1
|
Decker HC, Silver CM, Graham-Squire D, Pierce L, Kanzaria HK, Wick EC. Association of Homelessness with Before Medically Advised Discharge After Surgery. Jt Comm J Qual Patient Saf 2024; 50:655-663. [PMID: 38871598 DOI: 10.1016/j.jcjq.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Before medically advised (BMA) discharge, which refers to patients leaving the hospital at their own discretion, is associated with higher rates of readmission and death in other settings. It is not known if housing status is associated with this phenomenon after surgery. METHODS We identified all admitted adults who underwent an operation by one of 11 different surgical services at a single tertiary care hospital between January 2013 and June 2022. Chi-square tests and t-tests were used to compare demographic and clinical features between BMA discharges and standard discharges. Multivariable logistic regression was used to evaluate the association between housing status and BMA discharge, adjusting for demographic and admission characteristics. Documented reasons for BMA discharge were also abstracted from the medical record. RESULTS Of 111,036 patient admissions, 242 resulted in BMA discharge (0.2%). After adjusting for observable confounders, patients experiencing homelessness had substantially higher odds of BMA discharge after surgery (adjusted odds ratio 4.4, 95% confidence interval 3.0-6.4; p < 0.001) when compared to housed. Patients who underwent emergency surgery, patients with a documented substance use disorder, and those insured by Medicaid also had significantly higher odds of BMA discharge. System- or provider-related reasons (including patient frustration with the hospital environment, challenges in managing substance dependence, and perceived inadequacy of paint control) were documented in 96% of BMA discharges for patients experiencing homelessness (vs. 66% in housed patients). CONCLUSION BMA discharge is more common in patients experiencing homelessness after surgery even after adjusting for observable confounding characteristics. Deeper understanding of the drivers of BMA discharge in patients experiencing homelessness through qualitative methods are critical to promote more equitable and effective care.
Collapse
|
2
|
Curtis W, Kruger E, Fountain D, Chavez T, Treme G. Challenges of perioperative pain control in opioid use disorder patients following intramedullary nail fixation. J Perioper Pract 2024:17504589241262891. [PMID: 39138892 DOI: 10.1177/17504589241262891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
BACKGROUND Outcomes of patients with opioid use disorder undergoing elective procedures have been well studied, but research is lacking in the orthopaedic trauma population. AIM The aim was to compare perioperative pain and morphine equivalents required by patients with versus without opioid use disorder following intramedullary nail fixation of femoral or tibial fractures. METHODS We conducted a retrospective review of all patients with isolated femoral or tibial diaphyseal fractures treated with intramedullary nail fixation. Outcomes were compared between patients with diagnosed opioid use disorder and controls without, including daily morphine equivalents and patient-reported pain scores. RESULTS Patients with opioid use disorder (n = 42) required greater morphine equivalents and reported higher pain than controls (n = 42) at all time points but did not differ in change of morphine equivalents over the perioperative period. CONCLUSION This highlights the challenge of perioperative pain control in this population and need for improved specific pain management protocols.
Collapse
Affiliation(s)
- William Curtis
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, NM, USA
| | - Eric Kruger
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, NM, USA
| | - Damian Fountain
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, NM, USA
| | - Tyler Chavez
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, NM, USA
| | - Gehron Treme
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, NM, USA
| |
Collapse
|
3
|
do Carmo Pinheiro R, Souza Marques L, Ten Kathen Jung J, Nogueira CW, Zeni G. Recent Progress in Synthetic and Biological Application of Diorganyl Diselenides. CHEM REC 2024; 24:e202400044. [PMID: 38976862 DOI: 10.1002/tcr.202400044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/08/2024] [Indexed: 07/10/2024]
Abstract
Diorganyl diselenides have emerged as privileged structures because they are easy to prepare, have distinct reactivity, and have broad biological activity. They have also been used in the synthesis of natural products as an electrophile in the organoselenylation of aromatic systems and peptides, reductions of alkenes, and nucleophilic substitution. This review summarizes the advancements in methods for the transformations promoted by diorganyl diselenides in the main functions of organic chemistry. Parallel, it will also describe the main findings on pharmacology and toxicology of diorganyl diselenides, emphasizing anti-inflammatory, hypoglycemic, chemotherapeutic, and antimicrobial activities. Therefore, an examination detailing the reactivity and biological characteristics of diorganyl diselenides provides valuable insights for academic researchers and industrial professionals.
Collapse
Affiliation(s)
- Roberto do Carmo Pinheiro
- Laboratório de Síntese, Reatividade, Avaliação Farmacológica e Toxicológica de Organocalcogênios CCNE, UFSM, Santa Maria, Rio Grande do Sul, Brazil, 97105-900
| | - Luiza Souza Marques
- Laboratório de Síntese, Reatividade, Avaliação Farmacológica e Toxicológica de Organocalcogênios CCNE, UFSM, Santa Maria, Rio Grande do Sul, Brazil, 97105-900
| | - Juliano Ten Kathen Jung
- Laboratório de Síntese, Reatividade, Avaliação Farmacológica e Toxicológica de Organocalcogênios CCNE, UFSM, Santa Maria, Rio Grande do Sul, Brazil, 97105-900
| | - Cristina Wayne Nogueira
- Laboratório de Síntese, Reatividade, Avaliação Farmacológica e Toxicológica de Organocalcogênios CCNE, UFSM, Santa Maria, Rio Grande do Sul, Brazil, 97105-900
| | - Gilson Zeni
- Laboratório de Síntese, Reatividade, Avaliação Farmacológica e Toxicológica de Organocalcogênios CCNE, UFSM, Santa Maria, Rio Grande do Sul, Brazil, 97105-900
| |
Collapse
|
4
|
Liu O, Leon D, Gough E, Speed T, Hanna M, Jaremko K. A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service. Br J Clin Pharmacol 2024. [PMID: 38817150 DOI: 10.1111/bcp.16118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
AIMS To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). METHODS This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. RESULTS Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). CONCLUSIONS Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.
Collapse
Affiliation(s)
- Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Leon
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Gough
- Department of Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Traci Speed
- Department of Psychiatry and Behavioral Sciences, ohns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
5
|
Inchingolo AM, Dipalma G, Inchingolo AD, Palumbo I, Guglielmo M, Morolla R, Mancini A, Inchingolo F. Advancing Postoperative Pain Management in Oral Cancer Patients: A Systematic Review. Pharmaceuticals (Basel) 2024; 17:542. [PMID: 38675500 PMCID: PMC11054702 DOI: 10.3390/ph17040542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/02/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
The goal of this review is to shed light on the management of orofacial discomfort after a cancer diagnosis in the head and neck region. A search was conducted on PubMed, Scopus, and Web of Science to identify studies on postoperative pain control in oral cancer. The review included open-access research, investigations into pain management, randomized clinical trials, retrospective studies, case-control studies, prospective studies, English-written studies, and full-text publications. Exclusion criteria included animal studies; in vitro studies; off-topic studies; reviews, case reports, letters, or comments; and non-English language. Three reviewers independently accessed databases and assigned a quality rating to the chosen articles. The review explores postoperative pain management in oral cancer patients; highlighting persistent opioid use; the efficacy of adjuvant drugs, such as gabapentin; and a multimodal approach. It emphasizes the need for personalized pain management, recognizing individual pain perception and tailoring interventions. Integrating pharmacological and non-pharmacological strategies is crucial for comprehensive pain management. The review also serves as a guide for future research, emphasizing the need for standardized methodologies and diverse participant populations.
Collapse
Affiliation(s)
| | - Gianna Dipalma
- Correspondence: (G.D.); (F.I.); Tel.: +39-339-698-9939 (G.D.); +39-331-211-1104 (F.I.)
| | | | | | | | | | | | - Francesco Inchingolo
- Correspondence: (G.D.); (F.I.); Tel.: +39-339-698-9939 (G.D.); +39-331-211-1104 (F.I.)
| |
Collapse
|
6
|
Terasaki D, Abts D, Ferraro K. Questioning methadone split-dosing for analgesia among hospitalized patients with opioid use disorder. Addiction 2024. [PMID: 38615677 DOI: 10.1111/add.16502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/21/2024] [Indexed: 04/16/2024]
Abstract
Methadone is hypothesized to provide greater analgesic coverage when split into two or more divided doses. However, empirical data are lacking, and our anecdotal experience at a safety-net hospital among patients with opioid use disorder suggests that it may not be straightforward. Guidelines and clinicians should exercise appropriate caution when recommending this strategy.
Collapse
Affiliation(s)
- Dale Terasaki
- Denver Health & Hospital Authority, Department of Behavioral Health, Denver, CO, USA
| | - David Abts
- Denver Health & Hospital Authority, Department of Anesthesiology, Denver, CO, USA
| | - Kelly Ferraro
- Denver Health & Hospital Authority, Department of Palliative Care, Denver, CO, USA
| |
Collapse
|
7
|
Verma A, Chauhan A, Islam MM, Kahlon MS, Singh A. Navigating the Opioid Crisis: Exploring Innovative Approaches to Pain Management. Curr Pharm Biotechnol 2024; 25:1629-1631. [PMID: 38093445 DOI: 10.2174/0113892010277968231127072017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 09/04/2024]
Affiliation(s)
- Abhishek Verma
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Abhishek Chauhan
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Md Moidul Islam
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Milan Singh Kahlon
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Amandeep Singh
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| |
Collapse
|
8
|
Satapathy T, Singh G, Pandey RK, Shukla SS, Bhardwaj SK, Gidwani B. Novel Targets and Drug Delivery System in the Treatment of Postoperative Pain: Recent Studies and Clinical Advancement. Curr Drug Targets 2024; 25:25-45. [PMID: 38037995 DOI: 10.2174/0113894501271207231127063431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 10/18/2023] [Accepted: 11/07/2023] [Indexed: 12/02/2023]
Abstract
Pain is generated by a small number of peripheral targets. These can be made more sensitive by inflammatory mediators. The number of opioids prescribed to the patients can be reduced dramatically with better pain management. Any therapy that safely and reliably provides extended analgesia and is flexible enough to facilitate a diverse array of release profiles would be useful for improving patient comfort, quality of care, and compliance after surgical procedures. Comparisons are made between new and traditional methods, and the current state of development has been discussed; taking into account the availability of molecular and cellular level data, preclinical and clinical data, and early post-market data. There are a number of benefits associated with the use of nanotechnology in the delivery of analgesics to specific areas of the body. Nanoparticles are able to transport drugs to inaccessible bodily areas because of their small molecular size. This review focuses on targets that act specifically or primarily on sensory neurons, as well as inflammatory mediators that have been shown to have an analgesic effect as a side effect of their anti- inflammatory properties. New, regulated post-operative pain management devices that use existing polymeric systems were presented in this article, along with the areas for potential development. Analgesic treatments, both pharmacological and non-pharmacological, have also been discussed.
Collapse
Affiliation(s)
- Trilochan Satapathy
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Gulab Singh
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Ravindra Kumar Pandey
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Shiv Shankar Shukla
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Shiv Kumar Bhardwaj
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| | - Beena Gidwani
- Department of Pharmacology, Columbia Institute of Pharmacy, Raipur, Chhattisgarh-493111, India
| |
Collapse
|
9
|
Noor S, Sun MS, Pasmay AA, Pritha AN, Ruffaner-Hanson CD, Nysus MV, Jimenez DC, Murphy M, Savage DD, Valenzuela CF, Milligan ED. Prenatal alcohol exposure promotes NLRP3 inflammasome-dependent immune actions following morphine treatment and paradoxically prolongs nerve injury-induced pathological pain in female mice. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2023; 47:2262-2277. [PMID: 38151779 PMCID: PMC10764094 DOI: 10.1111/acer.15214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/23/2023] [Accepted: 10/18/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Neuroimmune dysregulation from prenatal alcohol exposure (PAE) may contribute to neurological deficits associated with fetal alcohol spectrum disorders (FASD). PAE is a risk factor for developing peripheral immune and spinal glial sensitization and release of the proinflammatory cytokine IL-1β, which lead to neuropathic pain (allodynia) from minor nerve injury. Although morphine acts on μ-opioid receptors, it also activates immune receptors, TLR4, and the NLRP3 inflammasome that induces IL-1β. We hypothesized that PAE induces NLRP3 sensitization by morphine following nerve injury in adult mice. METHODS We used an established moderate PAE paradigm, in which adult PAE and non-PAE control female mice were exposed to a minor sciatic nerve injury, and subsequent allodynia was measured using the von Frey fiber test. In control mice with standard sciatic damage or PAE mice with minor sciatic damage, the effects of the NLRP3 inhibitor, MCC950, were examined during chronic allodynia. Additionally, minor nerve-injured mice were treated with morphine, with or without MCC950. In vitro studies examined the TLR4-NLRP3-dependent proinflammatory response of peripheral macrophages to morphine and/or lipopolysaccharide, with or without MCC950. RESULTS Mice with standard sciatic damage or PAE mice with minor sciatic damage developed robust allodynia. Blocking NLRP3 activation fully reversed allodynia in both control and PAE mice. Morphine paradoxically prolonged allodynia in PAE mice, while control mice with minor nerve injury remained stably non-allodynic. Allodynia resolved sooner in nerve-injured PAE mice without morphine treatment than in morphine-treated mice. MCC950 treatment significantly shortened allodynia in morphine-treated PAE mice. Morphine potentiated IL-1β release from TLR4-activated PAE immune cells, while MCC950 treatment greatly reduced it. CONCLUSIONS In female mice, PAE prolongs allodynia following morphine treatment through NLRP3 activation. TLR4-activated PAE immune cells showed enhanced IL-1β release with morphine via NLRP3 actions. Similar studies are needed to examine the adverse impact of morphine in males with PAE. These results are predictive of adverse responses to opioid pain therapeutics in individuals with FASD.
Collapse
Affiliation(s)
- Shahani Noor
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Melody S Sun
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Andrea A Pasmay
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Ariana N Pritha
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Monique V Nysus
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Diane C Jimenez
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Minerva Murphy
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Daniel D Savage
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - C Fernando Valenzuela
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Erin D Milligan
- Department of Neurosciences, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| |
Collapse
|
10
|
Coffman CR, Leng JC, Ye Y, Hunter OO, Walters TL, Wang R, Wong JK, Mudumbai SC, Mariano ER. More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health. Semin Cardiothorac Vasc Anesth 2023; 27:273-282. [PMID: 37679298 DOI: 10.1177/10892532231200620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.
Collapse
Affiliation(s)
- Clarity R Coffman
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jody C Leng
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ying Ye
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Oluwatobi O Hunter
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Tessa L Walters
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Rachel Wang
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jimmy K Wong
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Seshadri C Mudumbai
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward R Mariano
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
11
|
Kim S, Song IA, Lee B, Oh TK. Risk factors for discontinuation of intravenous patient-controlled analgesia after general surgery: a retrospective cohort study. Sci Rep 2023; 13:18318. [PMID: 37884558 PMCID: PMC10603031 DOI: 10.1038/s41598-023-45033-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023] Open
Abstract
Identifying patients at risk for developing side effects secondary to intravenous patient-controlled analgesia (IV PCA) and making the necessary adjustments in pain management are crucial. We investigated the risk factors of discontinuing IV PCA due to side effects following general surgery; adult patients who received IV PCA after general surgery (2020-2022) were included. Data on postoperative pain intensity, PCA pain relief, side effects, continuity of PCA use, and PCA pump settings were collected from the records of the acute pain management team. The primary outcome was identifying the risk factors associated with PCA discontinuation due to side effects. Of the 8745 patients included, 94.95% used opioid-containing PCA, and 5.05% used non-steroidal anti-inflammatory drug (NSAID)-only PCA; 600 patients discontinued PCA due to side effects. Female sex (adjusted odds ratio [aOR] 3.31, 95% confidence interval [CI] 2.74-4.01), hepato-pancreatic-biliary surgery (aOR 1.43, 95% CI 1.06-1.94) and background infusion of PCA (aOR 1.42, 95% CI 1.04, 1.94) were associated with an increased likelihood of PCA discontinuation. Preoperative opioid use (aOR 0.49, 95% CI 0.28-0.85) was linked with a decreased likelihood of PCA discontinuation. These findings highlight the importance of individualized pain management, considering patient characteristics and surgical procedures.
Collapse
Affiliation(s)
- Saeyeon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, 13620, Seongnam, South Korea
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, 13620, Seongnam, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, 13620, Seongnam, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, 103 Daehak-ro, Jongno-gu, 03080, Seoul, South Korea
| | - Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, 13620, Seongnam, South Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, 13620, Seongnam, South Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, 103 Daehak-ro, Jongno-gu, 03080, Seoul, South Korea.
| |
Collapse
|
12
|
Arnet I, Dürsteler KM, Jaiteh C, Grossmann F, Hersberger KE. Rescue Analgesia for Opioid-Dependent Individuals on Opioid Agonist Treatment during Hospitalization: Adherence to Guideline Treatment. Eur Addict Res 2023; 29:253-263. [PMID: 37302389 PMCID: PMC10614254 DOI: 10.1159/000530266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 03/16/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Opioid agonist treatment (OAT) is the first-line treatment for opioid use disorder (OUD). Simultaneously, opioids are essential medicines in acute pain management. The literature is scarce on acute pain management in individuals with OUD, and guidelines are controversial for patients on OAT. We aimed at analyzing rescue analgesia in opioid-dependent individuals on OAT during hospitalization in the University Hospital Basel, Switzerland. METHODS Patient hospital records were extracted from the database over 6 months (Jan-Jun) in 2015 and 2018. Of the 3,216 extracted patient records, we identified 255 cases on OAT with full datasets. Rescue analgesia was defined according to established principles of acute pain management, e.g., i) the analgesic agent is identical to the OAT medication, and ii) the opioid agent is dosed above 1/6th morphine equivalent dose of the OAT medication. RESULTS The patients were on average 51.3 ± 10.5 years old (range: 22-79 years), of which 64% were men. The most frequent OAT agents were methadone and morphine (34.9% and 34.5%). Rescue analgesia was not documented in 14 cases. Guideline-concordant rescue analgesia was observed in 186 cases (72.9%) and consisted mostly of NSAIDs, including paracetamol (80 cases), and identical agents such as the OAT opioid (70 cases). Guideline-divergent rescue analgesia was observed in 69 (27.1%) cases, predominantly due to an underdosed opioid agent (32 cases), another agent other than the OAT (18 cases), or contraindicated agents (10 cases). DISCUSSION Our analysis suggests that rescue analgesia in hospitalized OAT patients was predominantly concordant with guidelines, while divergent prescriptions seemed to follow common principles of pain medicine. Clear guidelines are needed to appropriately treat acute pain in hospitalized OAT patients.
Collapse
Affiliation(s)
- Isabelle Arnet
- Department of Pharmaceutical Sciences, Pharmaceutical Care Research Group, University of Basel, Basel, Switzerland
| | - Kenneth M. Dürsteler
- University Psychiatric Clinics Basel, Basel, Switzerland
- Department for Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Christine Jaiteh
- Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Florian Grossmann
- Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Kurt E. Hersberger
- Department of Pharmaceutical Sciences, Pharmaceutical Care Research Group, University of Basel, Basel, Switzerland
| |
Collapse
|
13
|
Ridley A, Vial-Cholley E, Robert G, Jounis-Jahan F, Lervat C, Betremieux P, Viallard ML, Frache S, Cojean N. Nationwide Study of Continuous Deep Sedation Practices Among Pediatric Palliative Care Teams. J Pain Symptom Manage 2023; 65:308-317. [PMID: 36528187 DOI: 10.1016/j.jpainsymman.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/16/2022]
Abstract
CONTEXT Palliative sedation practices evolved in France when the Claeys-Leonetti law passed in 2016 authorized patient-requested continuous deep sedation (CDS) until death. Its implementation in the pediatric setting is less frequently encountered and can pose several clinical and ethical challenges for health care teams and families. OBJECTIVES Our study aimed to describe CDS requests and practices of patients receiving specialized pediatric palliative care in France since its legalization in 2016. METHODS We conducted a nationwide multicentric, descriptive, retrospective study using a self-report questionnaire completed by all Pediatric Palliative Care (PPC) Teams that were involved in a CDS case between January 2017 and December 2019. RESULTS Six PPC teams had cared for six patients that had requested CDS, predominantly male adolescents/young adults diagnosed with a solid tumour. The refractory symptoms were diverse (pain, bleeding, and sensory loss) and always coupled with psycho-existential suffering. Each request was analyzed in multidisciplinary collegial meetings. Parental consent was always obtained regardless of age. Sedation typically required the use of multiple drugs including Midazolam (n = 5 cases), Chlorpromazine (n = 3), Ketamine (n = 2), and Propofol (n = 2). Despite close monitoring, achieving a satisfactory level of deep sedation was challenging and most patients unexpectedly awoke during CDS. Death occurred between 27 and 96 hours after induction. CONCLUSION Managing patient-requested CDS in pediatrics is challenging due to its rarity, multi-factorial refractory symptoms and drug tolerance despite polytherapy. Few recommendations exist to guide CDS practice for pediatricians. Further studies investigating pediatric CDS practices across various cultural and legal settings, refractory symptom management and specific pharmacology are warranted.
Collapse
Affiliation(s)
- Ashley Ridley
- Necker Enfants Malades Children's Hospital, Pediatric Palliative Care Team (A.R., M.L.V.), Paris, France.
| | | | - Guillaume Robert
- Pediatric Palliative Care Team Bretagne (G.R.), Rennes, France; University of Rennes 1 (G.R.), Rennes, France
| | | | - Cyril Lervat
- Pediatric Palliative Care Team Hauts de France (C.L.), Lille, France; Pediatric, Adolescent and Young Adult Oncology Unit (C.L.), Oscar Lambret Centre, Lille, France
| | - Pierre Betremieux
- French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| | - Marcel-Louis Viallard
- Necker Enfants Malades Children's Hospital, Pediatric Palliative Care Team (A.R., M.L.V.), Paris, France
| | - Sandra Frache
- Pediatric Palliative Care Team Franche-Comté (S.F.), Besançon, France; French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| | - Nadine Cojean
- Pediatric Palliative Care Team Alsace (N.C.), Strasbourg, France; French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| |
Collapse
|
14
|
Identifying Barriers to Buprenorphine Treatment for Patients with Opioid Use Disorder Among Anesthesiologists and Pain Practitioners: A Survey Study. J Addict Med 2023; 17:e94-e100. [PMID: 36001078 DOI: 10.1097/adm.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study is to investigate barriers to opioid use disorder (OUD) care among acute and chronic pain physicians and advanced practice providers, including hypothesized barriers of lack of interest in OUD care and stigma toward this patient population. METHODS The study used an anonymous 16-item online survey through Google Forms. Respondents were 153 health practitioners across the United States and Canada, all of whom are registered in one of several pain or anesthesia professional societies. Data were analyzed with descriptive and categorical statistics. RESULTS The most common barriers include "lack of appropriate clinical environment for prescribing by both acute and chronic pain practitioners" (48%) and "lack of administrative/departmental support" (46%). A total of 32% of respondents reported that OUD care was important but they were not interested in doing more, while 28% of practitioners believed that they treat patients with OUD differently than others in a negative way. More males reported "difficulty" in treating OUD as a barrier (45% vs 25%). Chronic pain practitioners reported poor payor mix as a barrier twice as often as their acute pain colleagues. In free response, lack of multidisciplinary OUD care was a notable barrier. CONCLUSIONS The top barriers to OUD treatment were clinical environment, departmental support, difficulty in treating the condition, and payor mix, supporting the hypotheses. Given an OUD patient scenario, 55% of acute pain physicians and 73% of chronic pain physicians expressed a willingness to prescribe buprenorphine.
Collapse
|
15
|
Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare (Basel) 2022; 11:healthcare11010034. [PMID: 36611494 PMCID: PMC9818465 DOI: 10.3390/healthcare11010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.
Collapse
Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
- Correspondence:
| | - Andrea M. Wetshtein
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, OH 44111, USA
| | - Samantha J. Grable
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| | - Michelle P. Jackson
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| |
Collapse
|
16
|
Hargett J, Criswell A, Palokas M. Nonpharmacological interventions for acute pain management in patients with opioid abuse or opioid tolerance: a scoping review. JBI Evid Synth 2022; 20:2697-2720. [PMID: 36065876 DOI: 10.11124/jbies-21-00169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The objective of this scoping review was to identify and map the evidence on nonpharmacological interventions for acute pain management in patients with opioid tolerance or opioid abuse. INTRODUCTION Opioid therapy is the mainstay of pain management for adults experiencing moderate-to-severe acute pain. However, considering the known risks of opioid use and the growing number of patients with opioid tolerance or opioid abuse, nonpharmacological pain management interventions are of increasing interest to health care providers. Nonpharmacological techniques have shown potential in reducing postoperative pain, opioid consumption, stress, and anxiety. INCLUSION CRITERIA Eligible studies included participants in either inpatient or outpatient health care settings who were experiencing acute pain and a tolerance to opioid medications or opioid abuse. Studies that examined nonpharmacological interventions for treating acute pain in these patients were considered. Nonpharmacological interventions included, but were not limited to, acupuncture, electroacupuncture, massage, mindfulness, electroanalgesia, low-level light therapy, meditation, biofeedback, hypnosis, and relaxation techniques. METHODS MEDLINE, CINAHL, Scopus, Embase, Europe PubMed Central, PsycINFO, Cochrane Central Register of Controlled Trials, and the US National Library of Medicine ( https://ClinicalTrials.gov/ ) were searched, as were sources of unpublished studies on December 30, 2020. Only studies published in English were included, and there was no limit on date of publication. After screening the titles and abstracts of identified citations, 2 independent reviewers retrieved potentially relevant full-text studies and extracted data. Data are presented in diagrammatic format, and accompany the narrative synthesis. RESULTS Fourteen articles were included in the study, including 10 expert opinion papers or chapters, 3 case reports, and 1 implementation report. The most common setting was the perioperative setting, specifically orthopedic surgery. Nonpharmacological pain interventions identified in the literature included physical interventions such as acupuncture, physical therapy, therapeutic exercise, yoga, bracing, heat, cold, elevation, compression, chiropractic interventions, massage, manual therapy, transcutaneous electrical nerve stimulation, and pulsed electromagnetic field therapy. Behavioral and psychological modalities included positive affirmations, cognitive behavioral therapy, acceptance and commitment therapy, mindfulness, distraction, guided imagery, meditation, biofeedback, relaxation, hypnosis, breathing exercises, and energy healing. Many expert opinions included only brief mentions or recommendations for nonpharmacological interventions without full explanations, evidence from the literature, or discussion of the level of support for the recommendation. CONCLUSIONS The findings of this review indicate that nonpharmacological interventions for patients with opioid tolerance or dependence include physical, psychological, and multimodal approaches. Nonpharmacological interventions in this scoping review were often presented as combined with opioid or non-opioid medications for a pain management regimen that is opioid-sparing, opioid-free, or drug-free. More primary research is needed on the nonpharmacological acute pain management of patients with opioid dependence or opioid tolerance.
Collapse
Affiliation(s)
- Jennifer Hargett
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
| | - Amanda Criswell
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
| | - Michelle Palokas
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
| |
Collapse
|
17
|
Peri-OPerative Pain Management, Education & De-escalation (POPPMED), a novel anaesthesiologist-led program, significantly reduces acute and long-term postoperative opioid requirements: a retrospective cohort study. Pain Rep 2022; 7:e1028. [PMID: 36034601 PMCID: PMC9400930 DOI: 10.1097/pr9.0000000000001028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 05/30/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Perioperative pain management, education, and de-escalation, a single anaesthesiologist-led perioperative service, managed older, high-risk opioid-tolerant patients to achieve sustained oral morphine equivalent daily dosage reductions safely after major orthopaedic, abdominal, and neurosurgery. Introduction: The opioid tolerant patient requiring surgery is highly likely to be discharged on high Oral Morphine Equivalent Daily Dosages (OMEDDs), with concomitant risk of increased morbidity and mortality. Objectives: We proposed that a single anaesthesiologist-led POPPMED (Peri-Operative Pain Management, Education & De-escalation) service could reduce both short and long-term postoperative patient OMEDDs. Methods: From April 2017, our anaesthesiologist-led POPPMED service, engaged 102 perioperative patients treated with >50mg preoperative OMEDDs. We utilized behavioural interventions; acute opioid reduction and/ or rotation; and regional, multimodal and ketamine analgesia to achieve lowest possible hospital discharge and long term OMEDDs. Results: Patients' preoperative OMEDDs were [median (IQR): 115mg (114mg)], and were representative of an older [age 62 (15) years], high-risk [89% ASA status 3 or 4] patient population. 46% of patients received an acute opioid rotation; 70% received ketamine infusions; and 44% regional analgesia. OMEDDs on discharge [-25mg (82mg), p=0.003] and at 6-12 months [-55mg (105mg ), p<0.0001] were significantly reduced; 84% and 87% of patients achieved OMEDD reduction on discharge and at 6-12 months. Patients with >90mg preoperative OMEDDs achieved greater reductions [discharge: 71% of patients, -52 mg (118 mg) p<0.0001; 6-12 months: 90% of patients, -90mg (115mg), p<0.0001]. On comparison with a pre-POPPMED surgical cohort, Postoperative Day 1-3 11-point Numerical Rating Scale (NRS-11) area under the curve (AUC) measurements at rest and on movement were not significantly different (largest NRS-11:hours AUC difference [median(IQR)] 22 [13], p= 0.24). Hospital length of stay was variably increased. Conclusions: POPPMED achieved sustained OMEDD reductions safely in an older, high-risk opioid tolerant population, with analgesia comparable to a non-POPPMED cohort, and surgery specific effects on length of stay.
Collapse
|
18
|
Liu M, Ni R, Huang S, Yang X, Lin Q, Lin P, Yang J. Efficacy of non-pharmacological interventions in pain relief and opioid consumption after cardiac surgery: A systematic review and Bayesian network meta-analysis. J Clin Nurs 2022. [PMID: 35949177 DOI: 10.1111/jocn.16482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate and rank the evidence for the efficacy of non-pharmacological interventions in relieving pain after cardiac surgery using comprehensive comparisons. BACKGROUND Although several previous systematic reviews and meta-analyses showed that non-pharmacological interventions effectively control and reduce pain after cardiac surgery, none quantitatively compared the effect of these different types of interventions. DESIGN Systematic review and Bayesian network meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analysis guidelines. METHODS Six databases were searched from inception to April 2021 to collect all published evidence from randomised clinical trials. One author extracted the relevant information from the eligible trials; a second author independently reviewed the data. Before analysing the extracted data, two investigators independently assessed the quality of the included studies. Conventional meta-analysis was conducted using either fixed- or random-effects models according to statistical heterogeneity. The Bayesian network meta-analysis was conducted using the consistency model. RESULTS We identified 42 randomised clinical trials comparing 14 groups with 4253 patients. Transcutaneous electrical nerve stimulation, acupressure, music and massage were effective for pain relief, with transcutaneous electrical nerve stimulation being associated with the best probability of successful pain relief after cardiac surgery (cumulative ranking curve surface, 0.97; probability, 77.03%). Acupressure (cumulative ranking curve surface, 0.79; probability, 30.69%) was the second-best option. However, there was no evidence that any pair-up intervention significantly reduced opioid use or anxiety. CONCLUSIONS These findings suggest that transcutaneous electrical nerve stimulation, acupressure, music and massage may effectively alleviate postoperative cardiac pain, with transcutaneous electrical nerve stimulation representing the best choice for pain relief. RELEVANCE TO CLINICAL PRACTICE The results of this network meta-analysis can guide patients after cardiac surgery and healthcare providers to make optimal decisions in managing postoperative cardiac pain. TRIAL REGISTRATION PROSPERO CRD42021246183.
Collapse
Affiliation(s)
- Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Ruping Ni
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Shunmin Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Xin Yang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Qinghua Lin
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
| | - Pengtao Lin
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jing Yang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| |
Collapse
|
19
|
Downer K, Burgan C, Kezar CE, Galgano SJ. Procedural moderate sedation in patients with opioid addiction and chronic pain: a practical primer for the radiologist. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:2717-2720. [PMID: 34390369 DOI: 10.1007/s00261-021-03242-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 01/18/2023]
Abstract
Opioid use disorder and chronic pain are increasingly commonly encountered in medicine and many patients now are prescribed medications (such as buprenorphine) to help treat these conditions. Many radiologists are unfamiliar with how these medications work and how they impact providing procedural sedation during procedures in the radiology department. The focus of this manuscript is to provide radiologists background and guidance on how these medications interact with medications given for procedural sedation and the appropriate management strategy for patients with opioid use disorder and chronic pain who require procedural sedation.
Collapse
Affiliation(s)
- Kendall Downer
- Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, 35249, USA
| | - Constantine Burgan
- Department of Radiology, University of Alabama at Birmingham, 619 19th St S, JT J779, Birmingham, AL, 35249, USA
| | - Carolyn E Kezar
- Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, 35249, USA
| | - Samuel J Galgano
- Department of Radiology, University of Alabama at Birmingham, 619 19th St S, JT J779, Birmingham, AL, 35249, USA.
| |
Collapse
|
20
|
Bierle DM, Wight EC, Ganesh R, Himes CP, Sundsted KK, Jacob AK, Mohabbat AB. Preoperative Evaluation and Management of Patients With Select Chronic Gastrointestinal, Liver, and Renal Diseases. Mayo Clin Proc 2022; 97:1380-1395. [PMID: 35787866 DOI: 10.1016/j.mayocp.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/22/2021] [Accepted: 03/29/2022] [Indexed: 11/28/2022]
Abstract
Patients with chronic gastrointestinal, hepatic, and renal disease are frequently encountered in clinical practice. This is due in part to the rising prevalence of risk factors associated with these conditions. These patients are increasingly being considered for surgical intervention and are at higher risk for multiple perioperative complications. Many are able to safely undergo surgery but require unique considerations to ensure optimal perioperative care. In this review, we highlight relevant perioperative physiology and outline our approach to the evaluation and management of patients with select chronic gastrointestinal, hepatic, and renal diseases. A comprehensive preoperative evaluation with a multidisciplinary approach is often beneficial, and specialist involvement should be considered. Intraoperative and postoperative plans should be individualized based on the unique medical and surgical characteristics of each patient.
Collapse
Affiliation(s)
- Dennis M Bierle
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Elizabeth C Wight
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carina P Himes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Karna K Sundsted
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Arya B Mohabbat
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
21
|
Meyer-Frießem CH, Lipke E, Weibel S, Kranke P, Reichl S, Pogatzki-Zahn EM, Zahn PK, Schnabel A. Perioperative ketamine for postoperative pain management in patients with preoperative opioid intake: A systematic review and meta-analysis. J Clin Anesth 2022; 78:110652. [DOI: 10.1016/j.jclinane.2022.110652] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 01/24/2023]
|
22
|
Cerne R, Lippa A, Poe MM, Smith JL, Jin X, Ping X, Golani LK, Cook JM, Witkin JM. GABAkines - Advances in the discovery, development, and commercialization of positive allosteric modulators of GABA A receptors. Pharmacol Ther 2022; 234:108035. [PMID: 34793859 PMCID: PMC9787737 DOI: 10.1016/j.pharmthera.2021.108035] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 11/08/2021] [Indexed: 12/25/2022]
Abstract
Positive allosteric modulators of γ-aminobutyric acid-A (GABAA) receptors or GABAkines have been widely used medicines for over 70 years for anxiety, epilepsy, sleep, and other disorders. Traditional GABAkines like diazepam have safety and tolerability concerns that include sedation, motor-impairment, respiratory depression, tolerance and dependence. Multiple GABAkines have entered clinical development but the issue of side-effects has not been fully solved. The compounds that are presently being developed and commercialized include several neuroactive steroids (an allopregnanolone formulation (brexanolone), an allopregnanolone prodrug (LYT-300), Sage-324, zuranolone, and ganaxolone), the α2/3-preferring GABAkine, KRM-II-81, and the α2/3/5-preferring GABAkine PF-06372865 (darigabat). The neuroactive steroids are in clinical development for post-partum depression, intractable epilepsy, tremor, status epilepticus, and genetic epilepsy disorders. Darigabat is in development for epilepsy and anxiety. The imidazodiazepine, KRM-II-81 is efficacious in animal models for the treatment of epilepsy and post-traumatic epilepsy, acute and chronic pain, as well as anxiety and depression. The efficacy of KRM-II-81 in models of pharmacoresistant epilepsy, preventing the development of seizure sensitization, and in brain tissue of intractable epileptic patients bodes well for improved therapeutics. Medicinal chemistry efforts are also ongoing to identify novel and improved GABAkines. The data document gaps in our understanding of the molecular pharmacology of GABAkines that drive differential pharmacological profiles, but emphasize advancements in the ability to successfully utilize GABAA receptor potentiation for therapeutic gain in neurology and psychiatry.
Collapse
Affiliation(s)
- Rok Cerne
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA,Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, Ljubljana, Slovenia.,RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Arnold Lippa
- RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA
| | | | - Jodi L. Smith
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA
| | - Xiaoming Jin
- Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Xingjie Ping
- Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Lalit K. Golani
- Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - James M. Cook
- RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Jeffrey M. Witkin
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA,RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| |
Collapse
|
23
|
Hargett JL, McElwain SD, McNair ME, Palokas MJ, Martin BS, Adcock DL. Virtual Reality Based Guided Meditation for Patients with Opioid Tolerance and Opioid Use Disorders. Pain Manag Nurs 2022; 23:259-264. [PMID: 35331652 DOI: 10.1016/j.pmn.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/13/2021] [Accepted: 02/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The management of acute pain in patients with pre-existing opioid tolerance or opioid use disorders presents unique challenges. In light of the concerns regarding opioid use, safe and effective alternatives to opioid medications are of increasing interest. AIMS This study was conducted to determine if the use of guided meditation delivered through immersive virtual reality can reduce pain in patients with opioid tolerance or opioid use disorders, including opioid abuse or opioid dependence. DESIGN A quasi-experimental pre-test and post-test study design was used. SETTINGS A 31-bed inpatient orthopedic/trauma unit in the southeastern United States. PARTICIPANTS/SUBJECTS Subjects of the pilot study were hospitalized adults over the age of 18 with pre-existing opioid tolerance or opioid use disorder who were experiencing acute pain. METHODS This pilot study examined the effect of a 10-minute guided meditation activity through immersive virtual reality on the reported acute pain of hospitalized adults (n = 11) with pre-existing opioid tolerance or opioid use disorders. The Calm® application on an Oculus Go® virtual reality head-mounted display was used for the meditation activity. RESULTS Before the intervention, the mean patient-reported pain rating was 6.68, and the mean pain score after the virtual reality experience was 3.36. Using the Wilcoxon signed rank test, this was a statistically significant difference (p = .003). Patients were also observed and queried regarding any significant side effects or other incidental findings, none of which were reported. CONCLUSIONS This study demonstrates that the use of guided meditation through virtual reality can result in statistically significant reductions in patient-reported pain scores.
Collapse
Affiliation(s)
- Jennifer L Hargett
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Sharon D McElwain
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mary E McNair
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michelle J Palokas
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Bradford S Martin
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Dorothy L Adcock
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| |
Collapse
|
24
|
Martins CC, Rosa SG, Zborowski VA, Rodrigues RF, Maroneze A, Nogueira CW, Zeni G. Contribution of Opioid and Nitrergic Systems to m-Trifluoromethyl diphenyl Diselenide Attenuates Morphine-Induced Tolerance in Mice. ACS Chem Neurosci 2022; 13:910-919. [PMID: 35319862 DOI: 10.1021/acschemneuro.1c00691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
m-Trifluoromethyl diphenyl diselenide (TFDD) has antinociceptive and antidepressant-like properties and attenuates morphine withdrawal signs in mice. This study investigated if TFDD affects the development of morphine tolerance to its antinociceptive and antidepressant-like effects in mice. We also investigated whether TFDD modulates signaling pathways related to morphine tolerance, including the opioid receptors and some parameters of the nitrergic system. Male adult Swiss mice received morphine alone (5 mg/kg, subcutaneous) and in combination with TFDD (10 mg/kg, intragastric) for 7 days. Mice were subjected to hot plate and forced swim tests on days 1, 3, 5, and 7 of the experimental protocol. Repeated TFDD administrations avoided tolerance development mediated by morphine, including its antinociceptive and antidepressant-like effects. A single morphine dose increased MOR and NOx but decreased iNOS contents in the mouse cerebral cortex. In turn, single morphine and TFDD co-administration restored the MOR and iNOS protein levels. On the other hand, morphine repeated doses enhanced DOR and reduced MOR and NOx contents, whereas the morphine and TFDD association reestablished DOR and NOx levels in the mouse cerebral cortex. In conclusion, some opioid and nitrergic system parameters might contribute to TFDD attenuation of antinociceptive and antidepressant-like tolerance induced by morphine in mice.
Collapse
Affiliation(s)
- Carolina C. Martins
- LASRAFTO, CCNE, Federal University of Santa Maria, Santa Maria 97105-900 Rio Grande do Sul, Brazil
| | - Suzan G. Rosa
- LASRAFTO, CCNE, Federal University of Santa Maria, Santa Maria 97105-900 Rio Grande do Sul, Brazil
| | - Vanessa A. Zborowski
- LASRAFTO, CCNE, Federal University of Santa Maria, Santa Maria 97105-900 Rio Grande do Sul, Brazil
| | - Renata F. Rodrigues
- LASRAFTO, CCNE, Federal University of Santa Maria, Santa Maria 97105-900 Rio Grande do Sul, Brazil
| | - Adriano Maroneze
- LASRAFTO, CCNE, Federal University of Santa Maria, Santa Maria 97105-900 Rio Grande do Sul, Brazil
| | - Cristina W. Nogueira
- LASRAFTO, CCNE, Federal University of Santa Maria, Santa Maria 97105-900 Rio Grande do Sul, Brazil
| | - Gilson Zeni
- LASRAFTO, CCNE, Federal University of Santa Maria, Santa Maria 97105-900 Rio Grande do Sul, Brazil
| |
Collapse
|
25
|
The imidazodiazepine, KRM-II-81: An example of a newly emerging generation of GABAkines for neurological and psychiatric disorders. Pharmacol Biochem Behav 2022; 213:173321. [PMID: 35041859 DOI: 10.1016/j.pbb.2021.173321] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023]
Abstract
GABAkines, or positive allosteric modulators of γ-aminobutyric acid-A (GABAA) receptors, are used for the treatment of anxiety, epilepsy, sleep, and other disorders. The search for improved GABAkines, with reduced safety liabilities (e.g., dependence) or side-effect profiles (e.g., sedation) constituted multiple discovery and development campaigns that involved a multitude of strategies over the past century. Due to the general lack of success in the development of new GABAkines, there had been a decades-long draught in bringing new GABAkines to market. Recently, however, there has been a resurgence of efforts to bring GABAkines to patients, the FDA approval of the neuroactive steroid brexanolone for post-partum depression in 2019 being the first. Other neuroactive steroids are in various stages of clinical development (ganaxolone, zuranolone, LYT-300, Sage-324, PRAX 114, and ETX-155). These GABAkines and non-steroid compounds (GRX-917, a TSPO binding site ligand), darigabat (CVL-865), an α2/3/5-preferring GABAkine, SAN711, an α3-preferring GABAkine, and the α2/3-preferring GABAkine, KRM-II-81, bring new therapeutic promise to this highly utilized medicinal target in neurology and psychiatry. Herein, we also discuss possible conditions that have enabled the transition to a new age of GABAkines. We highlight the pharmacology of KRM-II-81 that has the most preclinical data reported. KRM-II-81 is the lead compound in a new series of orally bioavailable imidazodiazepines entering IND-enabling safety studies. KRM-II-81 has a preclinical profile predicting efficacy against pharmacoresistant epilepsies, traumatic brain injury, and neuropathic pain. KRM-II-81 also produces anxiolytic- and antidepressant-like effects in rodent models. Other key features of the pharmacology of this compound are its low sedation rate, lack of tolerance development, and the ability to prevent the development of seizure sensitization.
Collapse
|
26
|
Compton P, Aronowitz SV, Klusaritz H, Anderson E. Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study. Harm Reduct J 2021; 18:131. [PMID: 34915913 PMCID: PMC8679978 DOI: 10.1186/s12954-021-00581-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background Patients with substance use disorders are more likely than those without to have a self-directed hospital discharge, putting them at risk for poor health outcomes including progressing illness, readmissions, and death. Inadequate pain management has been identified as a potential motivator of self-directed discharge in this patient population. The objective of this study was to describe the association between acute pain and self-directed discharges among persons with opioid-related conditions; the presence of chronic pain in self-directed discharges was likewise considered. Methods We employed a large database of all hospitalizations at acute care hospitals during 2017 in the city of Philadelphia to identify adults with opioid-related conditions and compare the characteristics of admissions ending with routine discharge versus those ending in self-directed discharge. We examined all adult discharges with an ICD-10 diagnoses related to opioid use or poisoning and inspected the diagnostic data to systematically identify acute pain for the listed primary diagnosis and explore patterning in chronic pain diagnoses with respect to discharge outcomes. Results Sixteen percent of the 7972 admissions involving opioid-related conditions culminated in self-directed discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to complete a self-directed discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge. Conclusions These findings underscore the importance of pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain. Supplementary Information The online version contains supplementary material available at 10.1186/s12954-021-00581-6.
Collapse
Affiliation(s)
- Peggy Compton
- School of Nursing, University of Pennsylvania, Claire Fagin Hall, Room 402, 418 Curie Blvd, Philadelphia, PA, 19104, USA.
| | - Shoshana V Aronowitz
- School of Nursing, University of Pennsylvania, Claire Fagin Hall, Room 402, 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Heather Klusaritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Evan Anderson
- School of Nursing, University of Pennsylvania, Claire Fagin Hall, Room 402, 418 Curie Blvd, Philadelphia, PA, 19104, USA
| |
Collapse
|
27
|
Shah AA, Shah AA. Minimizing the Risk of Opioid Misuse and Abuse in the Surgical Setting. Orthopedics 2021; 44:353-359. [PMID: 34618639 DOI: 10.3928/01477447-20211001-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The misuse of opioids continues to be a public health problem. Acute post-surgical pain management requires a careful balance between the benefits and risks of opioids. Opioids should be part of a multimodal treatment plan, including the use of nonopioid and nonpharmacologic treatment options. Multimodal pain management allows for individualized treatment and improved patient satisfaction while limiting the risks inherent to opioids, including diversion. Surgeons should avoid overprescribing opioids and have a plan for decreasing the use of opioids in the postsurgical time frame. With careful consideration of the risks, opioids can be prescribed to treat acute postsurgical pain effectively. [Orthopedics. 2021;44(6):353-359.].
Collapse
|
28
|
Gonzalez M, Sanders-Jackson A. Traditional Cigarette and Poly-Tobacco Use Are Associated with Medical Opioid Use in Rural Areas of the US. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182211864. [PMID: 34831619 PMCID: PMC8619274 DOI: 10.3390/ijerph182211864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 11/16/2022]
Abstract
Introduction: Medical prescriptions for opioids are higher in rural areas of the US as compared to urban areas. Tobacco use may also play a role in this process. This analysis examines the association between differing types of tobacco use and medical opioid use. Methods: We analyze the relationship between tobacco product use and medical opioid use among the US general population living in rural (non-metropolitan) areas using the publicly available sample adult file 2019 National Health Interview Survey (NHIS) (n = 5028). Tobacco use was classified into the following categories: only using cigarettes, only using e-cigarettes/vapes, only using cigars, only using smokeless tobacco, or using two or more of the following products. We used a binary logistic regression, controlling for individual differences. Results: Individuals who reported using only traditional cigarettes (and no other tobacco product, OR = 1.62, 95% CI: 1.31, 2.01), or who reported being a poly-tobacco users (OR = 2.13, 95% CI: 1.40, 3.22) had higher odds of medical opioid use in the last twelve months. Conclusion: Results suggest a link between tobacco use, particularly cigarette use and poly-tobacco use, and medical opioid use in rural communities. Clinical and structural level interventions need to be implemented in rural communities to reduce comorbid tobacco and opioid use.
Collapse
Affiliation(s)
- Mariaelena Gonzalez
- Department of Public Health, School of Social Sciences Humanities and the Arts, University of California Merced, Merced, CA 95343, USA
- Nicotine and Cannabis Policy Center, University of California Merced, Merced, CA 95343, USA
- Correspondence:
| | - Ashley Sanders-Jackson
- Department of Advertising and Public Relations, College of Communications Arts and Sciences, Michigan State University, East Lansing, MI 48824, USA;
| |
Collapse
|
29
|
Daliya P, Adiamah A, Roslan F, Theophilidou E, Knaggs RD, Levy N, Lobo DN. Opioid prescription at postoperative discharge: a retrospective observational cohort study. Anaesthesia 2021; 76:1367-1376. [PMID: 33768532 DOI: 10.1111/anae.15460] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/31/2022]
Abstract
Opioid misuse is now considered a major public health epidemic in North America, with substantial social and financial consequences. As well as socio-economic and commercial drivers, modifiable risk-factors that have resulted in this crisis have been identified. The purpose of this study was to identify whether, within England, modifiable drivers for persistent postoperative opioid use were present. This was a retrospective cohort study of practice at 14 National Health Service hospitals across England. Data were collected retrospectively and validated for adult patients undergoing elective intermediate and major or complex major general surgical procedures between 1 and 31 March 2019. Of the 509 patients enrolled from 14 centres, 499 were included in the data analysis. In total, 31.5% (157/499) patients were in the intermediate surgery cohort and 68.5% (342/499) were in the major or complex major surgery cohort, with 21.0% (33/157) and 21.6% (74/342) discharged with opioid medicines to be taken at regular intervals, respectively. There were similar median oral morphine equivalent doses prescribed at discharge. Of patients prescribed regular opioid medicines, 76.6% (82/107) had a specified duration at discharge. However, 72.9% (78/107) had no written deprescribing advice on discharge. Similarly, of patients prescribed 'when required' opioids, 59.6% (93/156) had a specified duration of their prescription and 33.3% (52/156) were given written deprescribing advice. This study has identified a pattern of poor prescribing practices, a lack of guidance and formal training at individual institutions and highlights opportunities for improvement in opioid-prescribing practices within England.
Collapse
Affiliation(s)
- P Daliya
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - A Adiamah
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - F Roslan
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - E Theophilidou
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - R D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk Hospital, Bury St. Edmunds, UK
| | - D N Lobo
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| |
Collapse
|
30
|
Osani MC, Lohmander LS, Bannuru RR. Is There Any Role for Opioids in the Management of Knee and Hip Osteoarthritis? A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken) 2021; 73:1413-1424. [PMID: 32583972 PMCID: PMC7759583 DOI: 10.1002/acr.24363] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/16/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Opioids have long been prescribed for chronic pain conditions, including osteoarthritis (OA). However, there is little information about their temporal efficacy, or differences in efficacy and safety between opioids with strong versus weak/intermediate μ opioid receptor-binding affinity. To explore these research questions, we conducted a systematic review and meta-analyses of randomized controlled trials (RCTs) conducted in patients with knee and/or hip OA. METHODS We searched Medline, Embase, PubMed Central, and the Cochrane Central Register of Controlled Trials from inception to December 2019 and sought unpublished data. Placebo-controlled RCTs of oral opioids in patients with knee and/or hip OA were included. Standardized mean differences (SMDs) were calculated for pain and function at 2, 4, 8, and 12 weeks. Subgroup analyses for strong and weak/intermediate opioids were conducted. Meta-regression was performed to assess the impact of dosage (morphine equivalency) on pain relief. Risk ratios were calculated for safety at the final follow-up. RESULTS A total of 18 RCTs (9,283 participants) were included. Opioids demonstrated small benefits on pain at each time point, with SMDs ranging from -0.28 (95% confidence interval [95% CI] -0.38, -0.17) to -0.19 (95% CI -0.29, -0.08); similar effects were observed for function. Strong opioids demonstrated consistently inferior efficacy and overall worse safety than weak/intermediate opioids. Meta-regression revealed that incremental pain relief achieved beyond 20-50-mg doses was not substantial in the context of increased safety risks. CONCLUSION Opioids provide minimal relief of OA symptoms within a 12-week period, and they are known to cause discomfort in a majority of patients. Clinicians and policy makers should reconsider the utility of opioids in the management of OA.
Collapse
Affiliation(s)
- Mikala C. Osani
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Allergy, and Immunology, Tufts Medical Center, Boston, MA
| | | | - Raveendhara R. Bannuru
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Allergy, and Immunology, Tufts Medical Center, Boston, MA
| |
Collapse
|
31
|
Mariano ER, Dickerson DM, Szokol JW, Harned M, Mueller JT, Philip BK, Baratta JL, Gulur P, Robles J, Schroeder KM, Wyatt KEK, Schwalb JM, Schwenk ES, Wardhan R, Kim TS, Higdon KK, Krishnan DG, Shilling AM, Schwartz G, Wiechmann L, Doan LV, Elkassabany NM, Yang SC, Muse IO, Eloy JD, Mehta V, Shah S, Johnson RL, Englesbe MJ, Kallen A, Mukkamala SB, Walton A, Buvanendran A. A multisociety organizational consensus process to define guiding principles for acute perioperative pain management. Reg Anesth Pain Med 2021; 47:118-127. [PMID: 34552003 DOI: 10.1136/rapm-2021-103083] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/09/2021] [Indexed: 12/22/2022]
Abstract
The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.
Collapse
Affiliation(s)
- Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA .,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA.,Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Beverly K Philip
- American Society of Anesthesiologists, Schaumburg, Illinois, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Robles
- Department of Urology, Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Kristopher M Schroeder
- Department of Anesthesiology, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richa Wardhan
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Todd S Kim
- Department of Orthopedic Surgery, Palo Alto Medical Foundation, Burlingame, California, USA
| | - Kent K Higdon
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.,Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Gary Schwartz
- AABP Integrative Pain Care, Brooklyn, New York, USA.,Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Stephen C Yang
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Vikas Mehta
- Department of Otolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California Irvine School of Medicine, Orange, California, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amanda Kallen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
32
|
Abstract
OBJECTIVES We performed a descriptive analysis of patient and treatment characteristics in premature discharges "against medical advice" (AMA) in a cohort of patients with opioid-related hospitalizations. METHODS We abstracted data from 1152 opioid related hospitalizations of 928 adult patients in a large academic health system. Using electronic health record data, hospitalizations were categorized as AMA or conventional discharge (CD). To determine differences between AMA and CD regarding treatment characteristics, Fisher exact test, t tests, ANOVA, and logistic regression were performed. RESULTS 74 / 1152 (6%) of opioid-related hospitalizations were discharged AMA. Hospitalizations that resulted in AMA discharge had shorter median length of stay (AMA vs CD 3.5 vs 5.5 days, P < 0.001) and received fewer of any type of opioid agonist treatment (AMA vs CD 73% vs 84%, P = 0.03). Although the number of hospitalizations in which methadone was administered did not differ between the AMA and CD groups, hospitalizations that resulted in AMA had more dose reductions and lesser quantities of methadone overall before discharge. Buprenorphine use was low overall in AMA and CD (0% and 2.1%, respectively). CONCLUSION In this sample of opioid related hospitalizations, admissions that resulted in AMA discharge had fewer opioid agonist administrations and lower methadone dosing. These findings support efforts to initiate opioid agonist therapy during hospital admissions, and further studies should determine whether this practice mitigates AMA discharges.
Collapse
|
33
|
Ferrell JK, Shindo ML, Stack BC, Angelos P, Bloom G, Chen AY, Davies L, Irish JC, Kroeker T, McCammon SD, Meltzer C, Orloff LA, Panwar A, Shin JJ, Sinclair CF, Singer MC, Wang TV, Randolph GW. Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement. Head Neck 2021; 43:2281-2294. [PMID: 34080732 DOI: 10.1002/hed.26774] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 05/24/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking. METHODS An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements. CONCLUSIONS This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.
Collapse
Affiliation(s)
- Jay K Ferrell
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Maisie L Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Peter Angelos
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Gary Bloom
- Thyroid Cancer Survivors' Association (ThyCa), Olney, Maryland, USA
| | - Amy Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Louise Davies
- Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Susan D McCammon
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, Alabama, USA
| | - Charles Meltzer
- Department of Head and Neck Surgery, Kaiser Permanente Northern California, Santa Rosa, California, USA
| | - Lisa A Orloff
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Aru Panwar
- Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine F Sinclair
- Department of Otolaryngology Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, USA
| | - Michael C Singer
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Tiffany V Wang
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W Randolph
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
34
|
O'Rourke MJ, Keshock MC, Boxhorn CE, Correll DJ, O'Glasser AY, Gazelka HM, Urman RD, Mauck K. Preoperative Management of Opioid and Nonopioid Analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2021; 96:1325-1341. [PMID: 33618850 DOI: 10.1016/j.mayocp.2020.06.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/15/2020] [Accepted: 06/29/2020] [Indexed: 01/31/2023]
Abstract
There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.
Collapse
Affiliation(s)
- Michael J O'Rourke
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL; Department of Anesthesia, Edward Hines Jr Veteran Affairs Hospital, Hines, IL.
| | - Maureen C Keshock
- Department of Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH
| | - Christine E Boxhorn
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Boston, MA
| | - Darin J Correll
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Avital Y O'Glasser
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Halena M Gazelka
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
35
|
Ahmadi-Soleimani SM, Azizi H, Abbasi-Mazar A. Intermittent REM sleep deprivation attenuates the development of morphine tolerance and dependence in male rats. Neurosci Lett 2021; 748:135735. [PMID: 33592307 DOI: 10.1016/j.neulet.2021.135735] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 02/04/2023]
Abstract
Opioid agonists are used in clinic for pain management, however this application is challenged by development of tolerance and dependence following prolonged exposure. Various approaches have been suggested to address this concern, however, there is still no consensus among the researchers. Neural processing of sleep and nociception are co-regulated through shared brain regions having bidirectional interplays. Thus, we aimed to investigate whether application of REM sleep deprivation (REM-SD) could affect morphine analgesic tolerance and dependence. To this end, adult male rats underwent sleep deprivation during light and dark phases (LSD and DSD, respectively) using the inverted flower pot method and then tolerance and dependence was induced by repeated injection of morphine for 7 days (10 mg/kg, daily, i.p.). Results indicated that REM-SD delays the development of tolerance to morphine during both phases; however this effect was more potent following LSD. Moreover, LSD decreased the baseline thermal threshold and total withdrawal score. One possible hypothesis for our observations is REM-SD-induced attenuation of orexin system which is still controversial among the researchers. Other stronger possibilities might be down-regulation of opioid receptors in response to sleep loss experience. Finally, it seems that modification of sleep periods may assist to decrease the severity of opioid tolerance and dependence.
Collapse
Affiliation(s)
- S Mohammad Ahmadi-Soleimani
- Deparment of Physiology, School of Paramedical Sciences, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran; Neuroscience Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
| | - Hossein Azizi
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Alireza Abbasi-Mazar
- Student Research Committee, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| |
Collapse
|
36
|
Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
Collapse
Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| |
Collapse
|
37
|
Guillou Landreat M, Baillot M, Le Goff D, Le Reste JY. Acute pain management among patients with opioid maintenance therapy: specificities and difficulties identified in primary care: a qualitative study. BMJ Open 2021; 11:e044433. [PMID: 33468504 PMCID: PMC7817820 DOI: 10.1136/bmjopen-2020-044433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES In the last 30 years, opioid maintenance treatment prescription (OMT) has changed patients' and also changed physicians' practices. General practitioners (GPs) have to deal with patients on OMT who are in acute pain. The objective of this qualitative study was to explore medical care challenges and solutions identified by GPs in the management of acute pain among patients receiving OMT. DESIGN AND SETTING Qualitative study with semistructured interviews were used as a data collection technique with a sampling strategy using a snowball sampling method to obtain a purposive sample of practicing GPs. Analysis was undertaken using a thematic analysis method. PARTICIPANTS Twelve GPs, working in France (Brittany) who prescribe OMT were interviewed. RESULTS The thematic analysis resulted in two main themes relating to specificities and difficulties identified: (1) Medical care and training challenges identified by GPs treating patients on OMT with acute pain, with four subthemes : management of these situations not concerning primary care, lack of training prompts GPs to rely on peer and specialist support, lack of guidelines and conflicting recommendations between clinicians in different settings (2) linked to the patient-GP relationship, with six subthemes: Implementing an individualised centred approach, acute pain management during OMT relies on a relationship based on trust, GPs found difficulties in evaluating and treating pain, difficulties in care adherence, fear of patients destabilisation, fear of misuse and diversion. CONCLUSION The complexity of acute pain and OMT entails significant challenges for clinicians and patients. In primary care, it is hard to achieve a balance between pain relief and opioid use disorder treatment, in a global patient-centred approach. Fear of misuse or diversion was not a important factor, except for patients not known to the practitioners, but GPs were concerned with the risks of patient destabilisation in situations of acute pain.
Collapse
Affiliation(s)
- Morgane Guillou Landreat
- EA SPURBO, Universite de Bretagne Occidentale, Brest, France
- addictologie, CHRU de Brest, Brest, France
| | | | | | | |
Collapse
|
38
|
Management of Acute Pain Due to Traumatic Injury in Patients with Chronic Pain and Pre-injury Opioid Use. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
39
|
Mazer LS, Lovett PJ, Miller JM, Pitruzzello NE, Boone MK, Irizarry Alvarado JM. Improving satisfaction with postoperative pain management for patients with persistent pain: a preoperative pain medicine consultation intervention. J Perioper Pract 2020; 30:345-351. [PMID: 31694473 DOI: 10.1177/1750458919886720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Preoperative pain medicine consultations with opioid-tolerant patients allow for an accurate medication history, patient involvement in the postoperative plan, and realistic goal setting. The purpose of this quality improvement project was to increase attendance at preoperative pain consultations, thereby increasing patient satisfaction. METHODS Retrospective chart reviews identified patients who had a preoperative pain consultation ordered from May through July 2016. Patient interviews determined reasons for not attending appointments, involvement in goal setting, engagement in pain management planning, and satisfaction with postoperative pain management. RESULTS Retrospective chart reviews and interviews were conducted after the intervention (May-July 2017). Scheduling changes increased attendance at preoperative pain consultations by 14 percentage points (50% vs 64%). Those who attended consultations were more involved in goal setting and decisions and were more satisfied. CONCLUSIONS Preoperative pain consultations with opioid-tolerant patients can increase satisfaction through realistic goal setting and involvement in the pain management plan.
Collapse
Affiliation(s)
- Laura S Mazer
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic, Jacksonville, FL, USA
| | - Pamela J Lovett
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic, Jacksonville, FL, USA
| | - Joanne M Miller
- Department of Adult Health and Gerontological Nursing Rush University, Chicago, IL, USA
| | - Nancy E Pitruzzello
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic, Jacksonville, FL, USA
| | | | | |
Collapse
|
40
|
Biggerstaff A, Kivell B, Smith JL, Mian MY, Golani LK, Rashid F, Sharmin D, Knutson DE, Cerne R, Cook JM, Witkin JM. The α2,3-selective potentiators of GABA A receptors, KRM-II-81 and MP-III-80, produce anxiolytic-like effects and block chemotherapy-induced hyperalgesia in mice without tolerance development. Pharmacol Biochem Behav 2020; 196:172996. [PMID: 32668266 DOI: 10.1016/j.pbb.2020.172996] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022]
Abstract
Opiate analgesics are one of the treatment options for severe chronic pain, including late-stage cancer, chronic back pain and other disorders. The recent resurgence in opioid overdose has highlighted the serious need for alternative medicines for pain management. While a role for potentiators of α2/3-containing GABAA receptors in the modulation of pain has been known for several years, advancements in this area required data from selective compounds. KRM-II-81(5-(8-ethynyl-6-(pyridin-2-yl)-4H-benzo[f]imidazo[1,5-a][1,4]diazepin-3- yl)oxazole) and analogs selectively potentiate GABAA receptors containing α2/3 subunits and have recently been shown to attenuate pain behaviors in several acute and chronic pain models in rodents. The present study was designed to ascertain whether KRM-II-81 and the structural analog MP-III-80 (3-ethyl-5-(8-ethynyl-6-(pyridin-2-yl)-4H-benzo[f]imidazo[1,5-a][1,4]diazepin-3-yl)-1,2,4-oxadiazole) would block chemotherapeutic agent paclitaxel-induced pain in male, C57BL/6 mice. Both compounds significantly inhibited pain behaviors evoked by cold and tactile stimulation in paclitaxel-treated mice as did the neuropathic pain drug gabapentin. Subchronic dosing for 22 days with KRM-II-81 and MP-III-80 demonstrated enduring analgesic efficacy without tolerance development, while the effects of gabapentin showed evidence of tolerance development. KRM-II-81 and MP-III-80 also decreased marble-burying behavior in this mouse strain as did the anxiolytic drug chlordiazepoxide. In contrast to KRM-II-81 and MP-III-80, chlordiazepoxide had motor-impairing effects at anxiolytic-like doses. The data add to the literature documenting that these selective potentiators of α2/3-containing GABAA receptors are effective in a host of animal models used to detect novel analgesic drugs. The anxiolytic-like efficacy of these compounds fits well with the comorbidity of anxiety in patients with chronic pain and cancer.
Collapse
Affiliation(s)
- A Biggerstaff
- School of Biological Sciences, Centre for Biodiscovery, Victoria University of Wellington, Wellington, New Zealand
| | - B Kivell
- School of Biological Sciences, Centre for Biodiscovery, Victoria University of Wellington, Wellington, New Zealand
| | - J L Smith
- Laboratory of Antiepileptic Drug Discovery, Peyton Manning Hospital for Children, Ascension St. Vincent, Indianapolis, IN, USA
| | - Md Y Mian
- Department of Chemistry & Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - L K Golani
- Department of Chemistry & Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - F Rashid
- Department of Chemistry & Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - D Sharmin
- Department of Chemistry & Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - D E Knutson
- Department of Chemistry & Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - R Cerne
- Laboratory of Antiepileptic Drug Discovery, Peyton Manning Hospital for Children, Ascension St. Vincent, Indianapolis, IN, USA; Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, Ljubljana, Slovenia
| | - J M Cook
- Department of Chemistry & Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - J M Witkin
- Laboratory of Antiepileptic Drug Discovery, Peyton Manning Hospital for Children, Ascension St. Vincent, Indianapolis, IN, USA; Department of Chemistry & Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA; Departments of Neuroscience and Trauma Research, Ascension St. Vincent Hospital, Indianapolis, IN, USA.
| |
Collapse
|
41
|
Quaye ANA, Zhang Y. Perioperative Management of Buprenorphine: Solving the Conundrum. PAIN MEDICINE 2020; 20:1395-1408. [PMID: 30500943 DOI: 10.1093/pm/pny217] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE There is no consensus on the optimal perioperative management of patients on buprenorphine (BUP) for opioid use disorder (OUD). This article will review the available literature on BUP and the analgesic efficacy of BUP combined with full mu-opioid agonists and discuss the conflicting management strategies in the context of acute pain and our institution's protocol for the periprocedural management of BUP. METHODS We searched published data on BUP periprocedural management from inception through March 2018 without language restrictions. Study selection included publications reporting outcomes on perioperative pain management in OUD patients maintained on BUP. RESULTS Our search resulted in four case reports supporting periprocedural discontinuation of BUP and two case series, one secondary observational study, one prospective matched cohort study, and four retrospective cohort studies supporting periprocedural continuation of BUP. No clinical trials were identified. CONCLUSIONS Maintaining BUP perioperatively does not lead to worsened clinical outcomes. Patients can receive adequate pain control from mu-opioid agonists while maintained on BUP. Based upon available evidence, we recommend continuing BUP at a reduced dose when indicated to avoid withdrawal symptoms and to facilitate the analgesic efficacy of mu-opioid agonists administered in combination for acute postoperative pain.
Collapse
Affiliation(s)
- Aurora Naa-Afoley Quaye
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi Zhang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
42
|
Abstract
BACKGROUND The purpose of this study was to compare narcotic use in the 90-day postoperative period across orthopaedic trauma, spine, and adult reconstruction patients and examine whether patient-reported pain scores at discharge correlate with narcotic use during the 90-day postoperative period. METHODS Electronic medical record query was done between 2012 and 2015 using diagnosis-related groups for spine, adult reconstruction, and trauma procedures. Demographics, length of stay (LOS), visual analog scale pain scores during hospitalization, and narcotics prescribed in the 90-day postoperative period were collected. Multivariate analysis and linear regression were done. RESULTS Five thousand thirty patients were analyzed. Spine patients had the longest LOS, highest mean pain during LOS, and were prescribed the most morphine in the 90-day postoperative period. Linear regression revealed that pain scores at discharge markedly influence the quantity of narcotics prescribed in the 90-day postoperative period. DISCUSSION Patient-reported pain at hospital discharge was associated with increased narcotic use in the 90-day postoperative period.
Collapse
|
43
|
|
44
|
Pain management in trauma patients affected by the opioid epidemic: A narrative review. J Trauma Acute Care Surg 2020; 87:430-439. [PMID: 30939572 DOI: 10.1097/ta.0000000000002292] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.
Collapse
|
45
|
Small C, Laycock H. Acute postoperative pain management. Br J Surg 2020; 107:e70-e80. [DOI: 10.1002/bjs.11477] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/22/2019] [Indexed: 12/16/2022]
Abstract
AbstractBackgroundAcute postoperative pain is common. Nearly 20 per cent of patients experience severe pain in the first 24 h after surgery, a figure that has remained largely unchanged in the past 30 years. This review aims to present key considerations for postoperative pain management.MethodsA narrative review of postoperative pain strategies was undertaken. Searches of the Cochrane Library, PubMed and Google Scholar databases were performed using the terms postoperative care, psychological factor, pain management, acute pain service, analgesia, acute pain and pain assessment.ResultsInformation on service provision, preoperative planning, pain assessment, and pharmacological and non-pharmacological strategies relevant to acute postoperative pain management in adults is presented, with a focus on enhanced recovery after surgery pathways.ConclusionAdequate perioperative pain management is integral to patient care and outcomes. Each of the biological, psychological and social dimensions of the pain experience should be considered and understood in order to provide optimum pain management in the postoperative setting.
Collapse
Affiliation(s)
- C Small
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - H Laycock
- Department of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| |
Collapse
|
46
|
Compton P. Acute Pain Management for Patients Receiving Medication-Assisted Therapy. AACN Adv Crit Care 2019; 30:335-342. [DOI: 10.4037/aacnacc2019328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Evidence-based approaches for the treatment of opioid use disorder include the use of opioid medications (methadone, buprenorphine, or naltrexone), collectively referred to as medication-assisted therapy. Patients receiving medication-assisted therapy may present in the acute care setting with pain, often related to planned surgical procedures to treat health issues that were not addressed before entering treatment. Because these medications act on the same receptors as do analgesic opioids—and, in the cases of methadone and buprenorphine, have analgesic properties — managing acute pain in these patients can be challenging. Principles of effective pain management for these patients include continuing the usual medication-assisted therapy dose; using nonpharmacological and nonopioid pain management strategies as possible and immediate-release opioids, titrating to effect and monitoring for toxicity; anticipating tolerance and hyperalgesia; and establishing a collaborative treatment relationship with the medication-assisted therapy provider. Providing effective pain treatment supports ongoing recovery in patients with opioid use disorder.
Collapse
Affiliation(s)
- Peggy Compton
- Peggy Compton is Associate Professor, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Room 402, Philadelphia, PA 19104
| |
Collapse
|
47
|
Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs 2019; 80:9-21. [DOI: 10.1007/s40265-019-01236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
48
|
Pawasauskas J, Kelley M, Gill C, Facente M. Comparison of multimodal, sliding scale acute pain protocols with traditional prescribing in non-surgical patients. Postgrad Med 2019; 132:37-43. [DOI: 10.1080/00325481.2019.1672374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jayne Pawasauskas
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston, RI, USA
- Kent Hospital, Warwick, Rhode Island, USA
| | | | - Christian Gill
- PGY-2 Pharmacy Resident, Henry Ford Hospital, Detroit, MI, USA
| | | |
Collapse
|
49
|
Effects of ascending buprenorphine doses on measures of experimental pain: A pilot study. J Subst Abuse Treat 2019; 104:128-134. [DOI: 10.1016/j.jsat.2019.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/25/2019] [Accepted: 07/09/2019] [Indexed: 01/26/2023]
|
50
|
Athanasos P, Ling W, Bochner F, White JM, Somogyi AA. Buprenorphine Maintenance Subjects Are Hyperalgesic and Have No Antinociceptive Response to a Very High Morphine Dose. PAIN MEDICINE 2019. [PMID: 29514333 DOI: 10.1093/pm/pny025] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Acute pain management in opioid-dependent persons is complicated because of tolerance and opioid-induced hyperalgesia. Very high doses of morphine are ineffective in overcoming opioid-induced hyperalgesia and providing antinociception to methadone-maintained patients in an experimental setting. Whether the same occurs in buprenorphine-maintained subjects is unknown. Design Randomized double-blind placebo-controlled. Subjects were tested on two occasions, at least five days apart, once with intravenous morphine and once with intravenous saline. Subjects were tested at about the time of putative trough plasma buprenorphine concentrations. Setting Ambulatory. Subjects Twelve buprenorphine-maintained subjects: once daily sublingual dose (range = 2-22 mg); no dose change for 1.5-12 months. Ten healthy controls. Methods Intravenous morphine bolus and infusions administered over two hours to achieve two separate pseudo-steady-state plasma concentrations one hour apart. Pain tolerance was assessed by application of nociceptive stimuli (cold pressor [seconds] and electrical stimulation [volts]). Ten blood samples were collected for assay of plasma morphine, buprenorphine, and norbuprenorphine concentrations until three hours after the end of the last infusion; pain tolerance and respiration rate were measured to coincide with blood sampling times. Results Cold pressor responses (seconds): baseline: control 34 ± 6 vs buprenorphine 17 ± 2 (P = 0.009); morphine infusion-end: control 52 ± 11(P = 0.04), buprenorphine 17 ± 2 (P > 0.5); electrical stimulation responses (volts): baseline: control 65 ± 6 vs buprenorphine 53 ± 5 (P = 0.13); infusion-end: control 74 ± 5 (P = 0.007), buprenorphine 53 ± 5 (P > 0.98). Respiratory rate (breaths per minute): baseline: control 17 vs buprenorphine 14 (P = 0.03); infusion-end: control 15 (P = 0.09), buprenorphine 12 (P < 0.01). Infusion-end plasma morphine concentrations (ng/mL): control 23 ± 1, buprenorphine 136 ± 10. Conclusions Buprenorphine subjects, compared with controls, were hyperalgesic (cold pressor test), did not experience antinociception, despite high plasma morphine concentrations, and experienced respiratory depression. Clinical implications are discussed.
Collapse
Affiliation(s)
- Peter Athanasos
- Discipline of Psychiatry, Flinders University, Bedford Park, Australia
| | - Walter Ling
- Integrated Substance Abuse Programs, University of California, Los Angeles, California, USA
| | - Felix Bochner
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jason M White
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, Australia
| |
Collapse
|