Patient Satisfaction With Pain Relief After Ambulatory Hand Surgery
Status:
Terminated
Trial end date:
2016-01-01
Target enrollment:
Participant gender:
Summary
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 That study was repeated prospectively (unpublished) and confirmed that Dutch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.
Phase:
Phase 4
Details
Lead Sponsor:
Massachusetts General Hospital
Treatments:
Acetaminophen Acetaminophen, hydrocodone drug combination Hydrocodone Oxycodone