Intraoperative Methadone for Postoperative Pain Control

Study Overview
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Brief Summary
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To compare patient pain perception and satisfaction as well as opioid-related side effects during inpatient and outpatient care when undergoing bariatric enhanced recovery after surgery protocols with and without methadone.

Official Title
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Randomized Control Study on the Effectiveness of Intraoperative Methadone on Postoperative Pain Control

Conditions
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Bariatric Surgery Candidate

Intervention / Treatment
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* Drug: Methadone


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: • All patients undergoing initial gastric sleeve resection Exclusion Criteria: Age <18 years or >60 years Patients with BMI >60 AHI > 30 (AHI = Apnea-Hypopnea Index), indicative of severe Obstructive Sleep Apnea (OSA) ASA IV or V (American Society of Anesthesiology physical status classification system) Patients taking opioids for chronic conditions in the last 10 days preceding the surgery Patients currently being treated for chronic opioid addiction Patients with severe psychiatric diagnoses Allergies to medications used in protocol

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Methadone group<br>Patients in this group will receive intraoperative methadone. | Drug: Methadone<br>* One group will receive 10mg of methadone upon induction, while the other will receive a saline solution as placebo. We will see the effectiveness of methadone on postoperative pain management, while monitoring for opioid-related side effects.<br>|
| No Intervention: Control group<br>Patients in this group will receive saline (placebo), instead of methadone | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postoperative opioid use | Postoperative opioid use will be determined by the amount of morphine consumed (milligram morphine equivalents, MME) at 24 hours postoperatively | 24 hours postoperatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Total Postoperative opioid use | Total postoperative opioid use will be determined by the total amount of morphine consumed (milligram morphine equivalents, MME) at 48 hours postoperatively and during follow up visit | 48 hours postoperatively and approximately at 2 weeks (follow up visit upon discharge) | 
| Respiratory interventions | The number of respiratory interventions required postoperatively per patient in the PACU (Post-anesthesia care unit) will be determined | Up to 4 hours postoperatively | 
| Duration of hospital stay | The average duration of hospitalization will be determined per patient | Approximately 5 days postoperatively | 
| Patients Perception of Pain Management | Patients perceptions of pain management will be measured by administration of the International Pain Outcomes (IPO) questionnaire on Post-Operative Day 1 (POD 1). IPO will be used to assess key patient level outcomes of postoperative pain management and consists of 13 questions evaluating four outcome domains: 1) intensity of pain rated on Numeric Rating Scale (NRS) score (0 = no pain, 10 = worst possible pain); 2) interference of pain with activities and emotional well-being as determined by a score analogous to the NRS 0-10 scale above; 3) side effects of pain treatment, including nausea, drowsiness, itching, and dizziness, as determined by the NRS score >0; and 4) perception of care, treatment satisfaction and involvement in pain treatment decision-making on a scale from 0-10. Scores are aggregated per patient with higher overall scores indicative of a worsening perception of pain management. | 24 hours postoperatively | 
| Patients Perception of Pain Management | Patients perceptions of pain management will be measured by administration of the International Pain Outcomes (IPO) questionnaire on POD 1 (Post-Operative Day 1). IPO will be used to assess key patient level outcomes of postoperative pain management and consists of 13 questions evaluating four outcome domains: 1) intensity of pain rated on numeric rating score (0 = no pain, 10 = worst possible pain); 2) interference of pain with activities and emotional well-being as determined by a score analogous to the 0-10 scale above; 3) side effects of pain treatment, including nausea, drowsiness, itching, and dizziness, as determined by the NRS score >0; and 4) perception of care, treatment satisfaction and involvement in pain treatment decision-making on a scale from 0-10. Scores are aggregated per patient with higher overall scores indicative of a worsening perception of pain management. | 2 days postoperatively | 
| Sedation Score (POSS) | Sedation score will be determined using the Pasero Opioid-induced Sedation Scale (POSS) in the Post-anesthesia Care Unit (PACU) and on the floor. Average scores will be tabulated per patient using a four point numeric rating scale. Scoring is as follows: 1 = Awake and alert; 2 = Slightly drowsy, easily aroused; 3 = Frequently drowsy, arousable, drifts off to sleep during conversation; 4 = Somnolent, minimal or no response to verbal and physical stimulation | 2 days postoperatively | 
| Agitation and Sedation Severity (RASS) | Agitation and Sedation severity will determined using the Richmond Agitation-Sedation Scale (RASS) in the PACU and on the floor. Average scores will be determined per patient using a numeric rating scale ranging from +4 to -5 where +4 = combative, +3 = very agitated, +2 = agitated, +1 = restless, 0 = alert and calm, -1: = drowsy, -2 = light sedation, -3 = moderate sedation, -4 = deep sedation, and -5 = unarousable. Ideal RASS scores range from -1 to 1. | 2 days postoperatively | 
| Opioid-related side effects | Opioid related side effects including nausea, vomiting, pruritis, urinary retention, and necessity of supplemental oxygen will be recorded | Up to 2 days postoperatively | 
| Early Mobilization | The average duration of time to first ambulation after surgery will be recorded per patient | Up to 2 days postoperatively | 
| GI recovery time | The average duration of time to return of bowel function will be determined per patient | Up to 2 days postoperatively | 
| Adverse events due to procedure or anesthesia | Procedure related adverse events or adverse events related to anesthesia will be recorded | Up to 2 days postoperatively | 
| Pain Scores | Pain scores will be assessed by a research assistant blinded to the study group at regular intervals. Numerical pain scores (0=no pain, 10=most pain) will be assigned on an 11 point scale ranging from 0 (no pain) to 10 (most pain). Since most patients who get bariatric surgery are discharged at POD 1, the research assistant will call the patient the morning of POD 2 to assess the pain score if not on the inpatient floor. If the patients are not yet discharged, the pain score will be assessed the morning of POD 2, otherwise pain scores will be collected as detailed in the time frame below. | After 30 minutes in the PACU; upon discharge from PACU (variable timepoint); at 6, 12, 18, and 24 hours after being on the in-patient floor; and at hospital discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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methadone, bariatric surgery, pain management