Researchers from the Department of Anesthesia and Perioperative Medicine at the Medical University of South Carolina (MUSC) have found that an FDA-approved drug can help reduce the ache after surgery and consequently the use of opioids. In the pilot study, patients undergoing spine surgery who received N-acetylcysteine (NAC) during surgery.
In addition to standard treatments for pain control they reported lower pain scores and required fewer opioids after surgery than patients treated with a placebo.
The results of research were published in Pain Management.
Opioids: drug already approved could reduce their use
Opioids are often given for a short time after surgery to treat pain. While effective, their potency may decrease and the potential for addiction may be dangerous without careful supervision by a healthcare professional. Therefore, doctors welcome the opportunity to limit the use of opioids in pain management.
“Can we completely stop giving opioids? Probably not. Can we decrease the amount patients need? We should try it,” said Sylvia Wilson, MD, holder of the Jerry G. Reves Endowed Chair in Anesthesia Research in the Department of Anesthesia and Perioperative Medicine and principal investigator of the study.
Wilson has been working for years to improve pain management and limit opioid use after surgeries. As it turns out, a collaboration with a basic scientist within his own department could offer a solution.
Wilson began working closely with Michael Scofield, Ph.D., Jerry G. Reves Endowed Chair in Basic Science Anesthesiology Research and senior author of the published study. Scofield conducted laboratory research on NAC, an anti-inflammatory drug used to treat acetaminophen poisoning, mushroom poisoning and liver damage.
Researchers like Scofield have also studied its effects on the nervous system, especially in the areas of addiction and pain perception. Wilson's clinical goals and Scofield's research into NAC made them ideal collaborators.
“This project is truly an elegant synthesis of basic science and clinical research, using things that we believe are effective in the laboratory and bringing them to the clinic,” Scofield said.
Wilson believes partnerships between doctors and basic scientists can spur clinical advances. She credits the supportive environment within the department fostered by Chair Scott Reeves, MD, and former College of Medicine Dean Jerry G. Reves, MD, for making such collaborations possible.
The research team chose patients undergoing spine surgery for its pilot study because these patients often experience chronic pain before surgery and are more likely to be exposed to higher levels of opioids before, during, and after surgery. surgery.
During surgery, patients received a standard regimen of anesthesia in addition to a dose of NAC or a saline infusion. Information on patients' pain and opioid use was then collected.
In the 48 hours following surgery, patients who received NAC via intravenous infusion (150 mg/kg) received an average of 19% fewer opioid doses than patients who received saline.
NAC patients also reported lower pain scores and took longer to require pain medication after surgery than saline patients. The researchers were particularly encouraged to see that the beneficial effect seemed to last longer than NAC was expected to stay in the body.
“We've seen the persistent impact of administering this drug, and I think it's significant,” Wilson said. “We don't see a rebound effect when the drug's effect wears off.”
This extended effect on pain perception mirrored previous findings from Scofield's laboratory research.
“With respect to heroin addiction, we have seen in NAC preclinical studies that protection against vulnerability to relapse is long-lasting,” Scofield said. “Certainly the hope is that it is something that will have a long life.”
Next, the research team wants to see whether the findings can be translated into other procedures. They are currently enrolling patients who have undergone minimally invasive hysterectomy in a larger study.
As more patients are enrolled, researchers will be able to conduct more in-depth statistical tests to improve their understanding of the effects of NAC on pain associated with surgery. This will help them set the stage for future clinical studies of NAC during surgery.
“To change practice, you need several large clinical trials with different settings, different types of surgeries to show that you will cause benefit, not harm,” Wilson said. “We want to demonstrate good clinical efficacy, but also safety in that situation.”
A preoperative nerve block used in combination with other medications may reduce the need for opioids to manage pain after spine surgery, researchers at UT Southwestern Medical Center have found. The findings, published in the European Spine Journal, suggest a way to decrease dependence on opioids to reduce postoperative pain and help patients become more ambulatory.
Patients undergoing open lumbar spine surgery who received a bilateral erector spinae plane block (ESPB) as part of a multimodal analgesic regimen had a significant reduction in both pain scores and opioid consumption in the first 24 to 48 hours after surgery, compared to those who were treated only with a multimodal analgesic approach, according to the study.
These patients also needed fewer medications to control nausea or vomiting and had shorter recovery room stays.
“Patients undergoing spine surgery typically experience a moderate to high level of postoperative pain and require significant pain management efforts, which traditionally means large doses of opioids,” said study leader Girish Joshi, MD , professor of anesthesia and pain management at UT Southwestern and director. of Perioperative Medicine and Ambulatory Anesthesia at Parkland Health.
“But given the drawbacks of opioid use, many doctors are looking for alternative approaches to managing postoperative pain.
Our study demonstrates that erector spinae blockade is an effective tool to reduce the need for opioids when combined with a multimodal pain management approach that includes acetaminophen and nonsteroidal anti-inflammatory drugs.”
The retrospective study compared the postoperative measurements of 50 patients who underwent open lumbar laminectomy for spinal stenosis. Half received an ESPB together with standardized multimodal analgesia and the other half received multimodal analgesia alone. ESPBs are administered just before surgery through an ultrasound-guided injection.
At 24 hours after surgery, opioid requirements among ESPB patients were reduced by approximately half compared to non-ESPB patients and remained below the 48-hour mark. Pain scores in the post-anesthesia care unit (PACU) and up to the second day after surgery were also significantly lower, and time spent in the PACU was reduced by approximately 30 minutes.
“ESPBs are safe and easy to administer and can make a significant difference in a patient's postoperative pain level,” said Jesse Stewart, MD, associate professor of anesthesia and pain management and first author of the study.
“This is important because postoperative pain is a major factor in delayed recovery after surgery and reduced patient satisfaction, and we know that the use of opioids in pain management presents its challenges, including the risk of dependence.
These findings suggest that ESPBs may play an important role in an opioid-sparing recovery plan that uses a multimodal pain management approach, not only in spine surgery but potentially for other types of surgery as well.”
The study builds on previous UTSW research focused on multimodal analgesia and the creation of specific enhanced recovery plans for different types of procedures, primarily to help reduce the use of opioids to treat acute postoperative pain.
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