Spinal anesthesia associated with more pain, prescription analgesic use after hip surgery compared with general anesthesia

1. Spinal anesthesia associated with more pain, prescription analgesic use after hip surgery compared with general anesthesia

Abstract: https://www.acpjournals.org/doi/10.7326/M22-0320       

Editorial: https://www.acpjournals.org/doi/10.7326/M22-1391 

URLs go live when the embargo lifts

A randomized controlled trial (RCT) comparing spinal versus general anesthesia for hip surgery found that spinal anesthesia was associated with worse pain immediately after surgery and higher rates of pain reliever prescriptions at 60 days. However, differences in pain, satisfaction, or mental status between the two interventions seemed to diminish at 60, 180, or 365 days after surgery. The findings are published in Annals of Internal Medicine.

More than 250,000 older adults experience a hip fracture every year and nearly all are repaired through surgery. Patient recovery of ambulation and survival at 60 days, delirium, and hospital length of stay are similar whether patients have spinal or general anesthesia during surgery. Not much is known about which type of anesthesia demonstrates better outcomes, though previous studies suggest that patients may have less pain in the first few hours after hip fracture surgery with spinal anesthesia.

Researchers from the University of Pennsylvania Perelman School of Medicine conducted a preplanned secondary analysis of a RCT comparing spinal versus general anesthesia in 1,600 patients aged 50 years or older who were having hip fracture surgery. Trial participants were randomly assigned to general or spinal anesthesia and the researchers collected data on pain on days 1 to 3 after surgery. Pain and use of prescription pain relievers, mental status, and patient satisfaction were assessed at 60, 180, and 365 days after surgery. They authors found that patients who received spinal anesthesia reported worse pain in the 24 hours after surgery but reported similar pain at all other time points. The authors also found that 25 percent of patients in the spinal anesthesia group were using prescription pain relievers at 60 days compared to 18.8 percent of patients in the general anesthesia group. However, the authors note that they did not find differences in pain, satisfaction, or mental status at 60, 180, or 365 days.

In an accompanying editorial, authors from Harvard Medical School argue that this study challenges a dominant narrative about the risks and outcomes of general anesthesia in older adults. The authors also add that this study highlights that surgical repair of hip fractures in older adults carries the risk for severe postoperative pain, regardless of whether the surgery is done with regional or general anesthesia. They suggest that future research investigate the differences in reported pain as presented in this study and the RAGA (Regional Anesthesia vs General Anesthesia) trial but note that participants in the RAGA trial may have experienced more extensive postoperative care.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Mark D. Neuman, MD, MSc, please contact Frank Otto at Frank.Otto@pennmedicine.upenn.edu.  

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2.  Medical cannabis programs see four-fold enrollment increase between 2016 and 2020

Abstract: https://www.acpjournals.org/doi/10.7326/M22-0217 

URL goes live when the embargo lifts

An observational study has found that the number of patients enrolled in medical cannabis programs has increased four-fold between 2016 and 2020. The trend has been driven by a combination of new medical cannabis laws in 35 states, expanded qualifying conditions, and increased enrollment nationally. The findings are published in Annals of Internal Medicine.

Since 1996, 37 states have legalized the use of medical cannabis and 18 have legalized the use of recreational cannabis for adults. The ongoing conflict between state legalization and federal restriction creates medical and legal uncertainty for both users and clinicians.

Researchers from the University of Michigan Medical School analyzed medical cannabis program registry data from Washington, D.C. and 35 states to describe recent trends in medical cannabis licensure in the United States. The authors found that between 2016 and 2020, the national number of patients enrolled in medical cannabis programs increased from 678,408 in 2016 to 2,974,433 in 2020. Chronic pain was the most common patient-reported qualifying condition, accounting for 60.6 percent of all available data. Post-traumatic stress disorder (PTSD) was the second most common patient-reported qualifying condition, accounting for 10.6 percent of total data. The authors note that these conditions were more common in medical-only states, while states allowing recreational use reported comparably higher percentages of patients reporting experiencing multiple sclerosis, arthritis, and chemotherapy-induced nausea and vomiting. According to the authors, their findings highlight the value of aligned federal and state cannabis regulation. They note that changing the federal schedule 1 designation for cannabis would provide opportunities to create regulation that would improve state policies and labeling and potency testing, clarify legal and medical discrepancies, and ensure appropriate training for dispensary employees and health care professionals.

For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Kevin F. Boehnke, PhD, please contact Kelly Malcom at kmalcom@med.umich.edu.   

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3. Physicians debate statin use for patients with cardiovascular disease

‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center

Abstract:  https://www.acpjournals.org/doi/10.7326/M22-0908      

URL goes live when the embargo lifts

In a new Annals ‘Beyond the Guidelines’ feature, a preventive cardiologist and a general internist discuss their approach to the use of statins for primary prevention of cardiovascular disease (CVD) and how they would apply the guidelines to an individual patient. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine. 

CVD is the leading cause of death in the United States.  In addition to lifestyle modification, statins are an important tool to reduce risk for CVD in selected patients. One strategy to identify candidates for statins is to estimate the 10-year risk for CVD using a validated risk calculator. Multiple randomized controlled trials have shown that statins reduce the risk for CVD in patients without known CVD. The American College of Cardiology/American Heart Association and the U.S. Department of Veterans have each proposed an approach to the use of statins in primary prevention of CVD, which differ on the use of advanced testing to modify the 10-year CVD risk estimate and on the need for low-density lipoprotein cholesterol targets to establish the efficacy of statins. Advanced testing with coronary artery calcium measurement may be helpful for patients who are potentially eligible for statin therapy but who are uncertain if they wish to take a statin.

BIDMC Grand Rounds discussants, Mark D. Benson, MD, PhD, a preventive cardiologist, and Stephen P. Juraschek, MD, PhD, a general internist recently discussed the case of a 57-year-old woman with high cholesterol and a family history of heart disease. She is interested in being treated with statins. 

In his assessment, Dr. Benson would discuss clinical risk-enhancing factors with patients who are at intermediate risk or otherwise have a borderline indication to begin taking a statin in order to help recalibrate risk estimates if needed. Dr. Juraschek places less emphasis on the use of risk-enhancing factors to refine the 10-year CVD risk estimate provided by the PCE calculator. He also  recommends coronary artery calcium (CAC) testing for patients with borderline risk or low risk with risk-enhancing factors, while Dr. Benson feels that CAC testing can refine risk estimates in patients with borderline or intermediate risk but points out that this advanced testing has important limitations. Dr. Benson supports the VA recommendations to focus on the intensity of statin use rather than to titrate to a particular LDL cholesterol target. However, Dr. Juraschek recommends LDL cholesterol measurement after initiation of a statin, to ensure the patient is taking it, and because it guides the additoin of other lipid-lowering agents in some patients. Both clinicians emphasize the important of shared decision making when counseling patients.

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. For an interview with the discussants, please contact Kendra McKinnon at kmckinn1@bidmc.harvard.edu.

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Research and Reporting Methods

Abstract: https://www.acpjournals.org/doi/10.7326/M22-0276

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Abstract: https://www.acpjournals.org/doi/10.7326/M22-0039