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(362) ED Acupuncture: Feasibility, Acceptability, and Impact on Pain
The Journal of Pain (362) ED Acupuncture: Feasibility, Acceptability, and Impact on Pain J. Kram, J. Burns, V. Xiong, J. StarkCasadont, T. Mullen, N. Conway, and D. Baumgardner; Aurora Health Care, Inc. When patients present to the emergency department (ED) for pain, conventional treatment is often limited to prescription medications. Hospitals are now seeking non-pharmacological management options for acute pain due to the opioid crisis. Our quality improvement study aimed to determine the feasibility of implanting an employed acupuncturist within an urban ED to provide acupuncture as a nonpharmacological acute pain management option and to determine the impact of acupuncture on acute pain reduction. To our knowledge, few ED acupuncture models exist worldwide. Limited information has been reported about acceptance of acupuncture in the ED setting by physicians and patients, and it is unknown if there is enough time for acupuncture during the ED visit. The ED selected for this study had an average 1.5-2 hour wait time for treatment and annually treated an average of 34,000 patients of which 66% presented with an emergency severity index between 3-5(ESI; highest severity [1] - lowest severity [5]). In 2017, acupuncture services were offered to adult patients with ED physician approval based on their ESI level and reason for visit. Patient self-reported pre- and post-acupuncture pain scores (i.e., no pain [0] - worst pain [10]) were compared using paired t-tests. Multivariable regression models were also constructed. A total of 706 patients were approached, of which 379 (53.7%) consented to receive acupuncture services. Overall, patients presented with a median ESI score of 3, and 53.6% did not receive opioids at any time during their ED visit. Mean pain score improvement (6.5 vs. 3.4; p<0.001) was not impacted by receipt of opioids during the ED visit (p=0.948). Ultimately, ED acupuncture was well received by both patients and physicians and enrollment was higher than anticipated. ED acupuncture also significantly decreased pain regardless of whether a patient received opioids during their ED visit.
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(364) Administration of Pre-Operative Gabapentin to Patients Undergoing Laparoscopy: A Double-Blind, Placebo-Controlled Randomized Trial A. Benton, G. Harkins, C. Stetter, A. Kunselman, T. Deimling, and K. Riley; Penn State Health - Milton S Hershey Medical Center The objective of this study was to determine the influence of immediate pre-operative gabapentin on postoperative pain in patients undergoing laparoscopy for benign gynecologic indications. We completed a double-blind, placebo controlled, randomized trial at an academic tertiary care hospital. One-hundred-nine gynecologic patients undergoing laparoscopy between June 2015 and January 2016 were included in our study. We randomized 109 patients to receive pre-operative gabapentin (300mg) or placebo. The patients were stratified based on a history of chronic pelvic pain. Pain scores were assessed at 2, 4, 6 and 8 hours post-operatively as well as post-operative days 1-7. We found no difference between the groups in terms of age, body mass index, gravidity, parity, or past surgical history. Post-operative pain was assessed using the numeric pain rating scale (NRS), rated as 0-10, and the visual analog scale (VAS), rated as 0-100. These values were adjusted for morphine dose received. Findings included, no significant difference in pain scores at any of the immediate post-operative hours. A secondary analysis stratified by procedure, hysterectomy or operative laparoscopy, showed no significant difference in pain scores. There was also no significant difference in pain scores on post-operative days one through seven. In this study, a single dose of pre-operative gabapentin did not significantly decrease post-operative pain in gynecologic patients undergoing laparoscopy for benign indications. The study was supported in part by an award from The Penn State Hershey Department of Obstetrics and Gynecology.
(365) Is it Exercise or Pain Associated with Exercise that Leads to Hypoalgesia? K. Rudolph, E. Jacobsen, T. Nelson, and C. Welsh; University of New England
Treatment Approaches (Medical/ Interventional) (363) Antidepressant Use in Patients with a History of Depression is Associated with Reduced Opioid Use after Total Knee Arthroplasty J. Starr, T. BBaker, M. Backonja, and I. Rozel; University of Washington Chronic post-surgical pain (CPSP) affects up to 40% of patients and is associated with prolonged postoperative opioid use. Depression is one risk factor for CPSP, but it is unknown if antidepressants modulate the risk for CPSP or prolonged postoperative opioid use in patients undergoing procedures at high-risk for CPSP. This retrospective cohort study utilized the records of Veterans Affairs patients who underwent a total knee arthroplasty (TKA) between April 2012 − April 2016. Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) use was recorded. Exclusion criteria were no depression diagnosis, opioid use preoperatively, other antidepressant use, and chronic pain diagnoses. Outcomes included morphine equivalents through postoperative day one and opioid use through 30, 90, and 365 days after surgery. Generalized linear models were created to adjust for confounding covariates, and a secondary analysis stratified outcomes by antidepressant class. The study cohort included 1,655 TKAs after applying all exclusion criteria, and it was 90.6% male and 77.1% white with a mean age of 65 years. Patients meeting inclusion criteria and using an SSRI or SNRI comprised 454 cases (27.4%). After adjustment for age, BMI, sex, race, general or regional anesthesia, non-opioid adjunct pain medication use, and comorbidities recorded in the VA Surgical Quality Improvement Program (VASQIP), SSRI or SNRI use was associated with reduced opioid use through 30 days after surgery (OR = 0.74 (0.57, 0.95), p = 0.020). In the secondary analysis, SSRI use was associated with reduced opioid use through 90 days after surgery compared to SNRI use (OR = 0.35 (0.14, 0.89), p = 0.022). Perioperative SSRI or SNRI use, in patients with depression, is associated with reduced prescription opioid use 30 days after TKA. Prospective research is warranted to elucidate if there is a role for antidepressants as nonopioid analgesics in specific surgical populations.
The opioid epidemic has brought attention to the pain relieving effect of exercise, but exercise prescription for pain relief may be quite different from that typically recommended for cardiovascular and other health benefits. Exercise induced hypoalgesia (EIH) is complex and not entirely understood but possible mechanisms include the opioid and non-opioid systems. Hypoalgesia is also known to occur in response to pain itself. Conditioned pain modulation (CPM) is the inhibition of pain from a test stimulus by a painful conditioning stimulus. Studies of EIH often involve exercise paradigms in which long duration muscle contractions are used. Long duration muscle contractions are often painful so it raises the question, “Is it exercise or the pain associated with exercise that leads to EIH?” Nine individuals underwent pain testing on the right and left knees and middle finger before and after three conditions: 10 voluntary isometric contractions, 10 contractions elicited by neuromuscular electrical stimulation (NMES) and 10 bursts of noxious electrical stimulation without muscle contraction all on the right quadriceps muscles. The contractions or stimuli lasted 10 s separated by 50 s off. The average pain rating (0-100 VAS) during the noxious stimulation (84.4 +/- 12.1) was higher than during the NMES elicited contractions (61.4 +/- 18.9; p=0.001). Subjects reported no pain during the volitional contractions. The force of the contractions is reported in % maximum voluntary contraction (%MVIC) and the volitional contraction force averaged 59.6 (+/18.0) % MVIC while the NMES elicited contraction force averaged 52.0 (+/-14.5) % MVIC. Hypoalgesia was observed in the right and left knees response to the noxious stimulation and NMES elicited contractions but not the volitional contractions. The results suggest that the hypoalgesia associated with the NMES elicited contractions was due to the noxious nature of the contractions and that the mechanism involves spinal mechanisms.
(366) Opioid Prescription Practices in the Setting of Pediatric Fractures E. Wynia, and J. Schrock; MetroHealth Opioids are frequently prescribed to children with fractures. Although much research has been done surrounding the use of opioids in adult populations, use of opioids among children is much less understood. The purpose of this study was to investigate
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(364) Administration of Pre-Operative Gabapentin to Patients Undergoing Laparoscopy: A Double-Blind, Placebo-Controlled Randomized Trial A. Benton, G. Harkins, C. Stetter, A. Kunselman, T. Deimling, and K. Riley; Penn State Health - Milton S Hershey Medical Center The objective of this study was to determine the influence of immediate pre-operative gabapentin on postoperative pain in patients undergoing laparoscopy for benign gynecologic indications. We completed a double-blind, placebo controlled, randomized trial at an academic tertiary care hospital. One-hundred-nine gynecologic patients undergoing laparoscopy between June 2015 and January 2016 were included in our study. We randomized 109 patients to receive pre-operative gabapentin (300mg) or placebo. The patients were stratified based on a history of chronic pelvic pain. Pain scores were assessed at 2, 4, 6 and 8 hours post-operatively as well as post-operative days 1-7. We found no difference between the groups in terms of age, body mass index, gravidity, parity, or past surgical history. Post-operative pain was assessed using the numeric pain rating scale (NRS), rated as 0-10, and the visual analog scale (VAS), rated as 0-100. These values were adjusted for morphine dose received. Findings included, no significant difference in pain scores at any of the immediate post-operative hours. A secondary analysis stratified by procedure, hysterectomy or operative laparoscopy, showed no significant difference in pain scores. There was also no significant difference in pain scores on post-operative days one through seven. In this study, a single dose of pre-operative gabapentin did not significantly decrease post-operative pain in gynecologic patients undergoing laparoscopy for benign indications. The study was supported in part by an award from The Penn State Hershey Department of Obstetrics and Gynecology.
(365) Is it Exercise or Pain Associated with Exercise that Leads to Hypoalgesia? K. Rudolph, E. Jacobsen, T. Nelson, and C. Welsh; University of New England
Treatment Approaches (Medical/ Interventional) (363) Antidepressant Use in Patients with a History of Depression is Associated with Reduced Opioid Use after Total Knee Arthroplasty J. Starr, T. BBaker, M. Backonja, and I. Rozel; University of Washington Chronic post-surgical pain (CPSP) affects up to 40% of patients and is associated with prolonged postoperative opioid use. Depression is one risk factor for CPSP, but it is unknown if antidepressants modulate the risk for CPSP or prolonged postoperative opioid use in patients undergoing procedures at high-risk for CPSP. This retrospective cohort study utilized the records of Veterans Affairs patients who underwent a total knee arthroplasty (TKA) between April 2012 − April 2016. Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) use was recorded. Exclusion criteria were no depression diagnosis, opioid use preoperatively, other antidepressant use, and chronic pain diagnoses. Outcomes included morphine equivalents through postoperative day one and opioid use through 30, 90, and 365 days after surgery. Generalized linear models were created to adjust for confounding covariates, and a secondary analysis stratified outcomes by antidepressant class. The study cohort included 1,655 TKAs after applying all exclusion criteria, and it was 90.6% male and 77.1% white with a mean age of 65 years. Patients meeting inclusion criteria and using an SSRI or SNRI comprised 454 cases (27.4%). After adjustment for age, BMI, sex, race, general or regional anesthesia, non-opioid adjunct pain medication use, and comorbidities recorded in the VA Surgical Quality Improvement Program (VASQIP), SSRI or SNRI use was associated with reduced opioid use through 30 days after surgery (OR = 0.74 (0.57, 0.95), p = 0.020). In the secondary analysis, SSRI use was associated with reduced opioid use through 90 days after surgery compared to SNRI use (OR = 0.35 (0.14, 0.89), p = 0.022). Perioperative SSRI or SNRI use, in patients with depression, is associated with reduced prescription opioid use 30 days after TKA. Prospective research is warranted to elucidate if there is a role for antidepressants as nonopioid analgesics in specific surgical populations.
The opioid epidemic has brought attention to the pain relieving effect of exercise, but exercise prescription for pain relief may be quite different from that typically recommended for cardiovascular and other health benefits. Exercise induced hypoalgesia (EIH) is complex and not entirely understood but possible mechanisms include the opioid and non-opioid systems. Hypoalgesia is also known to occur in response to pain itself. Conditioned pain modulation (CPM) is the inhibition of pain from a test stimulus by a painful conditioning stimulus. Studies of EIH often involve exercise paradigms in which long duration muscle contractions are used. Long duration muscle contractions are often painful so it raises the question, “Is it exercise or the pain associated with exercise that leads to EIH?” Nine individuals underwent pain testing on the right and left knees and middle finger before and after three conditions: 10 voluntary isometric contractions, 10 contractions elicited by neuromuscular electrical stimulation (NMES) and 10 bursts of noxious electrical stimulation without muscle contraction all on the right quadriceps muscles. The contractions or stimuli lasted 10 s separated by 50 s off. The average pain rating (0-100 VAS) during the noxious stimulation (84.4 +/- 12.1) was higher than during the NMES elicited contractions (61.4 +/- 18.9; p=0.001). Subjects reported no pain during the volitional contractions. The force of the contractions is reported in % maximum voluntary contraction (%MVIC) and the volitional contraction force averaged 59.6 (+/18.0) % MVIC while the NMES elicited contraction force averaged 52.0 (+/-14.5) % MVIC. Hypoalgesia was observed in the right and left knees response to the noxious stimulation and NMES elicited contractions but not the volitional contractions. The results suggest that the hypoalgesia associated with the NMES elicited contractions was due to the noxious nature of the contractions and that the mechanism involves spinal mechanisms.
(366) Opioid Prescription Practices in the Setting of Pediatric Fractures E. Wynia, and J. Schrock; MetroHealth Opioids are frequently prescribed to children with fractures. Although much research has been done surrounding the use of opioids in adult populations, use of opioids among children is much less understood. The purpose of this study was to investigate