipital cutaneous region, and procedures that included ablation to this region were reviewed for complications. Postprocedural data were collected by reviewing follow-up appointment notes and telephone calls. Included were patients who had new neuropathic pain in the distribution of the TON after RFA. They described what they were feeling as burning, tingling, or numbness. All patients who presented with complaints had normal neurologic findings and no secondary cause for their symptoms. The included patient medical records were then reviewed for severity and duration of symptoms and the need for treatment with pain medication. Sixty-four patients underwent C2-3 RFA or TON RFA, and 12 patients were identified as experiencing ablation-induced third occipital neuralgia, an incidence rate of 19%. This finding suggests that patients undergoing RFA of the nerves supplying the C2-3 joint or TON are at risk for postprocedural third occipital neuralgia. This possibility may affect providing informed consent as well as anticipating and managing postprocedural pain.

Palliative Care Consultation and Associated End-of-Life Care After Pacemaker or Implantable Cardioverter-Defibrillator Deactivation.

The presence of cardiac pacemakers and defibrillators complicates making end-of-life (EOL) medical decisions. Palliative care/medicine consultation (PCMC) may benefit patients and primary providers, but data are lacking. We retrospectively reviewed 150 charts of patients who underwent device deactivation at our tertiary care center (between November 1, 2008, and September 1, 2012), assessing for PCMC and outcomes. Overall, 42% of patients received a PCMC, and 68% of those PCMCs specifically addressed device deactivation. Median survival following deactivation was 2 days, with 42% of deaths occurring within 1 day of deactivation. There was no difference in survival between the groups. The EOL care for patients with implanted cardiac devices is complex, but PCMC may assist with symptom management and clarification of goals of care for such patients.

Attitudes, Beliefs, Practices, and Concerns Among Clinicians Prescribing Opioids in a Large Academic Institution

Objectives Opioid treatment of chronic noncancer pain (CNCP) adds complexity and uncertainty to patient interactions. We sought to assess clinician attitudes, beliefs, practice styles, and concerns around opioid prescribing following the release of the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain. Methods E-mailed electronic survey to clinicians at a large academic medical institution. Results A total of 961 clinicians responded to the survey (response rate = 40%), 720 of whom prescribed opioids and were not in training. Sixty-five percent were physicians, and 35% were nurse practitioners or physician assistants, with a mean age of 47 years (SD ± 11.4 years). Eighty-two percent were reluctant to prescribe opioids for CNCP, and only 47% expressed confidence in their care for CNCP patients. Sixty-seven percent were aware of the CDC guideline, 55% were enrolled in the state Prescription Drug Monitoring Program (PDMP), and 2% always or frequently prescribed naloxone to patients on opioids. Guideline awareness was associated with increased confidence in caring for CNCP patients. Clinicians having knowledge of a patient overdose were 31% more likely to be enrolled in the PDMP (relative rate= 1.31, 95% confidence interval = 1.14-1.52, chi-square = 11.00, P <0.01). Clinicians who knew of a patient overdose event were also more likely to express concern about patient opioid dependence and addiction. Conclusions Opportunities exist to increase awareness of the CDC guideline and to increase clinician confidence in opioid prescribing. Knowledge of an overdose event may influence clinician behavior and concerns about dependence and addiction.

Bleeding Complications in Patients Undergoing Celiac Plexus Block.

Background and Objectives Celiac plexus blockade has known risks including bleeding and neurologic injury because of the close proximity of vascular and neuraxial structures. The aim of this study was to determine the incidence of bleeding complications in patients undergoing celiac plexus block (CPB), with an emphasis on preprocedural antiplatelet medication use and coagulation status. Methods This is a retrospective study from 2005 to 2014 of adult patients undergoing CPB by the pain medicine division at a tertiary care center. The primary outcome was red blood cell (RBC) transfusion within 72 hours of needle placement, with a secondary outcome of bleeding complications requiring emergency medicine, neurology, or neurosurgical evaluation within 31 days. Results A total of 402 procedures were performed on 298 unique patients, with 58 patients (14.4%) receiving aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) preoperatively. Five patients (1.2%) received RBC transfusion within 72 hours, of which one had received preprocedure NSAIDs. A platelet count measured within 30 days was available for 268 patients, with 7 patients (2.6%) having platelet counts of 100 × 109/L or less at the time of needle placement. A total of 187 patients had a valid preoperative international normalized ratio (INR), with 9 (4.8%) having an INR of 1.5 or higher (range, 1.5–2.6). One patient (11.1%) required RBC transfusion compared with an RBC transfusion rate of 2.3% (4 of 178) in those with normal INR (P = 0.221). We identified no bleeding complications requiring emergency medicine, neurology, or neurosurgical evaluation. Conclusions This study suggests that CPBs may be safely performed in patients receiving aspirin and/or NSAID therapy.

Serum Triamcinolone Levels Following Interlaminar Epidural Injection.

Background Lumbar interlaminar epidural steroid injections (ESIs) are one of the most commonly performed procedures in pain medicine, but little is known about the serum levels of steroids following injection into the epidural space. The primary objective of this study was to investigate the pharmacokinetics of fluoroscopy-guided epidural-administered triamcinolone acetonide in a cohort of patients with chronic low-back pain seeking treatment in a pain medicine clinic. Methods The study cohort included 10 patients undergoing a fluoroscopically guided L4-L5 or L5-S1 lumbar interlaminar ESI at a pain medicine specialty clinic. Blood was collected prior to the ESI and on days 1, 2, 4, 6, 8, 14, 21, 28, 35, and 42 following the injection. The sample extract was analyzed by tandem mass spectrometry. Results The terminal elimination half-life of epidural-administered triamcinolone in a noncompartmental analysis was 523 hours. In the noncompartmental analysis, peak triamcinolone concentrations of 4.1 ng/mL were detected within 24 hours after administration. Conclusions The pharmacokinetics of epidural-administered triamcinolone is consistent with previously observed adverse effects of the drug on endocrine function. The pharmacokinetics of other epidural-administered steroids should be determined and incorporated in clinical trials to investigate the potential associations between serum levels, clinical outcomes, and potential adverse endocrine effects.