RAPM Focus

Episode 17: Impact of COVID-19 on Opioid Overdose and Other Adverse Events in the USA and Canada

The impact of the COVID-19 pandemic was especially challenging for vulnerable populations, such asthose with chronic long-term health conditions, mental health conditions, and substance use disorders.Lockdowns and fear of spread led to barriers for patients whether they were accessing methadonethrough opioid treatment programs or being prescribed buprenorphine.
A systematic review first published online in October 2022 sought to identify whether there was achange in opioid use and misuse outcomes during the COVID-19 pandemic. Authors Siddartha Simha,MD, and Mark C. Bicket, MD, PhD, joined RAPM Editor-in-Chief Brian Sites, MD, to discuss their article,“Impact of the COVID-19 pandemic on opioid overdose and other adverse events in the USA andCanada: a systematic review,” published October 2022 (https://rapm.bmj.com/content/48/1/37). Theauthors found that opioid-related emergency medicine use increased in most studies for both servicecalls and emergency department visits. Urine drug testing positivity results increased in all studies forfentanyl, and in most studies for heroin and oxycodone. Naloxone dispensation was unchanged anddecreased in one study. The authors concluded that efforts to curb the spread of COVID-19 aligned withan increase in the opioid crisis severity, which has implications for future pandemic responses.
Dr. Siddartha Simha is a third-year anesthesiology resident at Michigan Medicine in Ann Arbor. Originallyfrom Troy, MI, he obtained his medical degree from Oakland University William Beaumont School ofMedicine in Auburn Hills, MI. Dr. Simha has a strong interest in acute and chronic pain management andresearch with plans to pursue a clinical fellowship in pain medicine.
Dr. Mark C. Bicket is the co-director of the Opioid Prescribing Engagement Network and an assistantprofessor at the University of Michigan Medical School with a joint appointment in the School of PublicHealth. A clinician scientist and practicing physician, his work has been supported by the NationalInstitutes of Health, the Substance Abuse and Mental Health Services Administration, the Foundation forAnesthesia Education and Research, and the Patient-Centered Outcomes Research Institute.
*The purpose of this podcast is to educate and to inform. The content of this podcast does notconstitute medical advice, and it is not intended to function as a substitute for a healthcarepractitioner’s judgement, patient care, or treatment. The views expressed by contributors are those ofthe speakers. BMJ does not endorse any views or recommendations discussed or expressed on thispodcast. Listeners should also be aware that professionals in the field may have different opinions. Bylistening to this podcast, listeners agree not to use its content as the basis for their own medicaltreatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.

Episode 16: Daring Discourse, Spinal Anesthesia vs General Anesthesia for Hip Fracture Patients

In November of 2021, the Regional versus General Anesthesia for Promoting Independence after Hip Fracture (REGAIN) trial was published in the New England Journal of Medicine. This study was a pragmatic randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in 1,600 patients. The authors concluded that “spinal anesthesia for hip fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days.”
In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, covers both angles of this story in a daring discourse with Alexander Stone, MD, lead author of “There remains a role for neuraxial anesthesia for hip fracture surgery in the post-REGAIN era,” published March 2023 (https://rapm.bmj.com/content/early/2023/03/27/rapm-2022-104071), and Eric Schwenk, MD, lead author of “General anesthesia is an acceptable choice for hip fracture surgery,” also published March 2023 (https://rapm.bmj.com/content/early/2023/03/27/rapm-2023-104454).
Dr. Alexander Stone is an anesthesiologist at Brigham and Women’s Hospital, and an assistant professor at Harvard Medical School. He completed his medical school at Johns Hopkins and his residency training at Brigham and Women’s. He went on to complete a regional anesthesia and acute pain fellowship at Hospital for Special Surgery, before returning to Brigham as a faculty member. His research interests include expanding access to regional anesthesia through enhanced recovery program implementation, as well as collaborating with other specialties.
Dr. Eric Schwenk completed a fellowship in regional anesthesia and acute pain at Thomas Jefferson University Hospital in 2013 and has remained on staff as a faculty member. His research interests center on ketamine for migraine, perioperative ketamine, outcomes after orthopedic surgery, and challenging long-held dogmas in medicine. He has been an active speaker for ASRA Pain Medicine, is on the Regional Anesthesia & Pain Medicine editorial board, and is a co-author of the REGAIN study.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.

Episode 15: Anterior QL Block Does Not Reduce Opioid Consumption After Laparoscopic Hemicolectomy

Proponents of fascial plane blocks argue that their value can be found in opioid reduction and improvement of pain scores. On the other hand, critics argue that the effect size tends to be very small, amounting to a placebo. To address these conflicting ideas, a recent study examined the role of quadratus blocks and analgesia for laparoscopic hemicolectomy. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Jens Borglum, MD, PhD, the senior author of “Anterior quadratus lumborum block does not reduce postoperative opioid consumption following laparoscopic hemicolectomy: a randomized, double-blind, controlled trial in an ERAS setting,” first published in September 2022 (https://rapm.bmj.com/content/48/1/7). This fascinating study had 69 patients randomized to receive either an anterior quadratus lumborum block or isotonic saline, a placebo.
Dr. Jens Borglum is a consultant anesthetist, clinical research associate professor, and head of research at Zealand University Hospital, University of Copenhagen, Denmark. His main interests are ultrasound-guided nerve blocks and he is a prolific researcher and contributor to Regional Anesthesia & Pain Medicine. His clinical and research insights during the peer-review process are invaluable.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.

Episode 14: Guidelines on Interventions for Cervical Spine (Facet) Pain from a Multispecialty Group

Guidelines hold great importance in pain medicine. With many interventional procedures, there is some evidence for efficacy, but wide variation in study results due to differences in technique, interpretation, and implementation. In this month’s RAPM Focus, Executive Editor Chad Brummett, MD, joins Steven Cohen, MD, the senior author of “Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group,” first published in November 2021 (https://rapm.bmj.com/content/47/1/3). These guidelines are a valuable resource for trainees, fellows, and anyone who works with them.
Dr. Steven Cohen is a professor of anesthesiology and critical care medicine, neurology, physical medicine and rehabilitation, and psychiatry and behavioral sciences at the Johns Hopkins School of Medicine and Uniformed Services University of the Health Sciences in Baltimore, MD. He is also chief of pain medicine and director of pain operations at Johns Hopkins and director of pain research at Walter Reed National Military Medical Center. He has published over 400 peer-reviewed articles and book chapters in journals such as Lancet, JAMA, BMJ, Canadian Medical Association Journal, Anesthesiology, Pain, and The New England Journal of Medicine. In addition to his academic work, Dr. Cohen is a retired colonel in the United States Army.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.

Episode 13: Lumbar Medial Branch Blocks: How Does The Second Block Influence Progression?

For interventional procedures that involve implanting devices or ablating tissues, it is common for patients to undergo prognostic tests to determine if they are responders prior to moving on to permanent procedures. However, definitions of responders and the number of prognostic tests necessary has caused some confusion. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins David Provenzano, MD, and Jozef Leech, to discuss their study “Evaluation of lumbar medial branch blocks: how does the second block influence progression to radiofrequency ablation?,” first published in July 2022 (https://rapm.bmj.com/content/47/12/719). In a single-center retrospective review, 224 patients with two consecutive local anesthetic-only blocks were examined for pain relief.
Dr. David Provenzano is president-elect of the American Society of Regional Anesthesia and Pain Medicine. He is currently an adjunct associate professor at the University of Pittsburgh, is on the executive committee of the Western PA Surgery Center, and is a critical member of the editorial board at Regional Anesthesia & Pain Medicine.
Jozef Leech is a native of Johnstown, PA, and graduated from Washington & Jefferson College in 2020 with his Bachelor of Arts in biology. He completed 2 years of internship work with Dr. Provenzano at Pain Diagnostics and Interventional Care located in Pennsylvania. In August of 2022, Jozef started Kent State University College of Podiatric Medicine in Independence, OH. He is an active member with the American College of Foot and Ankle Surgeons.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.

Episode 12: Association of Perioperative Anxiety and Postoperative Opioid-Related Outcomes

The International Association for the Study of Pain defines pain as: “An unpleasant sensory or emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
Among many other variables, mental health conditions play a critical role in determining the emotional experience. Thus, it is very reasonable to hypothesize that baseline anxiety, for instance, may influence pain and opioid prescribing. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Shay Nguyen and Jennifer Waljee, MD, authors on “Prospective cohort study on the trajectory and association of perioperative anxiety and postoperative opioid-related outcomes,” first published in August 2022 (https://rapm.bmj.com/content/47/10/637). In this fascinating study, 1,771 patients were prospectively followed; self-reported opioid use, pain, and anxiety were recorded on the day of surgery and at 1-, 3-, and 6-months post-surgery to examine whether or not anxiety was a mediator between pain and opioid use.
Shay N. Nguyen is a fourth-year medical student at the University of Michigan who is applying into classic surgery. She studied biochemistry in the University of California, Santa Barba, where she did research in chemistry and material science. Currently, her research interests include understanding risk factors for opioid use in the context of surgery and perioperative anxiety management.
Dr. Jennifer F. Waljee is a plastic surgeon in academic practice at the University of Michigan. She completed her medical school training at Emory University and completed clinical residencies in general
surgery and plastic surgery at the University of Michigan, followed by a hand surgery fellowship. Dr. Waljee is a co-founder and co-director of the Michigan Opioid Prescribing Engagement Network (OPEN),
a statewide collaborative program dedicated to enhancing opioid stewardship and developing best practices for the management of acute pain during procedural care.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this
podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical
treatment or for the medical treatment of others.

Episode 11: Effects of Hypnosis on Postoperative Opioid Use After Total Knee Arthroplasty

The International Association for the Study of Pain defines pain as: “An unpleasant sensory or emotional experience associated with, or resembling that associated with, actual or potential tissue damage. Pain is both a disease and a symptom.” The inclusion of the word emotional in the definition alludes to the fact that consciousness is part of the pain pathway. Despite the knowledge that neurocognitive aspects of human psychology are intimately related to pain, very little research exists examining behavioral interventions. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Jessie Markovits, MD, the lead author of “Effects of hypnosis versus enhanced standard of care on postoperative opioid use after total knee arthroplasty: the HYPNO-TKA randomized clinical trial,” first published in June 2022
(https://rapm.bmj.com/content/47/9/534). In this provocative study, 64 patients got either a 10-minute hypnosis session or an enhanced control during a hospital medicine pre-op visit before total knee
arthroplasty.
Dr. Jessie Markovits completed medical school at Tulane School of Medicine in New Orleans, followed by an internal medicine residency at Stanford. Her current appointment is associate professor of
medicine, with a courtesy appointment to psychiatry and behavioral sciences at Stanford University. She is board-certified in internal medicine and has developed a perioperative specialization over the past 6 years in her clinical role as surgical co-management hospitalist, primarily for orthopedic surgery.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this
podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical
treatment or for the medical treatment of others.

Episode 10: Quality of Meta-Analyses of Perioperative Interventions for Chronic Postsurgical Pain

Systematic reviews and meta-analyses are the main drivers of policy, evidence-based guidelines, and funding decisions, but many of them are fraught with errors, and the resources needed to peer-review
them are massive. A recent systematic review examined the quality of the current published meta-analyses in order to inform the design and reporting of future studies. In this month’s RAPM Focus,
Editor-in-Chief Brian Sites, MD, joins John Kramer MSc, PhD, the senior author of “Quality of meta-analyses of non-opioid, pharmacological, perioperative interventions for chronic postsurgical pain: a systematic review,” first published in January 2022 (https://rapm.bmj.com/content/47/4/263). The systematic review explored the idea that surgery may represent an environment, known as a transitional pain state, that could result in a patient developing chronic pain following surgery.
Dr. John Kramer is an associate professor in the faculty of medicine, department of anesthesiology, pharmacology and therapeutics, and principal investigator at ICORD at the University of British Columbia
in Vancouver, Canada. His lab is focused on improving outcomes for individuals with spinal cord injury and neuropathic pain.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this
podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical
treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.

Episode 9: Role of Regional Anesthesia and Analgesia in Enhanced Recovery After Colorectal Surgery

In surgical care worldwide, there has been a growing trend towards enhanced recovery with the emphasis on early mobility, avoidance of unnecessary procedures and drug-induced side effects, and
faster return of normal gastrointestinal function, with the end result of shorter hospital stay. It’s natural to assume that regional anesthesiology and acute pain medicine would play a central role in enhanced recovery protocols for all of the well-described benefits. However, the base evidence is continually evolving as both anesthetic and surgical practices change.
In this month’s RAPM Focus, Associate Editor Edward Mariano, MD, joins Kariem El-Boghdadly, MBBS, BSc, FRCA, EDRA, lead author of an international collaboration in the regional anesthesiology and
enhanced recovery world, “Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials,” first published in March 2022
(https://rapm.bmj.com/content/47/5/282). Investigators carefully evaluated thirteen published randomized controlled trial studies involving 1,170 participants and concluded that regional analgesia
may only have modest evidence to support its inclusion in enhanced recovery protocols involving colorectal surgery patients.
Dr. Kariem El-Boghdadly is a consultant anesthetist at Guy’s and St. Thomas’ NHS Trust in London, and an editor of the journal Anesthesia. Dr. El-Boghdadly completed his undergraduate training at University College of London in 2007 and proceeded to undertake his anesthetic training in Southeast School of Anesthesia. He was awarded the Nuffield Prize for the fellowship of the Royal College of Anaesthetists and completed fellowships in prehospital medicine in Australia, followed by regional anesthesia in Toronto, Canada. Dr. El-Boghdadly is an honorary senior lecturer at King’s College London, and his research interests include regional anesthesia, airway management, and research delivery. He is a brilliant researcher and writer and is well-known for his work in the COVIDSurg Collaborative during the ongoing pandemic, and the ASRA-ESRA regional anesthesia nomenclature project.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical
treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.

Episode 8: Postoperative Lidocaine Infusion Safety on Wards Without Continuous Cardiac Monitoring

Establishing new clinical pathways and accomplishing change often takes a super-human effort in a complex health system. In terms of systemic lidocaine, the analgesic effects of systemic lidocaine are well recognized, but what is novel is the application of this therapy in an environment once thought to be inappropriate, that is, in the general inpatient units. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Meagan Miller, APRN, MSN, AGACNP-BC, and Brian Allen, MD, to discuss their university-based study, “Safety of postoperative lidocaine infusions on general care wards without continuous cardiac monitoring in an established enhanced recovery program,” first published in January 2022 (https://rapm.bmj.com/content/47/5/320).
Meagan Miller graduated from the University of Alabama with her bachelor’s in nursing in 2012. She was then accepted into Vanderbilt University Medical Center Nurse Residency Program and joined the colorectal and general surgery floor, which sparked her interest in enhanced recovery after surgery, as it was the first floor to initiate lidocaine infusions outside of the ICU. She has her master’s in nursing science in adult gerontology acute care nurse practitioner and first assist.
Dr. Brian Allen is an associate professor at Vanderbilt University Medical Center, where he directs the fellowship in regional anesthesiology and acute pain medicine. He completed undergraduate in medical school at Washington University. He was a resident at Vanderbilt and did his regional fellowship at Oregon Health & Science University (OHSU) before returning to join the Vanderbilt faculty. His clinical focus is on regional and multimodal analgesia in ERAS pathways. His research interests include educational assessment, evaluating ERAS efficiency, efficacy and compliance, and opioid minimization.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.