搜索结果：Journal of opioid management

While opioid medications are commonly used to manage postoperative pain in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis, their use is associated with negative short and long-term effects. There is a paucity of data evaluating the feasibility and efficacy of opioid-free pain regimens in this population. The purpose of this study was to compare a multimodal opioid-free with a traditional opioid-containing protocol in pediatric patients undergoing instrumented PSF for idiopathic scoliosis. We hypothesized that the opioid-free pain management pathway would result in equivalent length of stay (LOS) and fewer opioids prescribed at discharge compared with an opioid-containing pathway. This was a prospective case-control study comparing opioid-free versus opioid-containing pathways. Eligible participants included patients aged 10-20 years at time of surgery with idiopathic scoliosis who underwent primary instrumented PSF by a single, fellowship-trained pediatric orthopedic surgeon during a 2-year period. Total opioid use was recorded. Statistical analysis included Wilcoxon, Chi-square, and Fisher's exact tests for group comparisons. Patients in the opioid-free group had a greater number of levels fused ( P &#x2005;=&#x2005;0.036), had a similar inpatient LOS postoperatively ( P &#x2005;=&#x2005;0.917), and required fewer opioid prescriptions at discharge [10/36 patients (27.8%) vs. 55/56 patients (98.2%), respectively; P &#x2005;<&#x2005;0.0001]. A comprehensive, multimodal, opioid-free pain management pathway following instrumented PSF for idiopathic scoliosis results in equivalent LOS and fewer opioids prescribed at discharge compared with an opioid-containing pathway. Establishing patient/family expectations beforehand is crucial to the successful engagement and implementation of this opioid-free protocol.

Pediatric opioid use has been associated with serious adverse effects, including persistent use and overdose. Recent studies have shown that opioid needs may be minimal following outpatient pediatric urologic surgery. Post-operative pain regimens following pediatric penile surgery are not standardized. This study aimed to identify current opioid prescribing practices following hypospadias repair. An online survey was administered to members of the Societies for Pediatric Urology, including eight questions surrounding physician demographics, hypospadias repair case volume, attitudes regarding opioid prescription in pediatric urology, and post-operative pain regimens. Responses were stratified for analysis. A total of 88 of 350 members responded to the survey, achieving a response rate of 25%. Most respondents practiced in an academic setting (73%) and had a case volume between 0-50 hypospadias repairs annually (76%). Only 26% of respondents reported using a standardized post-operative pain regimen following hypospadias repair. Respondents with higher case volumes were less likely to prescribe opioids. Following hypospadias repair, 61% of respondents reported regularly prescribing opioids, while 58% felt opioids are overprescribed following pediatric urologic procedures. This study demonstrates wide variability in opioid prescribing patterns and attitudes among pediatric urologists. Despite growing evidence that opioids may not be necessary following pediatric urologic surgery, over half of pediatric urologists regularly prescribe opioids following hypospadias repair. Additionally, over half of the respondents believe opioids are over-prescribed. These findings represent an opportunity to improve opioid stewardship, which is meaningful given the ongoing opioid crisis. This demonstrates the need for evidence-based pain management guidelines following hypospadias repair.

As opioid-related fatalities continue to climb, it is imperative to advance our understanding of the management of life-threatening opioid emergencies, including cardiac arrest. Emergency medical services (EMS) administered naloxone reverses critical respiratory depression within minutes; however, the role of naloxone in cases of opioid-associated cardiac arrest (OA-OHCA) is unknown. This systematic review sought to summarize patient outcomes following EMS-administered naloxone in OA-OHCA cases. Following PRISMA guidelines, a systematic search was conducted in OVID Medline, Embase, and Cochrane from database inception to December 2024. Original, peer-reviewed studies examining patients with OA-OHCA who were given naloxone by EMS were included. Two independent reviewers screened titles/abstracts and full-texts in Covidence based on predetermined inclusion criteria. Relevant data points were extracted, and a risk of bias assessment was conducted for included studies. No meta-analysis was performed due to heterogeneity across the included studies. The literature search yielded 4814 articles, of which 8 studies met eligibility and were included. Seven of the included studies were retrospective cohort studies conducted in the United States. The eighth included study was a prospective cohort study conducted in Denmark. The total sample size for drug-related OHCA patients was 1294 (range 16-471) from all the included studies. Risk of bias was assessed to be low to moderate in seven studies and serious in one study. A minority of patients achieved return of spontaneous circulation (ROSC), with ROSC ranging from 4.3% to 50%. Survival to hospital admission ranged from 11.1% to 55%, while survival to hospital discharge ranged from 0% to 20.4%. There are a limited number of studies assessing the use of naloxone in patients who present in opioid-associated out-of-hospital cardiac arrest (OA-OHCA). Further research is needed to evaluate the effectiveness of naloxone in this patient population.

The purpose of this systematic review was to analyze whether breathing therapy is effective in reducing pain, improving health-related quality of life, improving physical functioning/activity, and improving sleep quality in patients suffering from complex chronic non-cancer pain conditions (CNCP). An electronic literature search was conducted in MEDLINE, CINAHL, EMBASE, Cochrane Library, PEDro, and PsycINFO from inception to October 2024. The inclusion criteria were randomized clinical trials (RCT) examining breathing therapy as a sole or central intervention component in adult patients with CNCP. From 2,369 abstracts, a total of 10 RCTs (n=638) met the inclusion criteria. The population in the selected studies were patients with chronic neck pain, chronic low back pain, fibromyalgia, or tension-typed headache. Breathing therapy significantly improved pain and/or health-related quality of life in six studies. However, the quality of the included RCTs ranged from high to critically low, and substantial heterogeneity in participants, intervention, and methods prevented synthesis of results across studies. This systematic review highlights breathing therapy as a promising pain management strategy in patients suffering from CNCP. We evaluated two RCTs examining similar daily slow diaphragmatic breathing for 15&#x202f;min to have a low risk of bias; both demonstrating statistically significant relevant pain reduction up to 37&#x202f;%. However, the strength of recommendations for clinical practice depends on the level of evidence as indicated by a risk of bias assessment (internal validity), consistency of results between studies, and generalizability (external validity). Based on the findings of this systematic review evidence of breathing therapy invention in patients suffering from CNCP conditions remains sparse. Striving to eliminate or minimize opioid management for complex CNCP, high-quality research is needed to reinforce the evidence base for non-pharmacological interventions such as breathing therapy to support modern pain management rather than former traditional pharmacological treatment. Trial registry number: PROSPERO #CRD42023460181.

The 2023 iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimated prevalence, incidence, and health burden for 375 diseases and injuries, including 12 mental disorders. We assess past, current, and emerging trends in the prevalence and burden of mental disorders across sexes and age groups, for 21 regions, 204 countries and territories, and by Socio-demographic Index (SDI) quintile, from 1990 to 2023. Mental disorders included in GBD 2023 were anxiety disorders, major depressive disorder, dysthymia, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, anorexia nervosa, bulimia nervosa, idiopathic developmental intellectual disability, and a residual category of other mental disorders. A literature review identified epidemiological data for each disorder. These were analysed via a Bayesian meta-regression to estimate prevalence by disorder, sex, age, location, and year. Disorder-specific prevalence was multiplied by disability weights representing the severity of health loss associated with each disorder to estimate years lived with disability (YLDs). Deaths due to anorexia nervosa were assessed with a Cause of Death Ensemble modelling strategy to estimate deaths by sex, age, location, and year, and then multiplied by the standard life expectancy at age of death to estimate years of life lost (YLLs). YLDs equalled disability-adjusted life-years (DALYs) for all mental disorders except anorexia nervosa (the only mental disorder considered as an underlying cause of death in GBD), for which DALYs represented the sum of YLDs and YLLs. We presented prevalence, deaths, YLDs, YLLs, and DALYs as counts, age-specific rates per 100&#x2008;000 population, and age-standardised rates per 100&#x2008;000 population. We estimated 1&#xb7;17 billion (95% uncertainty interval 1&#xb7;06-1&#xb7;31) prevalent cases of mental disorders globally in 2023, equivalent to an age-standardised prevalence rate of 14&#x2008;210&#xb7;7 cases (12&#x2008;849&#xb7;5-15&#x2008;940&#xb7;1) per 100&#x2008;000 population. These estimates represented a 95&#xb7;5% (75&#xb7;0-121&#xb7;2) increase in prevalent cases and 24&#xb7;2% (11&#xb7;4-41&#xb7;4) increase in age-standardised prevalence rate between 1990 and 2023. All mental disorders showed increases in prevalent cases between 1990 and 2023, while notable increases were seen in age-standardised prevalence rates for anxiety disorders, major depressive disorder, dysthymia, anorexia nervosa, bulimia nervosa, schizophrenia, and conduct disorder. There were an estimated 171 million (127-228) DALYs due to mental disorders globally across sex and age in 2023, equivalent to an age-standardised DALY rate of 2070&#xb7;5 DALYs (1519&#xb7;1-2750&#xb7;5) per 100&#x2008;000 population. Mental disorders contributed to 6&#xb7;1% (4&#xb7;8-7&#xb7;6) of all-cause DALYs in 2023, making them the fifth leading cause of global DALYs (up from 12th in 1990). DALYs were almost entirely composed of YLDs. Mental disorders were the leading cause of YLDs in 2023 (up from second in 1990), explaining 17&#xb7;3% (14&#xb7;8-20&#xb7;6) of all-cause global YLDs. Leading causes of mental disorder DALYs were anxiety disorders (ranked 11th among the 304 diseases and injuries at Level 4 of the GBD cause hierarchy), major depressive disorder (15th), and schizophrenia (41st). Globally in 2023, mental disorder age-standardised DALY rates were higher among females (2239&#xb7;6 [1643&#xb7;7-3014&#xb7;1] per 100&#x2008;000) than among males (1900&#xb7;2 [1399&#xb7;8-2510&#xb7;8] per 100&#x2008;000), and peaked in the 15-19 years age group (2617&#xb7;3 [1850&#xb7;6-3696&#xb7;8] per 100&#x2008;000). All locations showed increased mental disorder DALY rates in 2023 compared with 1990, ranging across countries and territories from 1302&#xb7;4 (952&#xb7;7-1683&#xb7;7) per 100&#x2008;000 in Viet Nam to 3555&#xb7;8 (2661&#xb7;9-4715&#xb7;0) per 100&#x2008;000 in the Netherlands. Across SDI quintiles, DALY rates ranged from 1853&#xb7;0 (1352&#xb7;1-2469&#xb7;3) per 100&#x2008;000 for middle SDI to 2184&#xb7;1 (1606&#xb7;1-2890&#xb7;3) per 100&#x2008;000 for high SDI. A significant health burden was imposed by mental disorders in all countries and territories in 2023, irrespective of the health resources available. In some instances, this burden has increased over time and is unevenly distributed across populations. Stronger surveillance systems, particularly in low-income and middle-income countries, are required. Additionally, we need more coordinated and inclusive policies to reduce the burden through early treatment and prevention, tailored to sex and age differences across locations. Responding to the mental health needs of our global population, especially those most vulnerable, is an obligation, not a choice. Gates Foundation, Queensland Health, and University of Queensland.

Injection opioid misuse is associated with the transmission of infectious diseases (IDs) such as hepatitis B and C, and skin and soft tissue infections. Medications for opioid use disorder (MOUD) are effective treatments for opioid use disorder (OUD) and can reduce ID risk and improve outcomes. This study evaluated the association between treatment with buprenorphine extended-release (BUP-XR; SUBLOCADE&#xae;) or transmucosal buprenorphine (TM-BUP) and ID-specific incidence rates, all-cause healthcare resource utilization (HCRU), and ID-specific HCRU among patients treated for OUD continuously for &#x2265;90 days. This retrospective cohort study assessed differences in outcomes between patients receiving BUP-XR vs. TM-BUP using the Veradigm&#xae; Network EHR electronic health records and linked claims dataset. The study period spanned from January 1, 2018 to June 30, 2024, with an index selection window from July 1, 2018 to December 31, 2023. The first qualifying buprenorphine treatment claim (either BUP-XR injection or TM-BUP prescription) during the selection window defined the index date. Descriptive analyses compared baseline characteristics of the BUP-XR and TM-BUP cohorts, while inverse probability of treatment weighting (IPTW) controlled for confounding. The analysis utilized generalized linear models with a difference-in-differences design to examine the primary outcomes. A total of 467 patients met criteria for the BUP-XR cohort and 118,112 patients for the TM-BUP cohort. After applying IPTW, the weighted sample size was 437 in the BUP-XR cohort and 118,104 in the TM-BUP cohort. During the 6-month baseline period pre-index date, skin conditions and hepatitis B and C were the most common acute infections observed in both unweighted cohorts. The adjusted analyses demonstrated a statistically significant reduction of 62% in the incidence of bacteremia in the BUP-XR cohort during follow-up (95% CI: 26%-81%). Patients on BUP-XR consistently had lower overall HCRU compared to TM-BUP during follow-up, including 56% fewer inpatient visits (95% CI: 38%-69%), 22% fewer emergency department visits (95% CI: 6%-35%), 21% fewer all-cause outpatient visits (95% CI: 17%-24%), and 77% fewer outpatient visits for treating sexually transmitted infections (95% CI: 43.4%-90.5%). Patients on BUP-XR showed a reduction in the incidence of bacteremia and overall HCRU relative to those on TM-BUP.

Opioid misuse has become a widespread public health issue, affecting diverse patient populations, including those with heart failure. Given that heart failure with preserved ejection fraction (HFpEF) constitutes nearly half of all heart failure cases, understanding its management and the influence of various factors on patient outcomes is essential. This study seeks to evaluate the outcomes of chronic opioid therapy in patients with HFpEF. Utilizing the National Inpatient Sample (2016-2020), adult HFpEF patients were identified using the appropriate International Classification of Diseases, Tenth Revision codes, excluding those with end-stage renal disease. Outcomes were compared between chronic opioid users and nonusers. Multivariate logistic and linear regression analyses were conducted, controlling for various patient and hospital confounders. The primary outcome measured was all-cause in-hospital mortality, with secondary outcomes including acute kidney injury/hemodialysis (AKI/HD), cardiogenic shock, cardiac arrest, mechanical ventilation, length of stay, and total hospital charges. Among 1,557,344 HFpEF patients, 21,655 (1.4 percent) were on chronic opioid therapy. No significant difference in inpatient mortality was found (adjusted odds ratio [aOR] 1.04, 95 percent confidence interval [CI]: 0.88-1.24, p = 0.58). A nonsignificant increase in cardiogenic shock (aOR 1.12, 95 percent CI: 0.85-1.48, p = 0.39) and cardiac arrest (aOR 1.06, 95 percent CI: 0.81-1.38, p = 0.65) was noted in chronic opioid users. However, chronic opioid use was associated with a higher risk of AKI/HD (aOR 1.15, 95 percent CI: 1.07-1.24, p < 0.001) and mechanical ventilation (aOR 1.27, 95 percent CI: 1.14-1.41, p < 0.001). Opioid use was also linked to longer hospital stays (adjusted mean difference [aMD] 1.15 days, 95 percent CI: 0.83-1.47, p < 0.001) and a nonsignificant increase in total charges (aMD USD 3,615, 95 percent CI: USD -1.014 to USD 8,245, p = 0.12). While chronic opioid use in hospitalized HFpEF patients did not significantly affect in-hospital mortality, it was associated with a higher risk of other adverse events and longer hospital stays.

To assess the clinical effectiveness of a pilot multifaceted intervention to prevent persistent opioid use among patients undergoing orthopedic and spine surgery. Pre-post pilot study. Two hospitals (academic medical center and affiliated community hospital) in a single healthcare system. Preintervention period was July 1, 2021 to June 1, 2022; post-intervention period was June 2, 2022 to February 28, 2023. A total of 171 inpatient orthopedic and neurosurgical spine patients. Multifaceted persistent Opioid use Prevention Program (MOPP), including standardized order sets, pharmacist-led discharge counseling, a virtual post-discharge visit, and a mobile app for tracking pain, function, and opioid use for up to 180 days after hospital discharge. Persistent opioid use within 180 days post-discharge. Outcome assessors were blinded. Of 115 patients in the intervention group, 91 (79 percent) received at least one component of MOPP. Persistent opioid use was observed in 10.9 percent of usual care patients and 4.5 percent in intervention patients (weighted difference -6.4 percent, 95 percent confidence interval [CI] -21 percent, +8.2, p = 0.37). In subgroup analyses, the intervention demonstrated a significant reduction in persistent opioid use among nonopioid-naive patients (weighted difference -40 percent, 95 percent CI -76 percent, -4.2 percent), with evidence of effect modification by opioid-naive status (p value for interaction term 0.005). This pilot study demonstrated a nonsignificant overall effect on the primary outcome, with significant effects on nonopioid-naive patients. Further research with a larger trial is needed to validate these findings.

The opioid epidemic remains a critical public health issue, with orthopedic surgeons being among the highest prescribers of opioids for post-operative pain management. To elucidate the provisions of the Non-Opioid Prevent Addiction in the Nation (NOPAIN) Act and its implications for reducing opioid use in orthopedic surgery. A comprehensive review of the NOPAIN Act's legislative framework, historical opioid use in orthopedic practices, current nonopioid pain management strategies, and insights from relevant reports was conducted. The NOPAIN Act, effective January 1, 2025, mandates Medicare reimbursement for Food and Drug Administration-approved nonopioid pain treatments at 106 percent of the average sales price (+6 percent) in hospital outpatient departments and ambulatory surgery centers. This legislation incentivizes the adoption of nonopioid alternatives, promoting multimodal analgesia and regional anesthesia techniques. The Act may improve patient outcomes, reduce opioid-related adverse events, and help offset institutional costs. Implementation of the NOPAIN Act may influence orthopedic surgeons in adopting evidence-based, nonopioid pain management protocols, enhancing patient outcomes and contributing to national efforts against the opioid crisis. The Act's financial incentives and structured reimbursement framework may contribute to the transition toward safer practices.

Alcohol and opioid use disorders (AUD, OUD) cause significant morbidity and mortality among Veterans, yet only a minority receive evidence-based treatment. Beginning in February 2022, we piloted a telemedicine pharmacist-physician management model (PPMM) in 6 Veterans Health Administration (VHA) primary care community-based outpatient clinics (CBOCs) across one VHA Health Care System to improve rural Veteran access to medications for opioid and alcohol use disorder (MOAD). Veterans with AUD and/or OUD receiving primary care in participating CBOCs during the year following implementation were eligible for referral. Data obtained from study records and VHA electronic health records assessed patient sociodemographic and clinical characteristics and MOAD receipt among referred Veterans. There were 2274 Veterans diagnosed with AUD (n = 2062) and/or OUD (n = 307) receiving primary care from CBOCs during the study period. Of this population, 111 (4.9%) Veterans were referred and received PPMM services (AUD: n = 93; OUD: n = 9; AUD and OUD: n = 9), the mean age was 52 years, 92% were male, 68% White, and 39% lived in rural zip codes. Of the 102 Veterans referred to PPMM with AUD, 71% received medication. Of the 18 Veterans referred with OUD, 78% received medication. Most Veterans who were newly initiated on MOAD (N = 74) received medication within 72 h (N = 50, 68%). In this pilot implementation of same-day telemedicine PPMM, high rates of MOAD receipt were seen among referred Veterans. However, most Veterans with AUD/OUD seen in participating clinics were not referred. Further evaluation of barriers and/or facilitators to referral are needed to increase program uptake.

The opioid epidemic remains a public health crisis in the United States. Naloxone is a cornerstone of overdose reversal, and its increasing availability to bystanders has improved immediate survival. However, little is known about how bystander naloxone administration influences use of emergency medical services (EMS), particularly patient refusal of transport. Understanding these dynamics is critical for development of EMS protocol and harm reduction strategies. We performed a retrospective cohort study of suspected opioid overdoses reported to the Connecticut Statewide Opioid Reporting Directive (SWORD) between November 1, 2019-June 30, 2024. The primary outcome was EMS transport refusal, defined as non-transport after naloxone administration. The primary exposure was initial naloxone administrator (bystander vs first responder). Secondary variables included naloxone dose frequency, patient demographics, and time. Bivariate tests compared group differences. We used multivariable logistic regression to assess the association between bystander naloxone and refusal, adjusting for covariates. To evaluate temporal trends, we performed separate logistic regression models with calendar quarter (Q) modeled as a continuous variable (Q1 2020-Q2 2024). Among 15,025 nonfatal suspected overdoses involving naloxone in Connecticut, bystanders were initial administrators in 18%. Transport refusal occurred more often after bystander administration compared to first responder administration (16.1% vs 6.2%). In adjusted analyses, bystander administration was associated with nearly threefold higher odds of refusal (adjusted odds ratio [aOR] 2.90; 95% CI, 2.53-3.31). Multiple-dose incidents were associated with decreased refusal (aOR 0.83; 0.72-0.93). During the study period, bystander administration increased from 15% in Q4 2019 to 24% in Q2 2024, corresponding to a 3.8% increase in odds per quarter (OR 1.04; 95% CI 1.03-1.05, P < .001). Refusal more than doubled from 4% to 12%, with odds increasing 4.5% per quarter (OR 1.05; 1.04-1.06, P < .001). Bystander-administered naloxone is increasingly common and strongly associated with higher odds of EMS transport refusal. While refusal does not always equate to unsafe outcomes, it represents missed opportunities for initiation of medications for opioid use disorder, harm reduction counseling, and linkage to care. Emergency medical services agencies should consider strategies such as leave-behind naloxone, peer recovery coach deployment, and EMS-initiated buprenorphine to capitalize on these encounters.

Opioid use disorder (OUD) in pregnancy has increased substantially, with illicit fentanyl now the most common illicit opioid. Limited data exist on the impact of antenatal fentanyl exposure on neonatal opioid withdrawal syndrome (NOWS). We aimed to evaluate whether antenatal fentanyl exposure is associated with increased NOWS severity. We conducted a retrospective cohort study of mother-infant dyads with OUD between 2017 and 2024. Fentanyl exposure was determined by urine toxicology during the pregnancy and on admission. Infants were monitored using the Eat, Sleep, Console tool and a standardized NOWS protocol. NOWS hospitalization outcomes were compared between the fentanyl-exposed and nonexposed groups with adjustment for breastfeeding, year of birth, and relevant co-exposures. Among 504 dyads, 131 (26.0%) had fentanyl exposure. Maternal demographics were similar between groups, but fentanyl was associated with higher rates of polysubstance use. Fentanyl-exposed infants were more likely to receive pharmacologic NOWS treatment (61.1% vs 40.8%, P&#x2009;<&#x2009;.01), scheduled methadone dosing, secondary pharmacologic agents (15.4% vs 7.4%, P&#x2009;=&#x2009;.03), and feeding tubes (40.0% vs 24.5%, P&#x2009;<&#x2009;.001). Hospital length of stay (22.1 vs 13.3&#xa0;days, P&#x2009;<&#x2009;.01) and opioid treatment duration (14.2 vs 9.4&#xa0;days, P&#x2009;<&#x2009;.01) were longer in the fentanyl-exposed cohort. In adjusted regression models, fentanyl exposure remained independently associated with prolonged hospitalization (mean difference 5.1&#xa0;days [95% CI 1.7-8.5]) and increased odds of pharmacologic treatment (adjusted odds ratio 2.1 [95% CI 1.2-3.8]). Antenatal fentanyl exposure is strongly associated with intensive pharmacologic management and extended hospitalization. These findings are suggestive of more severe NOWS.

Rib fractures are common in trauma patients and are associated with significant morbidity due to pain-related respiratory compromise. Surgical stabilization of rib fractures (SSRF) improves outcomes in select cases, but postoperative pain can persist despite surgery. Intercostal nerve cryoablation (INCA) has emerged as a potential adjunct to enhance analgesia and recovery. This systematic review and meta-analysis evaluated postoperative outcomes associated with the use of INCA in conjunction with SSRF in adult patients with rib fractures. We conducted a systematic search of seven databases (PubMed, Embase, Scopus, Web of Science, Cochrane Library, Virtual Health Library, ClinicalTrials.gov) from inception to March 16, 2025. Comparative studies involving adult trauma patients undergoing SSRF with or without INCA were included. The primary outcomes were postoperative opioid consumption, intensive care unit (ICU) length of stay, and hospital length of stay. Secondary outcomes included pneumonia incidence, postoperative intubation rates, tracheostomy rates, and mortality. Meta-analyses were performed using random-effects models, and the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework. Four retrospective cohort studies comprising 479 patients were included. Relative to SSRF alone, SSRF with adjunctive INCA was associated with lower postoperative opioid consumption (mean difference [MD] -140.14 morphine milligram equivalent; 95% confidence interval (CI), -266.79 to -13.49; P = 0.03), shorter ICU stay (MD -2.76 d; 95% CI, -3.78 to -1.73; P < 0.0001), and shorter hospital stay (MD -1.79 d; 95% CI, -2.79 to -0.80; P < 0.01). Adjunctive INCA was also associated with lower postoperative intubation rates (risk ratio 0.47; 95% CI, 0.28-0.80; P < 0.01) and showed a borderline association with lower pneumonia incidence (risk ratio 0.43; P = 0.0506). No significant differences were identified for tracheostomy or mortality. The certainty of evidence was very low overall owing to risk of bias, imprecision, and the observational design of the included studies. Adjunctive INCA during SSRF was associated with lower postoperative opioid requirements, shorter ICU and hospital stays, and more favorable pulmonary outcomes in patients with rib fractures. These findings are encouraging but derive from a small number of retrospective studies with important methodological limitations and should therefore be interpreted as associative rather than causal. Prospective randomized trials are needed to determine whether these associations persist and to better define the role of INCA in the management of rib fractures.

Several studies support the benefits of music therapy (MT) for improving symptoms within a single session among patients with hematologic/oncologic conditions, but none have examined real-world longitudinal impacts. This study evaluated whether there was a dose-response relationship between MT intervention exposure and longitudinal changes in pain intensity and opioid utilization. A retrospective electronic health record review was conducted of 283 hospital admissions among adult patients with hematologic/oncologic conditions who received MT and either reported pain&#x2009;&#x2265;&#x2009;4/10 on the numeric rating scale (NRS) or received opioids in the first 48&#xa0;h of admission. Longitudinal changes in pain intensity on the 0-10 NRS and log-transformed morphine milligram equivalents were modeled using linear mixed-effects models with natural splines for time since first MT intervention interacting with MT exposure group (1, 2, or&#x2009;&#x2265;&#x2009;3 MT interventions). Models were adjusted for baseline values and length of stay. Of 283 hospital admissions, 122 (43.1%) included 1, 89 (31.4%) included 2, and 72 (25.4%) included&#x2009;&#x2265;&#x2009;3 MT interventions. No meaningful MT exposure-by-time effects were found for pain intensity (p&#x2009;=&#x2009;.131) or opioid utilization per day (p&#x2009;=&#x2009;.118). Among patients admitted with hematologic/oncologic conditions, greater MT exposure does not appear to reduce pain intensity or opioid exposure over time relative to receiving 1 MT intervention. Future evaluations of inpatient programs should consider collecting more robust data on outcomes that may be more sensitive to intervention (e.g., stress, anxiety) and increasing the MT dose to have a greater impact on outcomes over time.

Thoracic and cardiac surgical procedures are associated with significant postoperative pain. Intercostal nerve cryoablation (INC) is a non-opioid adjunctive pain management strategy. The objective of this study was to comprehensively review published outcomes of INC during non-pectus repair thoracic and cardiac surgeries to inform clinical practice and guideline development. A literature search was conducted in PubMed, Embase, Google Scholar, and using manual approaches to identify comparative studies of patients undergoing non-pectus repair thoracic or cardiac procedures with INC versus standard of care (SOC) without INC. Meta-analyses were performed to quantitively evaluate opioid consumption and hospital length of stay (LOS). Secondary outcomes were summarized qualitatively. Twenty-four studies were included encompassing 18465 patients, of whom 10.6% (n&#x2009;=&#x2009;1954) received INC. INC was applied during surgical stabilization of rib fractures, thoracotomy, pulmonary resections, lung transplants, aortic aneurysm repair, and cardiac procedures. Meta-analyses of adult studies demonstrated a significant reduction in inpatient opioid consumption by 102 morphine milligram equivalents (MME) (95% CI: -180.00, -23.87) and a non-significant reduction in opioid consumption after discharge by 89 MME (95% CI: -182.00, 4.56) with INC. Sub-group analysis demonstrated the largest effect size in inpatient opioid reduction for bilateral thoracotomy or thoracosternotomy for lung transplants. Meta-analysis demonstrated no significant difference in hospital stay for adult patients treated with INC. The results of this systematic review and meta-analysis provide evidence to support the association between INC and reduced inpatient opioid consumption in non-pectus repair thoracic and cardiac procedures.

Although palliative care (PC) is recognized as a component of comprehensive care throughout the life course and universal health coverage, more than 85% of the global need for PC is unmet. Nigeria has isolated PC provision, with a narrow scope, limited availability, and inadequate support for PC services, despite having adequate legislation to support the operation in the country. Given the rising incidence of chronic illnesses that are amenable to PC in Nigeria, this study aimed to explore healthcare professionals' (HCPs') knowledge and attitudes towards PC and identify targets for improving PC delivery nationally. Using a mixed-methods convergent design, an online survey was distributed to multidisciplinary HCPs in Nigeria. The survey included validated tools that assessed knowledge and attitudes related to PC, pain management, and end-of-life (EOL) care. Five focus group discussions (FGDs) were conducted and qualitatively analyzed using rapid matrix analysis to triangulate themes with survey responses. From February to December 2024, 117 HCPs from 26 hospitals across five of six geopolitical zones of Nigeria completed the quantitative survey. Most respondents were nurses (67%) or physicians (26%), worked in public teaching hospitals (70%), and provided care for patients with cancer (94%). Over half (56%) received some PC training, though many expressed interest in additional training on pain management (65%), EOL communication skills (50%), and EOL ethics and decision-making (49%). FGDs from three geopolitical zones revealed 3 major themes: (1) HCPs have a shared high-level understanding of the goals of PC with varied perceptions around PC delivery; (2) Challenges in the practical delivery of PC include systemic barriers, opioid costs and stigma, and patient receptivity; (3) Delivering PC impacts HCPs' job satisfaction and takes a psychological toll. Participant-identified strategies for overcoming barriers to PC delivery included the development of standardized PC protocols, opioid policy changes, patient education about PC, and HCP training and support. HCPs in this study demonstrated broad interest in and knowledge about PC. However, systemic barriers and limited patient and caregiver receptivity limit PC uptake in clinical practice. Future initiatives should involve clinical training related to PC communication, community education programs, and implementation of contextually appropriate protocols and policies for PC delivery.

Nonpharmacological strategies are advocated as evidence-based treatment options for pain, yet these are rarely offered within the emergency department (ED) setting. Understanding how ED providers perceive these strategies can guide implementation efforts. The objective of this study was to qualitatively examine ED provider perceptions of conventional and complementary nonpharmacological pain strategies. Nine ED physicians from a single academic medical center completed a semi-structured interview conducted by a trained qualitative researcher. The interview focused on the provider's current pain management approach and perceived benefits, barriers, and facilitators of nonpharmacological pain treatments. Each interview was audio-recorded, transcribed verbatim, and analyzed using an iterative deductive-inductive approach. Findings were organized into themes and subthemes to inform a conceptual model of nonpharmacological intervention implementation. Six major themes emerged: 1) institutional context around intervention implementation, 2) professional beliefs about nonpharmacological pain interventions, 3) patient characteristics as a modifying factor, 4) intervention characteristics as a modifying factor, 5) process of implementation, and 6) engagement. Providers acknowledged benefits of nonpharmacological strategies, particularly for patients with chronic pain or history of opioid use. However, perceived barriers included negative patient perceptions of mind-body therapies, minimal ED provider training or education, limited time or care coordination support, and lack of physical space. Possible facilitators for integration included provider education, leadership support, and intervention tailoring. ED providers recognize the potential value of nonpharmacological pain treatment strategies. However, both broad healthcare and ED-specific barriers to implementation may limit routine use in the ED. Future efforts for improving pain management in the ED should identify strategies to address implementation barriers of evidence-based nonpharmacological interventions.

Despite efforts to curtail prescribing, prescribing opioids remains common. With the impacts of the United States opioid epidemic continuing to multiply, effective and acceptable alternatives to opioids (and reduce opioid use) are needed. The Illinois' Opioid Alternative Patient Program (OAPP) is a novel program developed and implemented specifically to increase access to cannabis as an alternative to opioids. The current study aimed to: (1) characterize early adopters' attitudes toward cannabis as an alternative therapy and the OAPP; and (2) identify implementation barriers and facilitators to inform the refinement of future programming and program adaptations. OAPP certifying physicians were invited to participate in an anonymous, cross-sectional online, survey, including 28 closed&#x2011;ended items assessing demographics, practice characteristics, attitudes toward cannabis, and perceptions of the OAPP, as well as one open&#x2011;ended question soliciting additional feedback. Guided by Diffusion of Innovations Theory, data analysis included descriptive statistics and deductive thematic analysis. Participants were 199 physicians, 81 of whom provided write-in responses (40.7%). Attitudes about cannabis and the OAPP were mixed. Four cross-cutting qualitative themes were identified. Participants desired more education/training to guide their clinical practice and expressed concerns about dispensary staff acting as proxy clinicians. Alternatives to opioids, such as cannabis, are desired by patients and physicians alike. However, to increase the acceptability and uptake of this sort of programing, more research and provider training is needed to broach conversations around cannabis and opioid use in a way that mitigates stigma and maximizes patients' opportunities to have their needs met.

Total knee arthroplasty (TKA) is a widely performed procedure for end-stage knee osteoarthritis, with anaesthesia techniques evolving significantly in recent decades. This retrospective study examines trends in anaesthetic practice and postoperative outcomes at an Australian tertiary hospital network, using Acute Pain Service (APS) data from two distinct time periods (1999-2004 and 2018-2022). Elective TKA patients enrolled in the acute pain service database from January 1999 to December 2004 (Cohort 1) and January 2018 to December 2022 (Cohort 2) were included. Baseline demographics and anaesthetic practices were compared descriptively. Postoperative outcomes were analysed using mixed-effects regression models adjusted for demographic and perioperative factors, with hospital included as a random effect. Outcomes included invasive pain management strategies, opioid consumption, pain scores, time to mobilisation, APS review duration and length of hospital stay. A total of 1273 patients were included (150 in Cohort 1 and 1123 in Cohort 2). Use of spinal anaesthesia increased significantly in Cohort 2 compared with Cohort 1 (96.4% versus 24.0%, p < 0.001), as did the adoption of regional anaesthesia techniques (74.3% versus 1.3%, p < 0.001). After adjustment, patients in Cohort 2 had significantly lower odds of requiring invasive pain management strategies (OR: 0.02 and 95% CI: 0.00-0.09; p < 0.001), mobilised earlier (&#x3b2;: -0.39&#x2009;days, p = 0.009), required fewer days of APS review (&#x3b2;: -0.59&#x2009;days, p < 0.001) and had shorter hospital stays (&#x3b2;: -2.44&#x2009;days, p = 0.001). However, postoperative day one opioid consumption was higher in Cohort 2 (&#x3b2;: 55.19&#x2009;mg oral morphine equivalents, p < 0.001), and movement-related pain scores were modestly increased (&#x3b2;: 1.00, p = 0.02). Resting pain scores and opioid-related side effects were comparable between cohorts. Over two&#x2009;decades, anaesthetic practice for TKA has shifted substantially toward neuraxial and motor-sparing regional techniques. These changes were independently associated with earlier mobilisation, reduced reliance on invasive pain strategies and shorter hospitalisation, despite higher early postoperative opioid use. The findings reflect evolving international practice patterns and highlight the importance of ongoing evaluation of perioperative care pathways.