Journal Article Annotations
2023, 1st Quarter
Annotations by Alissa Hutto, MD and Julian J. Raffoul, MD, PhD
The VA/DoD Evidence-Based Practice Work Group assembles a team at least every 5 years to update the clinical practice guideline for opioid therapy for chronic pain. The current team included clinicians and researchers across many related specialties including internal medicine, family medicine, neurology, nursing, pharmacy, psychology, physical therapy, social work, acupuncture & Chinese medicine, and chiropractic & interventional medicine. The group continues to recommend against the use of opioids in the daily management of chronic pain, and if opioids are required, they still recommend using the lowest possible dose for the shortest duration of time. However, the following are 3 summaries of new transformative recommendations: 1) to screen patients for behavioral health conditions, prior traumatic brain injury, and psychological factors such as pain catastrophizing before and during opioid treatment, 2) to provide pre-operative opioid and pain management education and reduce post-operative opioid use, and 3) to use buprenorphine instead of daily use of full agonist opioids.
Strength and weaknesses:
The updated 2022 VA/DoD guideline reflects the challenge clinicians and patients experience when managing chronic pain and recognizes the need to assess for and treat behavioral health conditions that may co-occur. It also prioritizes the use of buprenorphine over full agonist opioids for patients requiring treatment for chronic pain. The guideline, however, does not clearly specify how buprenorphine should be implemented, as the quality of evidence for the use of buprenorphine is low. More research about the formulation, dosing, and clinical characteristics are needed to support the use of buprenorphine for treatment of chronic pain.
With the adoption of these guidelines, C-L psychiatrists may encounter an increase in consultations for behavioral health concerns during the peri-operative window. Providing liaison education and treatment for possible co-occurring psychiatric conditions and supporting the use of buprenorphine over full agonist opioids will reduce risk and exposure to prescription opioids while providing optimum care for patients with chronic pain. Furthermore, C-L psychiatrists currently following the above guideline are encouraged to publish their findings to reduce the clinical uncertainty that may surround this important topic.
This meta-analysis of 15 randomized controlled trials (RCTs) examining the effects of perioperative ketamine administration suggests ketamine can improve both depressive symptoms and pain, though with increased risk of adverse effects compared to controls. The effect was present by postoperative day 1 and continued for weeks—the furthest follow-up time point out of the studies was 42 days. The difference in depression scores remained significant compared to placebo in all subgroup analyses (with versus without a pre-operative depression diagnosis, spinal vs general anesthesia, continuous versus one time dose administration, coadministration versus no midazolam, and low versus high dose).
Strength and weaknesses:
This meta-analysis included a large group of participants among diverse settings and who received diverse methods of ketamine administration. The large sample size was a strength, but it also meant the authors were comparing very different study methods including different screening tools. Some studies used the PHQ9, a tool which evaluates mood over previous two weeks, to evaluate depression changes over just a few days, and the variation in tools makes it difficult to tell if the significant difference is truly a clinical difference in depression scores. They also point out the lack of data on blinding within some of the studies and highlight that some large well-blinded RCTs show no effect on depression; overall their discussion of weaknesses and biases becomes a strength of the paper.
There is ever-increasing interest in interventional psychiatry, with ketamine becoming more available in the inpatient and outpatient setting. Ketamine has more diverse uses compared to other psychiatry interventions with its analgesic and opioid tolerance-reducing effects. Even if a C-L psychiatrist is not directly involved in providing ketamine treatment, they are likely to come across ketamine during general consults work. Joining forces with anesthesiology or surgery teams to help decide if someone is an ideal recipient of perioperative ketamine may help prevent a scenario where psychiatry is only called in once post-operative depressed mood is already hindering a patient’s recovery. While such a setup could be an exciting collaborative path of the future, more investigation is needed to pave the way.