Pain management and opioid utilisation following implantable electronic device procedures

Effective and safe pain management is crucial in post-procedural care, as the techniques used can have lasting impacts—underscored by the ongoing opioid crisis in the United States. Most published data on pain management after cardiac implantable electronic device (CIED) procedures, such as pacemakers and defibrillators, come from the U.S., where one in six patients fills an opioid prescription within 14 days post-procedure. Reports on pain management practices outside the U.S., however, remain limited.

To characterize real-world pain management practices following CIED procedures, with a focus on opioid utilisation, at a single tertiary care center in Israel.

To compare, for the first time, previously published data from the U.S. with a large non-U.S. cohort.

We examined medical records of patients who underwent CIED procedures, including new implantations and generator replacements, from January 2012 to June 2024. We collected data on pain assessments and prescriptions for pain relief medications administered during hospitalisation and at discharge. Opioid prescriptions were manually verified in individual patient records. CIED procedures at our institution are performed under light sedation and subcutaneous anaesthesia.

The search identified 5,088 eligible patients, with 87 (1.7%) having baseline opioid use. Following the procedure, 1,289 (25%) patients received inpatient analgesics, which included: metamizole (dipyrone)(59.3%), paracetamol (24.1%), opioids (15.0%), and non-steroidal anti-inflammatory drugs (NSAIDs) in fewer than 1%, as shown in Figure 1.

Across the entire cohort, opioids were administered to 193 (3.8%) patients for inpatient pain relief and prescribed at discharge for 37 of 5,088 patients (<1%).

Opioid prescriptions were standardized using Oral Morphine Equivalent (OME), a product of the quantity of opioid tablets, tablet dosage, and a morphine conversion factor. Among opioid-naive patients, the mean prescription OME dose was 251.5 + 179 mg, equivalent to 17 tablets of oxycodone 10 mg, driven mainly by pain related to orthopaedic injuries caused by syncopal episodes that led to CIED implantation, rather than the CIED procedure itself.

Our data contrast with opioid prescription practices following CIED procedures in the U.S, as presented in figure 2.

This large dataset highlights the effectiveness of an opioid-sparing strategy in pain management following CIED procedures, offering a potential framework for mitigating the opioid crisis.

Pain management following CIED procedure