Saturday, September 29, 2018 9:00 am–10:00 am A Fresh Look at Opioids: 270. Comparing posterior approach lumbar and neck surgery with and without multimodal methadone

BACKGROUND CONTEXT Acute postoperative pain following posterior approach surgical techniques for lumbar and cervical surgery is frequently seen in patients. Traditional postoperative pain control measures involve intravenous and parenterally administered narcotics and adjuvants. Occasionally patient controlled analgesia infusions are utilized however analgesia remains an area for improvement. Patients undergoing back and neck surgery frequently may have preoperative chronic pain and may have been on narcotic analgesics and may demonstrate tolerance. Controlling pain postoperatively for patients on high doses of narcotics is a challenge for these patients. PURPOSE To improve perioperative pain control. STUDY DESIGN/SETTING A chart review of 97 sequential patients was performed on patients from a single surgeon with no exclusions. A total of 54 patients who had surgery sequentially before the start of the methadone group, and 43 sequential patients who then received methadone after induction of anesthesia. Both deep muscle lumbar and posterior cervical fusions were included in the study. In collecting data, we looked at the length of surgery, the time from the end of surgery until the first charted narcotic, the average pain score for the duration of stay, oral morphine equivalents given for the length of stay and the total length of stay. PATIENT SAMPLE A total of 97 consecutive patients for posterior approach lumbar and cervical surgery. OUTCOME MEASURES VAS, hospital stay, morphine equivalents. METHODS A chart review of 97 sequential patients was performed on patients from a single surgeon with no exclusions. A total of 54 patients who had surgery sequentially before the start of the methadone group, and 43 sequential patients who then received methadone after induction of anesthesia. Both deep muscle lumbar and posterior cervical fusions were included in the study. In collecting data, we looked at the length of surgery, the time from the end of surgery until the first charted narcotic, the average pain score for the duration of stay, oral morphine equivalents given for the length of stay and the total length of stay. Patients who received methadone were given a DNA test preoperatively to determine their CY2B6 morphology being extensive, intermediate and poor metabolizers (Millennium Labs, oral swab). Methadone patients received 20 mg of methadone upon induction, unless they were over 60 years of age and then they received 15 mg of methadone. They also received 15 mg of methadone if they were poor metabolizers of the medication. These patients also received 1,000 mg of acetaminophen and gabapentin 600 mg × 1 for ages less than 60, 300 mg for patients 60-69 and no gabapentin for patients 70 and older. All other pretreatment was the same for both groups. No changes were made to the way anesthesia proceeded during surgery. Postoperatively, patients who received methadone had specific pain management orders for the first 24 hours. The patient could receive methadone 2 mg IVP × 1 in PACU for pain if needed. Further orders would be given by pain management. Once the patient arrived to the floor, the patient could receive oxycodone or acetaminophen 7.5/325 mg one tablet by mouth every 4 hours prn moderate pain. If oxycodone or acetaminophen was ineffective, the patient could be given morphine – 2mg IV every 2 hours for mild pain, 4 mg IV every 2 hours for moderate pain or 6 mg IV every 2 hours for severe pain. For patients allergic to morphine, they would receive hydromorphone 0.25 mg IV every 3 hours for mild pain, 0.5mg IV every 3 hours for moderate pain and 1mg IV every 3 hours for severe pain. After 24 hours, the patient would begin postoperative neurosurgery pain medicine orders. Patients may have been continued on home long acting medications as deemed necessary by the neurosurgeon. RESULTS Pain VAS scores were significantly less in the methadone group than those in the traditional group (medians 3.2 vs. 4.7) (p CONCLUSIONS Posterior dissection back and neck surgery is often painful and difficult to treat. Traditional analgesic strategies include intermittent IV narcotic bolus injections, PCA narcotic infusions, IM and PO narcotic administration in addition to adjuvant agents like NSAIDS, gabapentinoids, muscle relaxers and anti-depressants. Intermittent administrations of narcotics likely cause fluctuating plasma levels, which in turn may be associated with relatively high pain VAS scores. In addition, patients with back and neck pain typically have had significant pain for a lengthy period preoperatively, and may have been on preoperative narcotics for a while. This may result in tolerance which makes treating their postoperative pain with narcotics more difficult. Patients may even experience hyperalgesia from narcotics, particularly if they are on them for an extended period of time. Higher total narcotic doses intraoperatively and likely postoperatively may also induce hyperalgesia. In this current investigation, the authors found intraoperative multimodal methadone to be superior to traditional narcotic administration. Significantly lower total morphine equivalents were needed for the entire hospital stay, 55% lower. The patients receiving methadone also had significantly lower pain VAS scores, 29% lower. The duration of a single dose of methadone at doses ∼20 mg has a half-life of 35 hours. This was seen with a significant time difference to first postPACU dose of narcotics, 2.72 hours versus 6.2 hours, 56% longer in the methadone group. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.