Background: Throughout the world, baby boomers reaching their sixth, seventh, and eighth decade of life are requiring a significant number of joint replacements—hips and knees. Due to the increasing number of joint replacements, it is important to find a multi-modal approach (MMA) to control pain, reduce the amount of opioid consumption, and improve patient satisfaction. Purpose: The purpose of this study was to evaluate the intraoperative, postoperative, and total opioid consumption of patients undergoing total hip and knee replacements in an effort to develop a multi-modal approach to decrease opioid consumption, minimize adverse effects secondary to narcotic administration, and to achieve better pain control. This MMA was achieved by administering oxycodone, gabapentin, celecoxib, and acetaminophen starting before surgical incision. Methods: The study sample consisted of 192 patients undergoing total hip and knee replacements over a 10-month period between June 2012 and March 2013 at UMASS Memorial performed by five orthopedic surgeons. The main objective was to record intraoperative, postoperative, total opioid consumption, and patient satisfaction amongst these patients. Furthermore, the patients were subdivided based on the type of procedure (hip vs knee), type of anesthetic (general vs spinal), and the presence or absence of an indwelling catheter to deliver anesthetic (catheter vs no catheter). Results: The data showed a large variability among the surgeons in regards to the amount of opioid used intraoperatively, postoperatively and total opioid consumption. In terms of type of anesthetic, the patients undergoing spinal anesthesia used statistically significantly less opioids intraoperatively but not postoperatively, compared to general anesthesia. As for catheter use with general and spinal anesthesia, surprisingly, there was no significant difference in opioid consumption compared to the non-catheter counterpart. Furthermore, there seems to be no correlation between body mass index (BMI) and intraoperative or postoperative opioid use. Patient satisfaction was another variable that showed no correlation with opioid use intraoperatively or postoperatively. In terms of age, the data suggests that older patients use less opioids postoperatively in both hip and knee replacements. Conclusions: Our results quantitatively show spinal anesthesia to be far superior than general anesthesia in both joint replacements. Spinal anesthesia provides better pain control intraoperatively which allows one to use less opioids, thereby minimizing the adverse side effects of narcotic administration which include respiratory depression, urinary retention, nausea and post-operative ileus to name just a few. One surgeon’s patients required significantly less opioids intraoperatively compared to the rest of the surgeons. Further studies might warrant examining this surgeon’s technique or the demographics of his patient population to determine how better pain control and less opioid consumption could be achieved across all joints with all participating surgeons.

OBJECTIVE--To examine changes in the prescribing of analgesics after the market entry and subsequent withdrawal of zomepirac sodium, a nonsteroidal anti-inflammatory drug (NSAID), following repeated reports of zomepirac-related deaths. DESIGN--To evaluate this natural quasi experiment, we conducted time-series analyses to compare prescribing in two cohorts of primary care physicians from July 1980 through September 1983. SETTING--Study physicians provided outpatient pharmaceutical care to patients enrolled in the New Jersey Medicaid program. PARTICIPANTS--We identified 260 primary care physicians who provided 10 or more prescriptions for zomepirac (zomepirac prescribers) and 308 who provided 10 or more prescriptions for NSAIDs other than zomepirac (other-NSAID prescribers) in Medicaid during the study period. MAIN OUTCOME MEASURES--Monthly rates of prescribing for zomepirac and several categories of substitute analgesics among Medicaid patients seen by study physicians. MAIN RESULTS--Zomepirac accounted for a stable 11.0% of analgesic prescribing among the zomepirac-prescriber cohort; label changes and manufacturer product-risk warnings 11 months before the product's withdrawal from the market had no impact on use. After market entry, zomepirac prescribers reduced use of other NSAIDs and propoxyphene (hydrochloride or napsylate) in comparison with other-NSAID prescribers (-8.1% and -2.8% of total analgesic prescribing, respectively; P < .001). After the product's withdrawal from the market, zomepirac prescribers showed significant increases in relative prescribing of other NSAIDs (+6.8%; P < .001), propoxyphene (+2.1%; P < .05), and analgesics containing barbiturates (+2.7%; P < .001). CONCLUSIONS--The sudden withdrawal of zomepirac from the market resulted in substitutions not only of other NSAIDs, but also of alternative analgesics that carry risks of habituation and adverse effects. Apparent gains in patient safety resulting from market withdrawal of medications must be evaluated in comparison with risks of medications likely to be substituted.

Objective: Whether short-term, low-potency opioid prescriptions for acute pain lead to future at-risk opioid use remains controversial and inadequately characterized. Our objective was to measure the association between emergency department (ED) opioid analgesic exposure after a physical, trauma-related event and subsequent opioid use. We hypothesized ED opioid analgesic exposure is associated with subsequent at-risk opioid use. Methods: Participants were enrolled in AURORA, a prospective cohort study of adult patients in 29 U.S., urban EDs receiving care for a traumatic event. Exclusion criteria were hospital admission, persons reporting any non-medical opioid use (e.g., opioids without prescription or taking more than prescribed for euphoria) in the 30 days before enrollment, and missing or incomplete data regarding opioid exposure or pain. We used multivariable logistic regression to assess the relationship between ED opioid exposure and at-risk opioid use, defined as any self-reported non-medical opioid use after initial ED encounter or prescription opioid use at 3-months. Results: Of 1441 subjects completing 3-month follow-up, 872 participants were included for analysis. At-risk opioid use occurred within 3 months in 33/620 (5.3%, CI: 3.7,7.4) participants without ED opioid analgesic exposure; 4/16 (25.0%, CI: 8.3, 52.6) with ED opioid prescription only; 17/146 (11.6%, CI: 7.1, 18.3) with ED opioid administration only; 12/90 (13.3%, CI: 7.4, 22.5) with both. Controlling for clinical factors, adjusted odds ratios (aORs) for at-risk opioid use after ED opioid exposure were: ED prescription only: 4.9 (95% CI 1.4, 17.4); ED administration for analgesia only: 2.0 (CI 1.0, 3.8); both: 2.8 (CI 1.2, 6.5). Conclusions: ED opioids were associated with subsequent at-risk opioid use within three months in a geographically diverse cohort of adult trauma patients. This supports need for prospective studies focused on the long-term consequences of ED opioid analgesic exposure to estimate individual risk and guide therapeutic decision-making.

OBJECTIVE: We estimated the use of prescribed analgesics and adjuvants among nursing home residents without cancer who reported pain at their admission assessment, in relation to resident-reported pain severity. METHODS: Medicare Part D claims were used to define 3 classes of analgesics and 7 classes of potential adjuvants on the 21st day after nursing home admission (or the day of discharge for residents discharged before that date) among 180,780 residents with complete information admitted between January 1, 2011 and December 9, 2016, with no cancer diagnosis. RESULTS: Of these residents, 27.9% reported mild pain, 46.6% moderate pain, and 25.6% reported severe pain. The prevalence of residents in pain without Part D claims for prescribed analgesic and/or adjuvant medications was 47.3% among those reporting mild pain, 35.7% among those with moderate pain, and 24.8% among those in severe pain. Among residents reporting severe pain, 33% of those > /= 85 years of age and 35% of those moderately cognitively impaired received no prescription analgesics/adjuvants. Use of all classes of prescribed analgesics and adjuvants increased with resident-reported pain severity, and the concomitant use of medications from multiple classes was common. CONCLUSION: Among nursing home residents with recognized pain, opportunities to improve the pharmacologic management of pain, especially among older residents, and those living with cognitive impairments exist.