Patient Satisfaction With Pain Relief After Ambulatory Hand Surgery
| Status: | Terminated |
|---|---|
| Conditions: | Orthopedic |
| Therapuetic Areas: | Orthopedics / Podiatry |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 4/21/2016 |
| Start Date: | July 2012 |
| End Date: | January 2016 |
Satisfaction With Pain Relief After Carpal Tunnel Release Surgery
Adequate pain relief has been a priority of the Joint Commission and is featured on national
inpatient surveys such as the H-CAHPS. When considering methods for improving satisfaction
with pain relief in the United States, a great deal of emphasis has been placed on opioid
pain medications. Some of this emphasis on opioid pain medication is driven by the
pharmaceutical industry and by advocacy groups with ties to the pharmaceutical industry.
There is evidence that the "pain is the fifth vital sign" campaign of the Joint Commission
led to an increased incidence of prescription of opioids, but there is less evidence of
improved satisfaction with pain relief. There is some evidence of an increase in
opioid-related adverse events. As the sales of opioids have tripled from 1999-2008, so has
the number of deaths caused by opioid overdose; 14,800 in 2008. The number of visits to the
Emergency Department for opioid overdose doubled between 2004 and 2008.
Patients in other countries take far less opioid pain medication and are equally satisfied
with pain relief. For instance, Lindenhovius et al. found in a retrospective study that
Dutch patients take a weak (Tramadol) or no opioid pain medication after ankle fracture
surgery and have comparable or better satisfaction with pain relief than American patients,
most of whom take oxycodone. That study was repeated prospectively (unpublished) and
confirmed that Dutch patients do not feel their pain is undertreated. A study of morphine
use after a femur fracture demonstrated that American patients used far more than Vietnamese
patients (30 mg/kg versus 0.9 mg/kg), but were more dissatisfied with their pain relief.
These sociological differences are striking and suggest strongly that personal factors may
be the most important determinant of satisfaction with pain relief.
It is our impression that most American hand surgeons give patients a prescription for an
opioid pain medication after carpal tunnel release, and that is certainly true in our
practice. This seems to be based primarily on the outliers, and intended to avoid
confrontation with patients that desire opioids; however, most patients take little or no
narcotic pain medication, and many who do use the opioids complain of the side
effects—nausea and pruritis in particular. It is therefore not clear whether routine opioids
is the optimal pain management strategy after carpal tunnel release. In the study of Stahl
et al. from Israel, patients were prescribed acetaminophen rather than opioids after carpal
tunnel release and only 20 of 50 patients used acetaminophen; 30 patients did not use
acetaminophen or other pain medication at all after the operation.
Our aim is to determine if there is a difference in satisfaction with pain relief between
patients advised to take opioids compared to patients advised to use over the counter
acetaminophen after carpal tunnel release under local anesthesia. A secondary aim is to
determine if personal factors account for more of the variability in satisfaction with pain
relief than opioid strategy.
inpatient surveys such as the H-CAHPS. When considering methods for improving satisfaction
with pain relief in the United States, a great deal of emphasis has been placed on opioid
pain medications. Some of this emphasis on opioid pain medication is driven by the
pharmaceutical industry and by advocacy groups with ties to the pharmaceutical industry.
There is evidence that the "pain is the fifth vital sign" campaign of the Joint Commission
led to an increased incidence of prescription of opioids, but there is less evidence of
improved satisfaction with pain relief. There is some evidence of an increase in
opioid-related adverse events. As the sales of opioids have tripled from 1999-2008, so has
the number of deaths caused by opioid overdose; 14,800 in 2008. The number of visits to the
Emergency Department for opioid overdose doubled between 2004 and 2008.
Patients in other countries take far less opioid pain medication and are equally satisfied
with pain relief. For instance, Lindenhovius et al. found in a retrospective study that
Dutch patients take a weak (Tramadol) or no opioid pain medication after ankle fracture
surgery and have comparable or better satisfaction with pain relief than American patients,
most of whom take oxycodone. That study was repeated prospectively (unpublished) and
confirmed that Dutch patients do not feel their pain is undertreated. A study of morphine
use after a femur fracture demonstrated that American patients used far more than Vietnamese
patients (30 mg/kg versus 0.9 mg/kg), but were more dissatisfied with their pain relief.
These sociological differences are striking and suggest strongly that personal factors may
be the most important determinant of satisfaction with pain relief.
It is our impression that most American hand surgeons give patients a prescription for an
opioid pain medication after carpal tunnel release, and that is certainly true in our
practice. This seems to be based primarily on the outliers, and intended to avoid
confrontation with patients that desire opioids; however, most patients take little or no
narcotic pain medication, and many who do use the opioids complain of the side
effects—nausea and pruritis in particular. It is therefore not clear whether routine opioids
is the optimal pain management strategy after carpal tunnel release. In the study of Stahl
et al. from Israel, patients were prescribed acetaminophen rather than opioids after carpal
tunnel release and only 20 of 50 patients used acetaminophen; 30 patients did not use
acetaminophen or other pain medication at all after the operation.
Our aim is to determine if there is a difference in satisfaction with pain relief between
patients advised to take opioids compared to patients advised to use over the counter
acetaminophen after carpal tunnel release under local anesthesia. A secondary aim is to
determine if personal factors account for more of the variability in satisfaction with pain
relief than opioid strategy.
Aim:
The specific aim of this study is to compare the effectiveness of Tylenol and Vicodin after
carpal tunnel release.
Primary Study Question:
There is no difference in satisfaction with pain relief at the time of suture removal
between those advised to use acetaminophen instead of opioids and those give standard advice
and a standard prescription for opioids.
Secondary Study Questions/Null Hypotheses:
1. Psychological and demographic factors do not account for variation in satisfaction with
pain relief.
2. Arm-specific disability does not correlate with use of opioid pain medication.
3. Overall pain during recovery does not correlate with use of opioid pain medication.
Adequate pain relief has been a priority of the Joint Commission and is featured on national
inpatient surveys such as the H-CAHPS. When considering methods for improving satisfaction
with pain relief in the United States, a great deal of emphasis has been placed on opioid
pain medications. Some of this emphasis on opioid pain medication is driven by the
pharmaceutical industry and by advocacy groups with ties to the pharmaceutical industry. For
instance 88% of the income of the American Pain Foundation is from industry. It is a
consistent finding that although opioid pain improves pain in comparison with placebo, there
is no difference in disability or pain relief compared to NSAIDs.
There is evidence that the "pain is the fifth vital sign" campaign of the Joint Commission
led to an increased incidence of prescription of opioids, but there is less evidence of
improved satisfaction with pain relief. There is some evidence of an increase in
opioid-related adverse events. As the sales of opioids have tripled from 1999-2008, so has
the number of deaths caused by opioid overdose; 14,800 in 2008. The number of visits to the
Emergency Department for opioid overdose doubled between 2004 and 2008.
Patients in other countries take far less opioid pain medication and are equally satisfied
with pain relief. For instance, Lindenhovius et al. found in a retrospective study that
Dutch patients take a weak (Tramadol) or no opioid pain medication after ankle fracture
surgery and have comparable or better satisfaction with pain relief than American patients,
most of whom take oxycodone. That study was repeated prospectively (unpublished) and
confirmed that Dutch patients do not feel their pain is undertreated. A study of morphine
use after a femur fracture demonstrated that American patients used far more than Vietnamese
patients (30 mg/kg versus 0.9 mg/kg), but were more dissatisfied with their pain relief.
These sociological differences are striking and suggest strongly that personal factors may
be the most important determinant of satisfaction with pain relief.
It is our impression that most American hand surgeons give patients a prescription for an
opioid pain medication after carpal tunnel release, and that is certainly true in our
practice. This seems to be based primarily on the outliers, and intended to avoid
confrontation with patients that desire opioids; however, most patients take little or no
narcotic pain medication, and many who do use the opioids complain of the side
effects—nausea and pruritis in particular. It is therefore not clear whether routine opioids
is the optimal pain management strategy after carpal tunnel release. In the study of Stahl
et al. from Israel, patients were prescribed acetaminophen rather than opioids after carpal
tunnel release and only 20 of 50 patients used acetaminophen; 30 patients did not use
acetaminophen or other pain medication at all after the operation.
Our aim is to determine if there is a difference in satisfaction with pain relief between
patients advised to take opioids compared to patients advised to use over the counter
acetaminophen after carpal tunnel release under local anesthesia. A secondary aim is to
determine if personal factors account for more of the variability in satisfaction with pain
relief than opioid strategy.
The specific aim of this study is to compare the effectiveness of Tylenol and Vicodin after
carpal tunnel release.
Primary Study Question:
There is no difference in satisfaction with pain relief at the time of suture removal
between those advised to use acetaminophen instead of opioids and those give standard advice
and a standard prescription for opioids.
Secondary Study Questions/Null Hypotheses:
1. Psychological and demographic factors do not account for variation in satisfaction with
pain relief.
2. Arm-specific disability does not correlate with use of opioid pain medication.
3. Overall pain during recovery does not correlate with use of opioid pain medication.
Adequate pain relief has been a priority of the Joint Commission and is featured on national
inpatient surveys such as the H-CAHPS. When considering methods for improving satisfaction
with pain relief in the United States, a great deal of emphasis has been placed on opioid
pain medications. Some of this emphasis on opioid pain medication is driven by the
pharmaceutical industry and by advocacy groups with ties to the pharmaceutical industry. For
instance 88% of the income of the American Pain Foundation is from industry. It is a
consistent finding that although opioid pain improves pain in comparison with placebo, there
is no difference in disability or pain relief compared to NSAIDs.
There is evidence that the "pain is the fifth vital sign" campaign of the Joint Commission
led to an increased incidence of prescription of opioids, but there is less evidence of
improved satisfaction with pain relief. There is some evidence of an increase in
opioid-related adverse events. As the sales of opioids have tripled from 1999-2008, so has
the number of deaths caused by opioid overdose; 14,800 in 2008. The number of visits to the
Emergency Department for opioid overdose doubled between 2004 and 2008.
Patients in other countries take far less opioid pain medication and are equally satisfied
with pain relief. For instance, Lindenhovius et al. found in a retrospective study that
Dutch patients take a weak (Tramadol) or no opioid pain medication after ankle fracture
surgery and have comparable or better satisfaction with pain relief than American patients,
most of whom take oxycodone. That study was repeated prospectively (unpublished) and
confirmed that Dutch patients do not feel their pain is undertreated. A study of morphine
use after a femur fracture demonstrated that American patients used far more than Vietnamese
patients (30 mg/kg versus 0.9 mg/kg), but were more dissatisfied with their pain relief.
These sociological differences are striking and suggest strongly that personal factors may
be the most important determinant of satisfaction with pain relief.
It is our impression that most American hand surgeons give patients a prescription for an
opioid pain medication after carpal tunnel release, and that is certainly true in our
practice. This seems to be based primarily on the outliers, and intended to avoid
confrontation with patients that desire opioids; however, most patients take little or no
narcotic pain medication, and many who do use the opioids complain of the side
effects—nausea and pruritis in particular. It is therefore not clear whether routine opioids
is the optimal pain management strategy after carpal tunnel release. In the study of Stahl
et al. from Israel, patients were prescribed acetaminophen rather than opioids after carpal
tunnel release and only 20 of 50 patients used acetaminophen; 30 patients did not use
acetaminophen or other pain medication at all after the operation.
Our aim is to determine if there is a difference in satisfaction with pain relief between
patients advised to take opioids compared to patients advised to use over the counter
acetaminophen after carpal tunnel release under local anesthesia. A secondary aim is to
determine if personal factors account for more of the variability in satisfaction with pain
relief than opioid strategy.
Inclusion Criteria:
- Age 18 years or older.
- All subjects will be competent adults able to consent on their own behalf for surgery
and care.
- Inclusion prior to surgery
- Carpal tunnel release
Exclusion Criteria:
- Pregnant women. Patients will be queried with the routine preoperative medical
history and an inclusion/exclusion checklist.
- Patients unable to give informed consent
- Non English-speaking subjects
- Patients with hypersensitivity to acetaminophen or hydrocodone
- Patients with chronic alcohol abuse
- Patients with severe impairment of renal or hepatic function. This will be assessed
in the routine preoperative medical history and review of the medical record. We will
also ask the patients specific for this history in the screening for the study
inclusion/exclusion criteria.
- Patients with hypothyroidism
- Patients with Addison's disease
- Patients with prostatic hypertrophy or urethral stricture
- Patients using any of the following medications:
MAO or tricyclic antidepressants Antihistaminics Antipsychotic or anti-anxiety medications
Phenothiazines Zidovudin Phenobarbital
- Patients who are taking opioid pain medication for another reason prior to surgery.
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