Opioid prescriptions for pain and epidemic of overdose death: can the dramatic reduction in anesthesia mortality serve as an example?

Developing Improved Translational Models of Pain: A Role for the Behavioral Scientist

The effective management of pain is a longstanding public health concern. Although opioids have been frontline analgesics for decades, they also have well-known undesirable effects that limit their clinical utility, such as abuse liability and respiratory depression. The failure to develop better analgesics has, in some ways, contributed to the escalating opioid epidemic that has claimed tens of thousands of lives and has cost hundreds of billions of dollars in health-care expenses. A paradigm shift is needed in the pharmacotherapy of pain management that will require extensive efforts throughout biomedical science. The purpose of the present review is to highlight the critical role of the behavioral scientist to devise improved translational models of pain for drug development. Despite high heterogeneity of painful conditions that involve cortical-dependent pain processing, current models often feature an overreliance on simple reflex-based measures and an emphasis on the absence, rather than presence, of behavior as evidence of analgesic efficacy. Novel approaches should focus on the restoration of operant and other CNS-mediated behavior under painful conditions.

Who is Overdosing? An Updated Picture of Overdose Deaths From 2008 to 2015

PURPOSE

To determine the role of opioids in drug overdose deaths in Allen County, Indiana between January 1, 2008, and December 31, 2015.

METHODS

File review of 418 overdose deaths was performed using Indiana State Department of Health death certificates available through the Allen County Coroner's Office. Data from autopsy and toxicology reports and coroner-requested prescribing data from Indiana's Prescription Monitoring Program were reviewed. Cause of death and available data were analyzed to identify patterns and trends related to overdose deaths.

RESULTS

Four hundred eighteen drug overdose deaths were identified (336 accidental, 66 intentional, and 16 undetermined). Mean age was 42.5 years, 88.5% were Caucasian, and 68.7% were employed. The majority of deaths occurred at a place of residence (71.4%) and with other people present (57.5% of the time). Depression was the most common comorbidity identified. The most common drug classes identified by toxicology were opioids, followed by benzodiazepines. Significant increases in both heroin (35% of deaths in 2015 versus 8.2% in 2013) and fentanyl (30% of deaths in 2015 versus 2.2% in 2011) were observed.

CONCLUSIONS

Drug overdose continues to be a significant cause of death in Allen County. The majority of deaths were accidental and in relatively young, employed individuals. Prevention and awareness strategies should be encouraged, given that the majority of overdose deaths occurred at a place of residence with other people frequently present. Additional concerns about patterns of drug use were confirmed with marked increases in both heroin and fentanyl contributing to overdose deaths in the latter part of the study.

Transitioning to an Intramedullary Lengthening and Compression Nail

The magnetic intramedullary lengthening nail is an innovative technology that allows for creative ways to treat difficult problems. The lengthening option has revolutionized femur fracture management with bone loss and malunion therapy. The compression version of this nail has provided a gradual method to compress nonunions and difficult fractures that may obviate the need for many current uses of external fixation. Three cases are presented in this manuscript demonstrating a new paradigm in the management of bone loss/shortening of the tibia and femur, and recalcitrant nonunions.

Association of sleep disordered breathing symptoms with early postoperative analgesic requirement in pediatric ambulatory surgical patients

INTRODUCTION

Sleep disordered breathing (SDB) symptoms are associated with increased rates of opioid-induced respiratory depression as well as enhanced nociception. Consequently, practitioners often withhold or administer lower intraoperative doses of opioids out of concern for postoperative respiratory depression. Therefore, SDB may be a critical determinant of analgesic requirement in the post-anesthesia care unit (PACU). We investigated whether preoperative SDB classification was independently associated with need for PACU analgesic intervention in a cross-sectional sample of 985 children who underwent elective, painful ambulatory surgical procedures.

METHODS

Using prospectively collected data, children aged 4-17yr were grouped into two categories based on whether or not they had symptoms of SDB. Perioperative variables were compared between the exposed and control groups using Chi-squared test for categorical or t-test for continuous variables. Logistic regression analysis was used to assess the association between SDB and the odds of requiring PACU IV opioids.

RESULTS

Children with preoperative SDB symptoms (N = 325) compared with the reference group of children who did not have these symptoms had higher rates of PACU analgesic intervention (47.1% vs. 37.4%; p = 0.004) and higher mean arousal pain scores (3.7 ± 3.5 vs.1.9 ± 2.9; p < 0.001). In our primary multivariable logistic regression model adjusted for a number of variables, preoperative SDB symptoms was associated with a two-fold increased odds of receiving PACU intravenous opioid (OR = 2.01, 95%CI, 1.29-3.12; p = 0.002).

CONCLUSION

These results suggest that preoperative SDB symptoms in children undergoing ambulatory surgery, exerts a significant influence on PACU pain behavior and analgesic requirement. Mechanisms underlying this enhanced pain experience deserve further elucidation.