Pain

Post-op Opioid Consumption

It would appear that opioid prescription post operatively is still excessive after abdominal surgery. “Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion”.  This study shows just how little opioid amounts are needed on average.

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Neuraxial Morphine / Diamorphine & Cesarean Respiratory Depression

A systematic review of the use of neuraxial Morphine and Diamorphine found that the highest and lowest prevalences of  clinically significant respiratory depression after Cesarean delivery with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62–8.77) and 1.08 per 10,000 (95% CI, 0.24–7.22), respectively. This study review is reassuring on the safety of neuraxial opioid analgesia at current practice doses (eg. 0.1 – 0.15mg spinal Morphine).

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Opioid-Induced Adrenal Insufficiency

An important reminder of the endocrine effects of chronic opioid use, namely opioid induced adrenal insufficiency. Symptoms of adrenal insufficiency include fatigue, nausea, vomiting, weight loss, dizziness, and muscular aches, many of which overlap with or may compound symptoms related to chronic pain syndrome.  The etiology, diagnosis and management are discussed in this Mayo Clinic review. The possibility should be considered in all anesthesia and critically ill patients, and appropriate steroid supplementation instituted.

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Cannabis and Chronic Non-Cancer Pain

 

A study on cannabis dispels the hype again, finding no evidence that it reduces pain, improves outcome or reduces opioid use. “People who used cannabis had greater pain and lower self-efficacy in managing pain” – this is increasingly the key to managing (not eliminating) pain, using education, quality of life and function improvement rather than focus on pain.

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Ketamine for Chronic Pain

Another consensus statement, akin to the consensus in acute pain ( blog link ).

The statement discusses the varying evidence for different conditions as well as the types of dosing regimes in conditions such as CRPS, spinal cord injury, fibromyalgia, other neuropathic conditions, cancer, headache and low back pain. The overall impression is that enthusiastic use is perhaps ahead of the evidence.

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Hip Arthroscopy and Fascia Iliaca Block

“Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population”.

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Note however that this block is highly recommended for elderly hip fracture blog link