Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

State of the Art Lecture on Environmental Geotechnics. Protecting the environment from contamination with barrier systems: advances and challenges

The state-of-the-art for barriers systems control of pollution migration and hydraulic structures including liner systems for landfills, mine waste, and dams/lagoons are discussed along with some comments on current significant environmental issues. Recent research on geomembranes, geosynthetic clay liners, and composite liners and the practical implications are discussed. The need to design taking account of the interactions between the liner system components is highlighted. Regional differences relating to environmental geotechnics of municipal solid waste and mining waste and the implications of differences in regulations and climate are discussed. Vertical barrier systems may be regarded as mature technologies and research funding is much more limited. A bibliography of key papers on cut-off walls has been compiled. It is recognized that major changes to cement-bentonite formulations will be necessitated by the drive to reduce carbon footprints together with the dwindling availability of pulverised fuel ash and blastfurnace slag. The implications for environmental geotechnics associated with recycled materials, waste minimization, and some overarching issues are discussed. The paper finishes with some thoughts about the future of environmental geotechnics and some concluding comments