Patient Satisfaction With Pain Relief After Ambulatory Hand 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 That study was repeated prospectively (unpublished) and confirmed that Dutch patients do not feel their pain is undertreated.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.
|Study Design:||Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
|Official Title:||Satisfaction With Pain Relief After Carpal Tunnel Release Surgery|
- Satisfaction with pain relief [ Time Frame: at the follow-up, 2 weeks after the operation with suture removal ] [ Designated as safety issue: Yes ]an 11-point ordinal scale to ask for the satisfaction of the patients with pain relief
- QuickDASH [ Time Frame: At enrollment prior to surgery and at the follow-up 2 weeks after the surgery with suture removal ] [ Designated as safety issue: No ]The short form of the Disabilities of Arm Shoulder and Hand to assess upper extremity disability
- PSEQ [ Time Frame: 1 day ] [ Designated as safety issue: No ]The pain self efficacy questionnaire
- PHQ-9 [ Time Frame: 1 day ] [ Designated as safety issue: No ]Patient Health Questionnaire-9 to assess symptoms of depression.
- pain patients expect after surgery [ Time Frame: 1 day ] [ Designated as safety issue: No ]an 11-point ordinal scale to assess the amount of pain the patients expect after surgery
- expectation of pain relief [ Time Frame: 1 day ] [ Designated as safety issue: No ]An 11-point ordinal scale to assess the expectation of the patients with pain relief.
- Pain scale [ Time Frame: At enrollment prior to surgery and at the follow-up 2 weeks after the surgery with suture removal ] [ Designated as safety issue: Yes ]11-point ordinal pain scale
|Study Start Date:||July 2012|
|Estimated Primary Completion Date:||December 2013 (Final data collection date for primary outcome measure)|
Active Comparator: Vicodin 5/325 mg
Half of the patients will be randomized to Vicodin
Other Name: Tylenol
Active Comparator: Acetaminophen 325 mg
Half of the patients will be randomized to Acetaminophen
Vicodin 5/325 mg
Other Name: Hydrocodon/Acetaminophen
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|United States, Massachusetts|
|Massachusetts General Hospital|
|Boston, Massachusetts, United States, 02114|
|Principal Investigator:||David C Ring, MD PhD||Massachusetts General Hospital|