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Borg SJ, Cameron CM, Luetsch K, Rolley A, Geraghty T, McPhail S, McCreanor V. Prevalence of opioid use in adults with spinal cord injury: A systematic review and meta-analysis. J Spinal Cord Med 2024:1-19. [PMID: 38466869 DOI: 10.1080/10790268.2024.2319384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
OBJECTIVE To determine the prevalence, reported harms and factors associated with opioid use among adults with spinal cord injury (SCI) living in the community. STUDY DESIGN Systematic review and meta-analysis. METHODS Comprehensive literature searches were conducted in PubMed (MEDLINE), EMBASE, CINAHL, Web of Science and Scopus for articles published between 2000 and 2023. Risk of bias was assessed using a prevalence-specific tool. Random-effects meta-analyses were conducted to pool prevalence data for any context of opioids. Sensitivity and subgroup analyses were also performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study protocol was registered via Prospero (CRD42022350768). RESULTS Of the 4969 potential studies, 38 were included in the review. Fifty-three percent of studies had a low risk of bias, with a high risk of bias in 5% of studies. The pooled prevalence for the 38 studies included in the meta-analysis (total cohort size of 50,473) across any opioid context was 39% (95% confidence interval [CI], 32-47). High heterogeneity was evident, with a prediction interval twice as wide as the 95% CI (prediction interval, 7-84%). Mean or median opioid dose was unreported in 95% of studies. Opioid dose and factors related to opioids were also rarely explored in the SCI populations. CONCLUSIONS Results should be interpreted with caution based on the high heterogeneity and imprecise pooled prevalence of opioids. Contextual details including pain, cohort-specific injury characteristics and opioid dosage were inconsistently reported, indicating a clear need for additional studies in a population at greater risk of experiencing opioid-related adverse effects.
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Affiliation(s)
- Samantha J Borg
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Herston, Australia
| | - Cate M Cameron
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Herston, Australia
| | - Karen Luetsch
- School of Pharmacy, University of Queensland, Woolloongabba, Australia
| | - Adam Rolley
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Herston, Australia
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, Australia
| | - Timothy Geraghty
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
- Department of Rehabilitation, Princess Alexandra Hospital, Metro South Health, Woolloongabba, Australia
| | - Steven McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Australia
| | - Victoria McCreanor
- Hunter Medical Research Institute, New Lambton Heights, Australia
- University of Newcastle, Newcastle, Australia
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Policastro C, Dispagna M, Smith G, Byler T, Wiener S. Factors associated with unplanned clinical encounters for ureteral stent-related symptoms. World J Urol 2024; 42:74. [PMID: 38324162 DOI: 10.1007/s00345-024-04768-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 01/02/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND, INTRODUCTION AND AIM Ureteral stent-related symptoms (USRS) often result in unplanned phone calls and ER visits. We hypothesize that patient factors can be identified to predict these unplanned encounters. METHODS AND MATERIALS Retrospective analysis of indwelling ureteral stent placements from 2014 to 2019 at a single institution by CPT code was performed. Patient demographics, discharge medications, and clinical factors were evaluated using multiple logistic regression with respect to postoperative telephone and emergency room (ER) encounters for USRS. RESULTS Of 374 patients, 75 (20.1%) had one or more encounters for USRS: 48 (12.8%) called the clinic and 39 (10.4%) returned to the ER. Chronic opioid use was predictive of calls to clinic and ER visits (OR 3.21 [CI 1.42-6.97], p < 0.01 and OR 3.64 [CI 1.45-8.98], p < 0.01). Survival analysis stratified by history of chronic opioid use and discharge opioid prescriptions demonstrated that opioid naïve patients receiving opioids at discharge had unplanned encounters sooner and more often [Calls p = 0.025, ER p = 0.041]), whereas patients with chronic opioid use returned to the ER sooner and more frequently when prescribed additional opioids (Calls p = 0.4, ER p = 0.002). CONCLUSION Patients with a history of chronic opioid use may experience more intense USRS or have a lower threshold to seek medical care than opioid naïve patients and tend to bypass calling the clinic for the ER. Given that none of the studied medications reduced unplanned patient contact for USRS, urologists should consider upfront definitive management of urinary obstruction when appropriate.
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Affiliation(s)
- Connor Policastro
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Mauro Dispagna
- School of Medicine, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
| | - Garrett Smith
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Timothy Byler
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Scott Wiener
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA.
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Gao Y, Chen Z, Huang Y, Sun S, Yang D. Comparison of dexmedetomidine and opioids as local anesthetic adjuvants in patient controlled epidural analgesia: a meta-analysis. Korean J Anesthesiol 2024; 77:139-155. [PMID: 37127531 PMCID: PMC10834722 DOI: 10.4097/kja.22730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Data on the efficacy and incidence of adverse effects associated with dexmedetomidine (DEX) as a local anesthetic adjuvant for patient-controlled epidural analgesia (PCEA) are inconclusive. This meta-analysis assessed the efficacy and risks of DEX for PCEA using opioids as a reference. METHODS Two researchers independently searched PubMed, Embase, Cochrane Library, and China Biology Medicine for randomized controlled trials comparing DEX and opioids as local anesthetic adjuvants in PCEA. RESULTS In total, 636 patients from seven studies were included in this meta-analysis. Postoperative patients who received DEX had lower visual analog scale (VAS) scores than those who received opioids at 4-8 h (mean difference [MD]: 0.61, 95% CI [0.45, 0.76], P < 0.001, I2 = 0%), 12 h (MD: 0.85, 95% CI [0.61, 1.09], P < 0.001, I2 = 0%), 24 h (MD: 0.59, 95% CI [0.06, 1.12], P = 0.030, I2 = 82%), and 48 h (MD: 0.54, 95% CI [0.05, 1.02], P = 0.030, I2 = 91%). Additionally, patients who received DEX had a lower incidence of itching (odds ratio [OR]: 2.86, 95% CI [1.18, 6.95], P = 0.020, I2 = 0%) and nausea and vomiting (OR: 6.83, 95% CI [3.63, 12.84], P < 0.001, I2 = 24%). In labor analgesia, no significant differences in neonatal (pH and PaO2 of cord blood, fetal heart rate) or maternal outcomes (duration of labor stage, mode of delivery) were found between the DEX and opioid groups. CONCLUSIONS Compared with opioids, using DEX as a local anesthetic adjuvant in PCEA improved postoperative analgesia and reduced the incidence of itching and nausea and vomiting without increasing the incidence of adverse events.
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Affiliation(s)
- Yafen Gao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhixian Chen
- Department of Pathology, Block T, Queen Mary Hospital, Hong Kong, China
| | - Yu Huang
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shujun Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Pain, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dong Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Pain, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Beck M, Schreiber KL, Wilson JM, Flowers KM, Edwards RR, Chai PR, Azizoddin DR. A secondary analysis: the impact of pre-existing chronic pain among patients with cancer presenting to the emergency department with acute pain. Support Care Cancer 2024; 32:129. [PMID: 38270721 DOI: 10.1007/s00520-024-08314-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/08/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE Patients with cancer may experience pain from cancer itself or its treatment. Additionally, chronic pain (CP) predating a patient's cancer diagnosis may make the etiology of pain less clear and the management of pain more complex. In this brief report, we investigated differences in biopsychosocial characteristics, pain severity, and opioid consumption, comparing groups of cancer patients with and without a history of CP who presented to the emergency department (ED) with a complaint of cancer-related pain. METHODS This secondary analysis of a prospective cohort study included patients with cancer who presented to the ED with a complaint of pain (≥ 4/10). Sociodemographic, clinical, psychological, and pain characteristics were assessed in the ED and subsequent hospitalization. Mann-Whitney U-, T-, and Chi-square tests were used to compare differences between patients with and without pre-existing CP before cancer. RESULTS Patients with pre-existing CP had lower income (p = 0.21) and less formal education (p = 0.25) and were more likely to have a diagnosis of depression or substance use disorder (p < 0.01). Patients with pre-existing CP reported significantly greater pain severity in the ED and during hospitalization compared to those without pre-existing CP (p < 0.05), despite receiving greater amounts of opioid analgesics (p = 0.036). CONCLUSION Identifying a history of pre-existing CP during intake may help identify patients with cancer with difficult to manage pain, who may particularly benefit from multimodal interventions and supportive care. In addition, referral of these patients for the management of co-occurring pain disorders may help decrease the usage of the ED for undertreated pain.
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Affiliation(s)
- Meghan Beck
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jenna M Wilson
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - K Mikayla Flowers
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter R Chai
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- The Fenway Institute, Boston, MA, USA
| | - Desiree R Azizoddin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Thomford NE, Abraham SA, Nyarko SB, Biney RP. A consideration of CYP2D6 genetic variations in the Ghanaian population as a potential 'culprit' for the tramadol 'abuse crisis'. BMC Med Genomics 2024; 17:28. [PMID: 38254077 PMCID: PMC10804791 DOI: 10.1186/s12920-023-01773-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Cytochrome P450 2D6 is involved in the metabolism of several important medicines including opioids. Variations in CYP2D6 have been implicated in drug response and according to the Clinical Pharmacogenetics Implementation Consortium Guideline (CPIC) for CYP2D6, dosing for CYP2D6 substrates should be based on variants carried by individuals. Although CYP2D6 variations in Ghana had been previously recorded, not all variants have been reported in the Ghanaian population. In this exploratory study we set to investigate certain unreported variations in the Ghanaian population in addition to the previously reported ones and use that to understand the tramadol 'abuse' crisis that is currently being experienced in Ghana. METHODS This study employed a convenience sampling approach to include 106 unrelated participants who were recruited as part of the PHARMABIOME project. We successfully genotyped 106 samples using Iplex GOLD SNP genotyping protocol after extracting DNA from these individuals. Allele and diplotype frequencies were undertaken by counting from observed genotypes. Comparison of alleles reported from various studies were done. RESULTS Unreported alleles such as *3, *9 and *41 which are classified as no function and decreased function were observed in our study cohort. In addition, variants such as (*1, *2, *4, *5, *10, *17 and *29 were observed with different frequencies. Our study showed 26% representation of intermediate metabolizers (IM) and 2% poor metabolizers (PM) in the study population. CONCLUSION The implications for informal sector workers who use tramadol for recreational purposes, is that IMs and PMs will overdose as they may have reduced analgesic effects which will translate into increased risks of unforeseen adverse events. We therefore propose that CYP2D6 should be considered in opioid dosage while making use of these observed variations to implement new approaches to tackle the tramadol 'abuse crisis' in Ghana.
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Affiliation(s)
- Nicholas Ekow Thomford
- Department of Medical Biochemistry, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana.
- Pharmacogenomics and Genomic Medicine Group, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana.
- Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
| | - Susanna Aba Abraham
- Department of Adult Health, School of Nursing and Midwifery, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Samuel Badu Nyarko
- Department of Medical Biochemistry, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
- Pharmacogenomics and Genomic Medicine Group, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Robert Peter Biney
- Pharmacogenomics and Genomic Medicine Group, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
- Department of Pharmacotherapeutics and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
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Langford AV, Bero L, Lin CWC, Blyth FM, Doctor JN, Holliday S, Jeon YH, Moullin JC, Murnion B, Nielsen S, Penm J, Reeve E, Reid S, Wale J, Osman R, Gnjidic D, Schneider CR. Context matters: using an Evidence to Decision (EtD) framework to develop and encourage uptake of opioid deprescribing guideline recommendations at the point-of-care. J Clin Epidemiol 2024; 165:111204. [PMID: 37931823 DOI: 10.1016/j.jclinepi.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES To describe the development and use of an Evidence to Decision (EtD) framework when formulating recommendations for the Evidence-Based Clinical Practice Guideline for Deprescribing Opioid Analgesics. STUDY DESIGN AND SETTING Evidence was derived from an overview of systematic reviews and qualitative studies conducted with healthcare professionals and people who take opioids for pain. A multidisciplinary guideline development group conducted extensive EtD framework review and iterative refinement to ensure that guideline recommendations captured contextual factors relevant to the guideline target setting and audience. RESULTS The guideline development group considered and accounted for the complexities of opioid deprescribing at the individual and health system level, shaping recommendations and practice points to facilitate point-of-care use. Stakeholders exhibited diverse preferences, beliefs, and values. This variability, low certainty of evidence, and system-level policies and funding models impacted the strength of the generated recommendations, resulting in the formulation of four 'conditional' recommendations. CONCLUSION The context within which evidence-based recommendations are considered, as well as the political and health system environment, can contribute to the success of recommendation implementation. Use of an EtD framework allowed for the development of implementable recommendations relevant at the point-of-care through consideration of limitations of the evidence and relevant contextual factors.
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Affiliation(s)
- Aili V Langford
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.
| | - Lisa Bero
- School of Medicine, Colorado School of Public Health and Center for Bioethics and Humanities, University of Colorado Anschutz Medical Center, Denver, CO, USA
| | - Chung-Wei Christine Lin
- Faculty of Medicine and Health, School of Public Health, Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia; Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Fiona M Blyth
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Simon Holliday
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Yun-Hee Jeon
- Faculty of Medicine and Health, Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joanna C Moullin
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Bridin Murnion
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sharon Reid
- Specialty of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Drug Health Services, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Janet Wale
- Independent Consumer Representative, Melbourne, Victoria, Australia
| | - Rawa Osman
- NPS MedicineWise, Sydney, New South Wales, Australia
| | - Danijela Gnjidic
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Carl R Schneider
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
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Wallén S, Szabo E, Palmetun-Ekbäck M, Näslund I, Ottosson J, Näslund E, Stenberg E. Impact of socioeconomic status on new chronic opioid use after gastric bypass surgery. Surg Obes Relat Dis 2023; 19:1375-1381. [PMID: 37532668 DOI: 10.1016/j.soard.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/02/2023] [Accepted: 06/17/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Socioeconomic status may influence weight loss, postoperative complications, and health-related quality of life after bariatric surgery. Chronic use of opioid analgesics is a known risk after bariatric surgery, but whether socioeconomic factors are associated with new chronic use of opioid analgesics has not been investigated in depth. OBJECTIVES The aim of this study was to identify socioeconomic factors associated with the development of new chronic use of opioid analgesics after gastric bypass surgery. SETTING All hospitals performing bariatric surgery in Sweden. METHODS This was a retrospective cohort study with prospectively collected data including all primary gastric bypass procedures in Sweden between 2007 and 2015. Data were collected from the Scandinavian Obesity Surgery Registry, the Swedish Prescribed Drug Register, and Statistics Sweden. The primary outcome was new chronic opioid use. RESULTS Of the 44,671 participants, 1438 patients became new chronic opioid users. Longer education (secondary education; odds ratio [OR] = .71; 95% CI, .62-.81) or higher education (OR = .45; 95% CI, .38-.53), higher disposable income (20th-50th percentile: OR = .75; 95% CI, .66-.85; 50th-80th percentile: OR = .50; 95% CI, .43-.58; and the highest 80th percentile: OR = .40; 95% CI, .32-.51) were significantly associated with lower risk for new chronic opioid use. Being a second-generation immigrant (OR = 1.54; 95% CI, 1.24-1.90), being on a disability pension or early retirement (OR = 3.04; 95% CI, 2.67-3.45), receiving social benefits (OR = 1.88; 95% CI, 1.59-2.22), being unemployed for <100 days (OR = 1.25; 95% CI, 1.08-1.45), being unemployed for >100 days (OR = 1.41; 95% CI, 1.16-1.71), and being divorced or a widow or widower (OR = 1.35; 95% CI, 1.17-1.55) were significantly associated with a higher risk for chronic opioid use. CONCLUSION Given that long-term opioid use has detrimental effects after bariatric surgery, it is important that information and follow-up are optimized for patients with shorter education, lower income, and disability pension or early retirement because they are at an increased risk of new chronic opioid analgesics use.
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Affiliation(s)
- Stefan Wallén
- Pharmacology and Therapeutic Department, School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - Eva Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Maria Palmetun-Ekbäck
- Pharmacology and Therapeutic Department, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ingmar Näslund
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Erik Näslund
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Korkusuz M, Basaran B, Et T, Bilge A, Yarimoglu R, Kurucay Y. The effects of dexamethasone added to ilioinguinal/iliohypogastric nerve (IIN/IHN) block on rebound pain in inguinal hernia surgery: a randomized controlled trial. Hernia 2023; 27:1571-1580. [PMID: 37477788 DOI: 10.1007/s10029-023-02841-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE The purpose of the present study was to evaluate the effects of IV dexamethasone added to one single injection Ilioinguinal/Iliohypogastric Nerve (IIN/IHN) block on tramadol consumption and Modified Rebound Pain Score (MRPS) in the first postoperative 24 h in inguinal hernia surgery. METHODS Five mg IV dexamethasone as an analgesic adjunct in the multimodal analgesia was administered to the patients who were scheduled for Inguinal Hernia Surgery and randomized to Group Dex and normal saline was administered to the patients who were randomized to the Control Group in addition to IIN/IHN Block. Postoperative tramadol consumption, Modified Rebound Pain Score (MRPS), the incidence of Rebound Pain, Rebound Pain time, postoperative 48-h opioid consumption, Numerical Rating Scale (NRS) scores, Quality of Recovery Score (QoR-15), Sleep Quality, and adverse events were evaluated in the patients. RESULTS The mean scores of MRPS were lower in Group Dex than in the Control Group, both at rest (p = 0.001) and with motion (p = 0.001). Tramadol consumption in the first postoperative 24 h was 45.17 ± 49.59 mg in Group Dex and 95 ± 59.23 mg in the Control Group. The difference between the groups was statistically significant (p < 0.001). CONCLUSIONS In conclusion, adding IV dexamethasone as a part of multimodal analgesia to IIN/IHN block for inguinal hernia surgery resulted in lower MRPS and lower postoperative opioid (tramadol) consumption. For this reason, IV dexamethasone can be added to the IIN/IHN block after inguinal hernia surgery to reduce the incidence of rebound pain, rebound pain scores, and NRS scores for pain, decrease postoperative opioid consumption, and improve the quality of recovery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: Ref; NCT05172908, Date: December 29, 2021.
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Affiliation(s)
- Muhammet Korkusuz
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey.
| | - Betul Basaran
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Tayfun Et
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Aysegul Bilge
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Rafet Yarimoglu
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Yıldıray Kurucay
- Department of Surgery, Karaman Training and Research Hospital, Karaman, Turkey
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Yao JS, Kibu OD, Asahngwa C, Ngo NV, Ngwa W, Jasmin HM, Gobina RM, Foretia DA. A scoping review on the availability and utilization of essential opioid analgesics in Sub-Saharan Africa. Am J Surg 2023; 226:409-421. [PMID: 37024407 DOI: 10.1016/j.amjsurg.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND Management of acute, post-operative, and chronic pain requires access to and availability of opioids. While often oversupplied in high-income countries, significant shortages exist in low- and middle-income countries. We conducted a scoping review on availability and usage of opioids in Sub-Saharan Africa (SSA). METHODS The five-stage approach of Arksey and O'Malley (2005) was used. MEDLINE via PubMed, EMBASE, and SCOPUS were search and results categorized into themes: 1) Local/regional availability and supply, 2) Consumption patterns, 3) Legislation and policy, 4) Costs and financing, 5) Knowledge and cultural beliefs, and 6) Education and training. RESULTS 6923 studies were identified from which 69 (1%) met inclusion criteria. Five key findings were: 1) Significant shortages exist, especially in rural areas, 2) Non-opioid analgesics commonly used as first-line acute pain management, 3) Barriers to market entry and bureaucratic processes prevent local production, 4) Significant knowledge gaps/myths exist amongst healthcare practitioners on opioid use, and 5) Continuous education and short courses will be critical. CONCLUSIONS Major challenges significantly limit availability and utilization of essential opioids in SSA. Reforms needed to upscale training and education, increase uptake by professionals, and increase market entry.
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Affiliation(s)
- Jane S Yao
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Odette D Kibu
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Department of Public Health, University of Buea, Cameroon; Faculty of Health Science, University of Buea, Cameroon
| | - Constantine Asahngwa
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Department of Anthropology, University of Yaoundé 1, Yaoundé, Cameroon
| | - Ngo V Ngo
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| | - Wilfred Ngwa
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| | - Hilary M Jasmin
- Health Science Library, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ronald M Gobina
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Health Science Library, University of Tennessee Health Science Center, Memphis, TN, USA; Buea Regional Hospital, Buea, Cameroon
| | - Denis A Foretia
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Center for Multicultural and Global Health, University of Tennessee Health Science Center, Memphis, TN, USA; Global Surgery Institute, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
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10
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Kim JH, Park KN, Park EY, Jang MJ, Park YJ, Kim Y, Chang SJ, Park SY, Yun JY, Lim MC. Impact of warm saline irrigation, hyperthermic intraperitoneal chemotherapy on postoperative pain in primary ovarian cancer from the KOV-HIPEC-01 randomized trial. Gynecol Oncol 2023; 177:32-37. [PMID: 37634257 DOI: 10.1016/j.ygyno.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/12/2023] [Accepted: 08/16/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a treatment option at the time of cytoreductive surgery after neoadjuvant chemotherapy. The effect of active warming of HIPEC on postoperative pain needs to be investigated. This study aimed to investigate whether HIPEC reduces postoperative pain. METHODS From the KOV-HIPEC-01 trial, a randomized controlled trial of HIPEC for advanced primary ovarian cancer, 184 patients with a residual tumor size <1 cm were randomly assigned to the HIPEC and control groups at a 1:1 ratio. The consumption of analgesics and pain scales were analyzed. Hyperthermic intraperitoneal chemotherapy was administered after cytoreductive surgery. The primary objective was to compare the consumption of opioids measured in morphine milligram equivalents and non-opioids measured as the maximum daily dose between the HIPEC and control groups. The secondary objective was to compare the minimum and maximum pain intensities on numeric rating scales between the two groups using a linear mixed model. RESULTS Lesser consumption of non-opioids, with a lower mean maximum daily dose on postoperative days 1 and 2, was observed. The HIPEC group also experienced lower maximum pain intensities on postoperative day 1. No overall differences in the minimum or maximum pain intensities were observed on postoperative day 7. CONCLUSION The addition of HIPEC to cytoreductive surgery did not lead to increased postoperative pain, as demonstrated by a reduction in the use of analgesics and lower scores on postoperative pain scales during the early postoperative period.
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Affiliation(s)
- Ji Hyun Kim
- Center for Gynecologic Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Kyung Nam Park
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang, Republic of Korea; Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Eun Young Park
- Biostatistics Collaboration Team, National Cancer Center, Goyang, Republic of Korea
| | - Min Jung Jang
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang, Republic of Korea
| | - Yoen Jung Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youseok Kim
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang, Republic of Korea
| | - Suk-Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sang-Yoon Park
- Center for Gynecologic Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Jung Yeon Yun
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang, Republic of Korea.
| | - Myong Cheol Lim
- Center for Gynecologic Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea; Rare and Pediatric Cancer Branch and Immuno-oncology Branch, Division of Rare and Refractory Cancer, Research Institute, National Cancer Center, Goyang, Republic of Korea; Center for Clinical Trials, Hospital, National Cancer Center, Goyang, Republic of Korea.
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11
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Elhaddad AM, Hefnawy SM, El-Aziz MA, Ebraheem MM, Mohamed AK. Pectoral nerve blocks for transvenous subpectoral pacemaker insertion in children: a randomized controlled study. Korean J Anesthesiol 2023; 76:424-432. [PMID: 36632640 PMCID: PMC10562074 DOI: 10.4097/kja.22681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Postoperative pain management after pacemaker insertion routinely requires opioid agents, nonsteroidal anti-inflammatory drugs, or paracetamol. However, interest in opioid-sparing multimodal pain management to minimize postoperative narcotic use has increased recently. This study aimed to assess the pectoral nerve (PECS) block versus standard treatment on postoperative pain control and opioid consumption in pediatric patients after transvenous subpectoral pacemaker insertion. METHODS In this randomized controlled study, 40 pediatric patients underwent transvenous subpectoral pacemaker insertion with either congenital or postoperative complete heart block. Patients were randomly assigned to two groups: Group C (control) received conventional analgesic care without any block and Group P (pectoral) received a PECS block. Demographics, procedural variables, postoperative pain, and postoperative opioid consumption were compared between the two groups. RESULTS In children undergoing transvenous subpectoral pacemaker insertion, the PECS block was associated with a longer procedure time; however, the cumulative dose of fentanyl and atracurium was reduced and the hemodynamic profile was superior in Group P compared with Group C intraoperatively. Postoperatively, the PECS block was associated with lower postprocedural pain scores, which was reflected by the longer interval before the first call for rescue analgesia and lower postoperative morphine consumption, without an increase in the rate of complications. CONCLUSION Ultrasound-guided PECS blocks are associated with a good intraoperative hemodynamic profile, reduced postoperative pain scores, and lower total opioid consumption in children undergoing transvenous subpectoral pacemaker placement.
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Affiliation(s)
- Ahmed Mohamed Elhaddad
- Department of Anesthesia, Kasr Alainy, Cairo University/Abo Elreesh Children’s Hospital, Cairo, Egypt
| | - Salwa Mohamed Hefnawy
- Department of Anesthesia, Kasr Alainy, Cairo University/Abo Elreesh Children’s Hospital, Cairo, Egypt
| | - Mohamed Abd El-Aziz
- Department of Anesthesia, Faculty of Medicine, Misr University for Science and Technology, Cairo, Egypt
| | - Mahmoud Mostafa Ebraheem
- Department of Anesthesia, Faculty of Medicine, Misr University for Science and Technology, Cairo, Egypt
| | - Ahmed Kareem Mohamed
- Department of Anesthesia, Kasr Alainy, Cairo University/Abo Elreesh Children’s Hospital, Cairo, Egypt
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12
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Hsieh J, Wei W, Nie JZ, Barnett GH, Mohammadi AM, Stevens G, Vogelbaum M, Angelov L. The impact of opioid administration for post gamma knife radiosurgery frame removal: a prospective quality-improvement study. J Neurooncol 2023; 164:721-728. [PMID: 37749305 DOI: 10.1007/s11060-023-04436-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/24/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE In our center, five Gamma Knife proceduralists differed in opioid administration practices prior to Leksell frame removal, providing the opportunity to improve the care of patients with brain metastases by studying whether opioid medications improve pain scores and patient satisfaction during Gamma Knife treatment in a prospective, pseudorandomized fashion. METHODS We prospectively administered a questionnaire to patients undergoing Gamma Knife Radiosurgery for metastases between November, 2017 and July, 2018. Using multivariable methods, we assessed whether opioid pain medication administration influenced the change in pain scores after frame removal, and whether they influenced patient satisfaction on how often their pain was controlled, and their overall satisfaction. RESULTS We included 142 patients. Mean age was 65.2 ± 10.8 years and 52.7% were female. Morphine was the most commonly administered medication. Pain increases were greater around frame removal than placement. Opioids were not associated with any difference in the change in pain scores before and after frame removal, or patient satisfaction. Patients with higher pre-removal pain scores had smaller increases in pain scores after removal; they also had worse pain control and overall satisfaction with their treatment. CONCLUSION Morphine administration prior to frame removal did not improve pain scores or pain control satisfaction. Absence of efficacy may be related to delayed onset of action, and stronger and faster-acting agents should be explored. Pre-removal pain scores were associated with decreased pain control and overall satisfaction, further identifying earlier and stronger pain treatment as a potential area for improvement.
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Affiliation(s)
- Jason Hsieh
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Wei Wei
- Department of Quantitative and Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey Z Nie
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Alireza M Mohammadi
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Glen Stevens
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Michael Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Lilyana Angelov
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA.
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA.
- Department of Neurological Surgery, Rose Ella Burkhart Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Ave CA51, Cleveland, OH, 44195, USA.
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13
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Caplan M, Friedman BW, Siebert J, Takematsu M, Adewunmi V, Gupta C, White DJ, Irizarry E. Use of clinical phenotypes to characterize emergency department patients administered intravenous opioids for acute pain. Clin Exp Emerg Med 2023; 10:327-332. [PMID: 37092185 PMCID: PMC10579725 DOI: 10.15441/ceem.23.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/25/2023] Open
Abstract
OBJECTIVE Individual experience with opioids is highly variable. Some patients with acute pain do not experience pain relief with opioids, and many report no euphoria or dysphoric reactions. In this study, we describe the clinical phenotypes of patients who receive intravenous opioids. METHODS This was an emergency department-based study in which we enrolled patients who received an intravenous opioid. We collected 0 to 10 pain scores prior to opioid administration and 15 minutes after. We also used 0 to 10 instruments to determine how high and how much euphoria the patient felt after receipt of the opioid. Using a cutoff point of ≥50% improvement in pain and the median score on the high and euphoria scales, we assigned each participant to one of the following clinical phenotypes: pain relief with feeling high or euphoria, pain relief without feeling high or euphoria, inadequate relief with feeling high or euphoria, and inadequate relief without feeling high or euphoria. RESULTS A total of 713 patients were enrolled, 409 (57%) of whom reported not feeling high, and 465 (65%) reported no feeling of euphoria. Median percent improvement in pain was 37.5% (interquartile range, 12.5%-60.0%). One hundred seventy-eight participants (25%) were classified as experiencing pain relief with euphoria or feeling high, 190 (27%) experienced inadequate relief with euphoria or feeling high, 101 (14%) experienced pain relief without euphoria or feeling high, and 244 (34%) reported inadequate relief without euphoria or feeling high. CONCLUSION Among patients who receive intravenous opioids in the emergency department, the experiences of pain relief and euphoria are highly variable. For many, pain relief is independent of feeling high.
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Affiliation(s)
- Mordechai Caplan
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin W. Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jason Siebert
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mai Takematsu
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Victoria Adewunmi
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Chiraag Gupta
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Deborah J. White
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddie Irizarry
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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14
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Priyank H, Shankar Prasad R, Shivakumar S, Sayed Abdul N, Pathak A, Cervino G, Cicciù M, Minervini G. Management protocols of chronic Orofacial Pain: A Systematic Review. Saudi Dent J 2023; 35:395-402. [PMID: 37520608 PMCID: PMC10373074 DOI: 10.1016/j.sdentj.2023.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 08/01/2023] Open
Abstract
Objective Chronic orofacial pain (CP) is a persistent and debilitating condition that affects the face, mouth, and jaw and can have a significant impact on an individual's quality of life by posing problems to eat, speak, and perform everyday activities. By the means of this narrative review, we aim to assess different types of management modalities that exist to combat chronic orofacial pain. Design Various databases were explored with MeSH keywords of chronic orofacial pain, orofacial pain, and interventions and treatment protocols for eligible articles. After an extensive literature search, it was ascertained that this review identified four major categories of treatment modalities for the management of chronic orofacial pain, namely pharmacological management, psychological management, lifestyle interventions-based management, and current stimulation-based management. Results Of the four categories discussed, although pharmacological intervention offered the most immediate relief-especially from orofacial pain that was of a sudden, stab-like in nature-psychological management demonstrated a remarkable ability to reduce/alleviate the more serious aspect of chronic orofacial pain and was deemed better in comparison to the rest. Lifestyle-based techniques and current stimulation-based management were of limited use since they tended to focus more on the causal and not the symptomatic aspect of orofacial pain. Conclusions Many patients with persistent orofacial discomfort can experience notable improvements in their symptoms and general well-being by all the treatment modalities evaluated.
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Affiliation(s)
- Harsh Priyank
- Department of Conservative, Endodontics & Aesthetic Dentistry, Dental College, Rajendra Institute of Medical Sciences, India
| | - Ravi Shankar Prasad
- Department of Conservative, Endodontics & Aesthetic Dentistry, Dental College, Rajendra Institute of Medical Sciences, India
| | - Sahana Shivakumar
- Public Health Dentistry, Peoples College of Dental Sciences and Research Centre, Peoples University, Bhopal, India
| | - Nishath Sayed Abdul
- Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia
| | - Anuja Pathak
- Public Health Dentistry, Peoples College of Dental Sciences and Research Centre, Peoples University, Bhopal, India
| | - Gabriele Cervino
- School of Dentistry Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, via Consolare Valeria, 1, 98125 Messina, Italy
| | - Marco Cicciù
- Department of General Surgery and Medical-Surgical Specialties, School of Dentistry, University of Catania, Catania, Italy
| | - Giuseppe Minervini
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy
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15
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Lara-Cátedra C, López-Cabezas C, García-López I, Elviro-Lloréns M, Letéllez-Fernández J, de Rosales-Cabrera AMM, Alonso-Herreros JM, SalaVilajosana N. Map of use of parenteral analgesic admixtures in Spain. MEDPAIN project. Farm Hosp 2023; 47:161-167. [PMID: 37244846 DOI: 10.1016/j.farma.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 05/29/2023] Open
Abstract
OBJETIVE This study is the first part of the MEDPAIN project "Update of analgesic parenteral admixtures: studies of use, compatibility and stability", and its goal is to develop a national map about the use of analgesic parenteral admixtures in healthcare settings. METHODS Observational study, based on a survey aimed at Spanish hospital pharmacists, during the period December 2020-April 2021. The questionnaire was designed in the RedCap® platform and disseminated through the Spanish Society of Hospital Pharmacy distribution list. An analgesic parenteral admixture (AM) was defined as the combination of two or more drugs, with at least one of them being an analgesic. The same combination of active ingredients, at different concentration and/or administered by different routes, was considered as a unique AM in this study. Some registered endpoints were related to the characteristics of the healthcare settings participating in the study, and others were related to the AM, such as drugs, doses and concentration range, route of administration, frequency of use, indication and type of patient (adult/pediatric) and where they are prepared. RESULTS A total of 67 valid surveys from healthcare settings of 13 Spanish Autonomous Communities were received. They reported 462 AM. Every healthcare center informed an average of 6 AM (ICR p25-p75 =4.0-9.0). Most of the reported mixtures were used in adults (93.9%) at hospital settings (91.8%), and they were mostly protocolized and frequently used. The 21.4% of them were compounded at the Pharmacy service. The AM included 26 different drugs, with opioid analgesics being present at the 87.4% of them. Midazolam was the most usual adjuvant drug. According to the definition of AM in this study, there were finally 137 different combinations mainly with two drugs (40.6%), but also with three (37.7%), four (15.2%) and five ingredients (6.5%). CONCLUSION This study reveals the wide variability in current clinical practice and shows which are the most used analgesic parenteral admixtures in our country.
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Affiliation(s)
- Catalina Lara-Cátedra
- Servicio de Farmacia, Hospital Universitario La Paz, Madrid, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España.
| | - Carmen López-Cabezas
- Servicio de Farmacia, Hospital Clínic Barcelona, Barcelona, España; Grupo de Trabajo Farmacotecnia, Sociedad Española de Farmacia Hospitalaria, España
| | - Isabel García-López
- Servicio de Farmacia, Hospital Infantil Universitario Niño Jesús, Madrid, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España
| | - María Elviro-Lloréns
- Servicio de Farmacia, Clínica Nuestra Señora del Pilar, Zaragoza, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España
| | - Javier Letéllez-Fernández
- Servicio de Farmacia, Hospital Universitario Fuenlabrada, Fuenlabrada, Madrid, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España
| | - Ana María Martín de Rosales-Cabrera
- Servicio de Farmacia, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España; Grupo de Trabajo Farmacotecnia, Sociedad Española de Farmacia Hospitalaria, España
| | - José María Alonso-Herreros
- Servicio de Farmacia, Hospital Los Arcos Mar Menor, Pozo Aledo, Murcia, España; Grupo de Trabajo Farmacotecnia, Sociedad Española de Farmacia Hospitalaria, España
| | - Núria SalaVilajosana
- Servicio de Farmacia, Fundació Althaia, Manresa, Barcelona, España; Grupo de Trabajo Dolor, Sociedad Española de Farmacia Hospitalaria, España
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16
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Lara-Cátedra C, López-Cabezas C, García-López I, Elviro-Lloréns M, Letéllez-Fernández J, Martín de Rosales-Cabrera AM, Alonso-Herreros JM, SalaVilajosana N. [Translated article] Map of use of parenteral analgesic admixtures in Spain. MEDPAIN project. Farm Hosp 2023; 47:T161-T167. [PMID: 37438171 DOI: 10.1016/j.farma.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVE This study is the first part of the MEDPAIN project "Update of analgesic parenteral admixtures: studies of use, compatibility and stability", and its goal is to develop a national map about the use of analgesic parenteral admixtures in healthcare settings. METHODS Observational study, based on a survey aimed at Spanish hospital pharmacists, during the period December 2020 - April 2021. The questionnaire was designed in the RedCap® platform and disseminated through the Spanish Society of Hospital Pharmacy distribution list. An analgesic parenteral admixture (AM) was defined as the combination of two or more drugs, with at least one of them being an analgesic. The same combination of active ingredients, at different concentration and/or administered by different routes, was considered as a unique AM in this study. Some registered endpoints were related to the characteristics of the healthcare settings participating in the study, and others were related to the AM, such as drugs, doses and concentration range, route of administration, frequency of use, indication and type of patient (adult/pediatric) and where they are prepared. RESULTS A total of 67 valid surveys from healthcare settings of 13 Spanish Autonomous Communities were received. They reported 462 AM. Every healthcare center informed an average of 6 AM (ICR p25-p75 = 4.0-9.0). Most of the reported mixtures were used in adults (93.9%) at hospital settings (91.8%), and they were mostly protocolized and frequently used. The 21.4% of them were compounded at the Pharmacy service. The AM included 26 different drugs, with opioid analgesics being present at the 87.4% of them. Midazolam was the most usual adjuvant drug. According to the definition of AM in this study, there were finally 137 different combinations mainly with two drugs (40.6%), but also with three (37.7%), four (15.2%) and five ingredients (6.5%). CONCLUSION In conclusion, this study reveals the wide variability in current clinical practice and shows which are the most used analgesic parenteral admixtures in our country.
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Affiliation(s)
| | | | - Isabel García-López
- Servicio de Farmacia, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Victor G, Ray B, Del Pozo B, Jaffe K, King A, Huynh P. Buprenorphine and opioid analgesics: Dispensation and discontinuity among accidental overdose fatalities in the Indianapolis metropolitan area, 2016-2021. J Subst Use Addict Treat 2023; 150:209053. [PMID: 37105266 DOI: 10.1016/j.josat.2023.209053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/28/2022] [Accepted: 04/15/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND This study describes overall trends and sociodemographic disparities in buprenorphine and opioid analgesic uptake and prescribing patterns prior to fatal overdose events. METHODS We examined toxicology data from all accidental overdose deaths from 2016 to 2021 (N = 2682) in a large metropolitan area. These data were linked at the individual-level with a prescription drug monitoring program (PDMP). RESULTS Fewer than half of all deaths had any kind of PDMP record (39.9 %, n = 1070). Among those with a buprenorphine prescription, 10.6 % (n = 35) of decedents had a buprenorphine dispensation within 7 days of their death, while the majority (64.7 %, n = 214) were dispensed buprenorphine more than 30 days prior to death. Evidence existed of racial disparities among those with any buprenorphine uptake, whereby Black individuals (7.3 %, n = 24) had significantly fewer any dispensations compared to White individuals (92.7 %, n = 307). Among those with an opioid analgesic prescription, about 12.2 % (n = 90) were dispensed within 7 days of death, with the majority (68.5 %, n = 506) occurring more than 30 days prior to death. Like buprenorphine dispensations, Black individuals were prescribed a significantly smaller proportion of opioid analgesics (21.9 %, n = 162) versus White individuals (77.7 %, n = 574). Buprenorphine was detected in 78.5 % of deaths where fentanyl was present in the toxicology record, significantly greater when compared to opioid analgesics (57.5 %). CONCLUSION Consistent with prior research, our findings suggest prescription opioid analgesics may protect against fatal overdoses. Access to buprenorphine treatment did not keep pace with the rising lethality of the overdose crisis, and in recent years, a smaller percentage of the people at risk of fatal overdose availed themselves of MOUD preceding their death.
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Affiliation(s)
- Grant Victor
- School of Social Work, Rutgers, The State University of New Jersey, 120 Albany St, New Brunswick, NJ 08901, United States of America.
| | - Bradley Ray
- RTI International, Division for Applied Justice Research, 3040 Cornwallis Road, Research Triangle Park, NC 27709, United States of America
| | - Brandon Del Pozo
- Miriam Hospital/Warren Alpert Medical School of Brown University, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States of America
| | - Kaitlyn Jaffe
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, 2800 Plymouth Road Bldg. 14, G016, Ann Arbor, MI 48109, United States of America
| | - Andy King
- School of Emergency Medicine, Wayne State University, 4201 St. Antoine, University Health Center - 6G, Detroit, MI 48201, United States of America
| | - Philip Huynh
- Center for Behavioral Health and Justice, Wayne State University, Detroit, MI 48208, United States of America
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18
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Alonso-Prieto M, Pujol D, Angustias Salmerón M, de-Ceano Vivas-Lacalle M, Ortiz Villalobos A, Martínez Moreno M, González Morán G, Torres-Luna R, Miró J, Reinoso-Barbero F. Clinical differences in a multidisciplinary pediatric pain unit between primary and secondary chronic pain. Rev Esp Anestesiol Reanim (Engl Ed) 2023; 70:148-155. [PMID: 36842690 DOI: 10.1016/j.redare.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/19/2021] [Indexed: 02/26/2023]
Abstract
INTRODUCTION Chronic pain affects an important part of the pediatric population in developed countries. secondary chronic pain (SCP) can have a well-defined medical cause, but primary chronic pain (PCP) can have an unknown etiology. In Spain, there is as yet no information on the clinical differences between patients treated in multidisciplinary units. METHODS Retrospective analysis of the clinical records of patients seen in 2018 at the Children's Chronic Pain Unit in University La Paz Hospital. RESULTS A total of 92 patients were included, (age between 3 and 19 years), with a mean age of 12.4 (SD = 4.1) years, mostly female (55%), with a mean duration of pain of 11.3 (SD = 10.4) months. A comparison of patients with PCP (n = 31) and SCP (n = 61) showed that both groups, on average, presented intense pain (X = 5.9; SD = 2.2; range = 0-10), with similar duration and functional repercussions, although PCP was less likely to be associated with neuropathic descriptors than SCP (p = 0.040), and was more extensive (p < 0.001). Both groups received similar treatment, based on rehabilitation, psychotherapy, invasive techniques and analgesic medication, although patients in the PCP group received less analgesic medication (gabapentinoids and opioids) than the SCP (p = 0.011). CONCLUSION Patients treated in a multidisciplinary Child Pain Unit for PCP or SCP present a very similar clinical profile, though with differences in the number and type of analgesic drugs used. This shows the importance of etiologic diagnosis for adequate pharmacological treatment.
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Affiliation(s)
- M Alonso-Prieto
- Unidad de Dolor Infantil-->, Servicio de Anestesiología-Reanimación Infantil, Hospital Universitario La Paz-->, Madrid, Spain
| | - D Pujol
- Servicio de Anestesiología-Reanimación-->, Hospital Universitario CEMIC, Buenos Aires, Argentina
| | | | | | - A Ortiz Villalobos
- Unidad de Psiquiatría Infantil y del adolescente-->, Servicio de Psiquiatría-->, Hospital Universitario La Paz-->, Madrid, Spain
| | - M Martínez Moreno
- Unidad de Rehabilitación Infantil-->, Servicio de Rehabilitación y Fisioterapia-->, Hospital Universitario La Paz-->, Madrid, Spain
| | - G González Morán
- Servicio de Ortopedia-->, Hospital Universitario La Paz-->, Madrid, Spain
| | - R Torres-Luna
- Unidad de Dolor Infantil-->, Servicio de Anestesiología-Reanimación Infantil, Hospital Universitario La Paz-->, Madrid, Spain
| | - J Miró
- Cátedra del Dolor Infantil de la Universidad Rovira i Virgili de Tarragona-->, Spain
| | - F Reinoso-Barbero
- Unidad de Dolor Infantil-->, Servicio de Anestesiología-Reanimación Infantil, Hospital Universitario La Paz-->, Madrid, Spain; Fundación de Investigación IdiPaz-->, Hospital Universitario La Paz-->, Madrid, Spain.
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19
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Won YJ, Oh SK, Lim BG, Kim YS, Lee DY, Lee JH. Effect of surgical pleth index-guided remifentanil administration on perioperative outcomes in elderly patients: a prospective randomized controlled trial. BMC Anesthesiol 2023; 23:57. [PMID: 36803564 PMCID: PMC9936695 DOI: 10.1186/s12871-023-02011-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/03/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND During general anesthesia, the surgical pleth index (SPI) monitors nociception. The evidence of SPI in the elderly remains scarce. We aimed to investigate whether there is a difference in perioperative outcomes following intraoperative opioid administration according to the surgical pleth index (SPI) value versus hemodynamic parameters (heart rate or blood pressure) in elderly patients. METHODS Patients aged 65-90 years who underwent laparoscopic colorectal cancer surgery under sevoflurane/remifentanil anesthesia were randomized to receive remifentanil guided by SPI (SPI group) or conventional clinical judgment based on hemodynamic parameters (conventional group). The primary endpoint was intraoperative remifentanil consumption. Secondary endpoints were intraoperative hemodynamic instability, pain score, fentanyl consumption and delirium in the post-anesthesia care unit (PACU), and perioperative changes in interleukin-6 and natural killer (NK) cell activity. RESULTS Seventy-five patients (38, SPI; 37, conventional) were included in the study. The SPI group consumed significantly more remifentanil intraoperatively than the conventional group (mean ± SD, 0.13 ± 0.05 vs. 0.06 ± 0.04 μg/kg/min, P < 0.001). Intraoperative hypertension and tachycardia were more common in the conventional group than in the SPI group. Pain score in the PACU (P = 0.013) and the incidence of delirium in the PACU were significantly lower in the SPI group than the conventional group (5.2% vs. 24.3%, P = 0.02). There was no significant difference in NK cell activity and interleukin-6 level. CONCLUSIONS In the elderly patients, SPI-guided analgesia provided appropriate analgesia with sufficient intraoperative remifentanil consumption, lower incidence of hypertension/ tachycardia events, and a lower incidence of delirium in the PACU than the conventional analgesia. However, SPI-guided analgesia may not prevent perioperative immune system deterioration. TRIAL REGISTRATION The randomized controlled trial was retrospectively registered in the UMIN Clinical Trials Registry (trial number: UMIN000048351; date of registration: 12/07/2022).
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Affiliation(s)
- Young Ju Won
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
| | - Seok Kyeong Oh
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308, Republic of Korea.
| | - Young Sung Kim
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
| | - Do Yeop Lee
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
| | - Jae Hak Lee
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
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20
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Yoo Y, Oh JH, Lee H, Choi H, Joo S, Han AH, Moon JY. Myth and Truth in Opioid Consumption with Intrathecal Morphine Pump Implantation in Chronic Pain: A Retrospective Cohort Study with Claims Database in South Korea. Pain Med 2023; 24:79-88. [PMID: 35881702 DOI: 10.1093/pm/pnac110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/22/2022] [Accepted: 07/18/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate the opioid consumption and the healthcare resource utilization in patients with the intrathecal drug delivery system (IDDS) therapy and the comprehensive medical management (CMM) alone. DESIGN A retrospective cohort study with a customized claims database. SETTING In a university-based hospital. SUBJECTS Patients with complex regional pain syndrome, post-laminectomy syndrome, and fibromyalgia. METHODS Using propensity score matching (1:3), we selected patients with morphine infusion through IDDS (IDDS group) and CMM alone (CMM group). The primary endpoints were comparisons of average morphine equivalents daily dosages (MEDD, mg/day) for 6 and 12 months from an index date. The number of emergency room (ER) visits and hospitalizations and the total medical expenditures were compared as secondary outcomes. RESULTS In total, 82 patients (N = 23 in the IDDS group and N = 59 in the CMM group) were analyzed. Although a 6-month average MEDD did not reach statistical significance, a 12-month average MEDD was significantly decreased in the IDDS group compared to the CMM group (53.2 ± 46.3 vs 123.9 ± 176.4, respectively; P = 0.008). ER visits were more frequent in the IDDS group than the CMM group at baseline (5.4 vs 0.5, respectively; P = .002), which was maintained for 12 months (P < 0.001). Otherwise, the number of hospitalization and the medical expenditures for pain management were not different between the groups for 12 months. CONCLUSIONS The combined IDDS therapy had some benefits in reducing opioid consumption for 1-year follow-up compared to the CMM alone in chronic noncancer pain patients.
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Affiliation(s)
- Yongjae Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joo Hyeon Oh
- Department of Anesthesiology and Pain Medicine, Boramae Medical Center, Seoul, Republic of Korea
| | - Haine Lee
- Healthcare Economics and Government Affairs, Medtronic Korea, Inc., Seoul, Republic of Korea
| | - Hyunsook Choi
- Healthcare Economics and Government Affairs, Medtronic Korea, Inc., Seoul, Republic of Korea.,Department of Health Convergence, Ewha Womans University, Seoul, Republic of Korea
| | - Somin Joo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Jee Youn Moon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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21
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Mutter R, Black J, Iwanicki J. Changes in the Street Prices of Prescription Opioids During the COVID-19 Pandemic. Psychiatr Serv 2023; 74:63-65. [PMID: 35770425 DOI: 10.1176/appi.ps.202100689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE This study analyzed changes in prescription opioid street prices during the COVID-19 pandemic. METHODS Crowdsourced prescription opioid street prices were obtained from the Researched Abuse, Diversion and Addiction-Related Surveillance System StreetRx Program. Percentage changes in street price per milligram of different opioids between April and December 2020 compared with the same months in 2019 were calculated by using linear regression. RESULTS Street prices of high-potency drugs hydromorphone and oxycodone increased 23% and 12% per milligram, respectively. Prices of low-potency drugs hydrocodone and morphine increased 9% and 12% per milligram, respectively. Changes in prices of medications for opioid use disorder were not statistically significant. CONCLUSIONS Decreased access to opioid analgesics during the pandemic combined with contributors to opioid demand may have led to increases in street prices of prescription opioids. Measures taken to increase access to medications for opioid use disorder were not associated with changes in those drugs' street prices.
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Affiliation(s)
- Ryan Mutter
- Health Policy Studies Unit, Health Analysis Division, Congressional Budget Office, Washington, D.C. (Mutter); Rocky Mountain Poison & Drug Safety Research Department, Denver Health and Hospital Authority, Denver (Black, Iwanicki)
| | - Joshua Black
- Health Policy Studies Unit, Health Analysis Division, Congressional Budget Office, Washington, D.C. (Mutter); Rocky Mountain Poison & Drug Safety Research Department, Denver Health and Hospital Authority, Denver (Black, Iwanicki)
| | - Janetta Iwanicki
- Health Policy Studies Unit, Health Analysis Division, Congressional Budget Office, Washington, D.C. (Mutter); Rocky Mountain Poison & Drug Safety Research Department, Denver Health and Hospital Authority, Denver (Black, Iwanicki)
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22
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Noufal Y, Kringel D, Toennes SW, Dudziak R, Lötsch J. Pharmacological data science perspective on fatal incidents of morphine treatment. Pharmacol Ther 2023; 241:108312. [PMID: 36423714 DOI: 10.1016/j.pharmthera.2022.108312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
Morphine prescribed for analgesia has caused drug-related deaths at an estimated incidence of 0.3% to 4%. Morphine has pharmacological properties that make it particularly difficult to assess the causality of morphine administration with a patient's death, such as its slow transfer between plasma and central nervous sites of action and the existence of the active metabolite morphine-6-glucuronide with opioid agonistic effects, Furthermore, there is no well-defined toxic dose or plasma/blood concentration for morphine. Dosing is often adjusted for adequate pain relief. Here, we summarize reported deaths associated with morphine therapy, including associated morphine exposure and modulating patient factors such as pharmacogenetics, concomitant medications, or comorbidities. In addition, we systematically analyzed published numerical information on the stability of concentrations of morphine and its relevant metabolites in biological samples collected postmortem. A medicolegal case is presented in which the causality of morphine administration with death was in dispute and pharmacokinetic modeling was applied to infer the administered dose. The results of this analytical review suggest that (i) inference from postmortem blood concentrations to the morphine dose administered has low validity and (ii) causality between a patient's death and the morphine dose administered remains a highly context-dependent and collaborative assessment among experts from different medical specialties.
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Affiliation(s)
- Yazan Noufal
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Dario Kringel
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Stefan W Toennes
- Goethe-University, University Hospital Frankfurt, Institute of Legal Medicine, Kennedyallee 104, 60596 Frankfurt am Main, Germany
| | - Rafael Dudziak
- Goethe-University, University Hospital Frankfurt, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jörn Lötsch
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany.
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23
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Krebs EE, Becker WC, Nelson D, DeRonne BM, Nugent S, Jensen AC, Amundson EC, Manuel JK, Borsari B, Kats AM, Seal KH. Design, methods, and recruitment outcomes of the Veterans' Pain Care Organizational Improvement Comparative Effectiveness (VOICE) study. Contemp Clin Trials 2023; 124:107001. [PMID: 36384218 DOI: 10.1016/j.cct.2022.107001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/29/2022] [Accepted: 11/09/2022] [Indexed: 11/14/2022]
Abstract
The Veterans' Pain Care Organizational Improvement Comparative Effectiveness (VOICE) study is a 12-month pragmatic randomized comparative effectiveness trial conducted at ten United States Veterans Affairs (VA) health care sites. The overall goal was to test interventions to improve pain while reducing opioid use among VA patients with moderate-severe chronic pain despite treatment with long-term opioid therapy (LTOT). Aims were 1) to compare lower-intensity telecare collaborative pain management (TCM) versus higher-intensity integrated pain team management (IPT), and 2) to test the option of switching to buprenorphine (versus no option) in a high-dose subgroup. Recruitment challenges included secular trends in opioid prescribing and the COVID-19 pandemic. Participants were recruited over 3.5 years. Of 6966 potentially eligible patients, 4731 (67.9%) were contacted for telephone eligibility interview; of those contacted, 3398 (71.8%) declined participation, 359 (7.6%) were ineligible, 821 (24.2%) enrolled, and 820 (24.1%) were randomized. The most common reason for declining was satisfaction with pain care (n = 731). The most common reason for ineligibility was not having moderate-severe chronic pain (n = 110). Compared with the potentially eligible population, randomized participants were slightly younger, more often female, had similar prescribed opioids, and had similar or higher rates of pain and mental health diagnoses. The enrolled patient number was lower than the original target, but sufficient to power planned analyses. In conclusion, the VOICE trial enrolled a diverse sample similar to the population of VA patients receiving LTOT. Results will add substantially to limited existing evidence for interventions to improve pain while reducing opioid use. ClinicalTrials.gov identifier: NCT03026790.
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Affiliation(s)
- Erin E Krebs
- Minneapolis VA Health Care System, Minneapolis, MN, United States of America; University of Minnesota Medical School, Minneapolis, MN, United States of America.
| | - William C Becker
- Connecticut VA Health Care System, West Haven, CT, United States of America; Yale University, New Haven, CT, United States of America
| | - David Nelson
- Minneapolis VA Health Care System, Minneapolis, MN, United States of America; University of Minnesota Medical School, Minneapolis, MN, United States of America
| | - Beth M DeRonne
- Minneapolis VA Health Care System, Minneapolis, MN, United States of America
| | - Sean Nugent
- Minneapolis VA Health Care System, Minneapolis, MN, United States of America
| | - Agnes C Jensen
- Minneapolis VA Health Care System, Minneapolis, MN, United States of America
| | - Erin C Amundson
- Minneapolis VA Health Care System, Minneapolis, MN, United States of America
| | - Jennifer K Manuel
- San Francisco VA Health Care System, San Francisco, CA, United States of America; University of California, San Francisco, San Francisco, CA, United States of America
| | - Brian Borsari
- San Francisco VA Health Care System, San Francisco, CA, United States of America; University of California, San Francisco, San Francisco, CA, United States of America
| | - Allyson M Kats
- University of Minnesota School of Public Health, Minneapolis, MN, United States of America
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, CA, United States of America; University of California, San Francisco, San Francisco, CA, United States of America
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Walton RF, Yeh C, Shannon R, Rosoklija I, Rague JT, Johnson EK, Alpern ER, Ellison JS, Routh JC, Tasian GE, Chu DI. Variation in care between pediatric and adult patients presenting with nephrolithiasis to tertiary care pediatric emergency departments in the United States (2009-2020). J Pediatr Urol 2022; 18:742.e1-742.e11. [PMID: 35945144 PMCID: PMC9771899 DOI: 10.1016/j.jpurol.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/06/2022] [Accepted: 07/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Individuals with nephrolithiasis frequently present to the Emergency Department (ED). Safety and quality principles are often applied in pediatric EDs to children presenting with nephrolithiasis, such as limiting ionizing radiation exposure and opioid analgesics. However, it is unknown whether pediatric EDs apply these same principles to adult patients who present with nephrolithiasis. We hypothesized that adult patients would be associated with higher use of radiation-based imaging and opioid analgesics. OBJECTIVE To assess variations in diagnostic and treatment interventions and hospital utilization between pediatric and adult patients presenting to the pediatric ED with nephrolithiasis. STUDY DESIGN A retrospective cohort study was conducted, examining outcomes for pediatric (<18-years-old) versus adult (≥18-years-old) patients in 42 pediatric EDs from 2009 to 2020 using the Pediatric Health Information System (PHIS) database. Patients with an ICD-9/10 principal diagnosis code of nephrolithiasis with no nephrolithiasis-related visits within the prior 6 months were included. Primary outcomes were imaging, medications, and surgical interventions. Secondary outcomes were hospital admissions, 90-day ED revisits, and 90-day readmissions. Generalized linear mixed models with random effects were used to adjust for confounding and clustering. RESULTS In total, 16,117 patients with 17,837 encounters were included. Most hospitals were academic (95.2%), and a plurality were located in the South (38.1%). Most patients were <18-years-old (84.4%, median (interquartile range): 15 (12-17)-years-old), female (57.9%), and White (76.3%), and 17.1% were Hispanic/Latino. Most had no complex chronic conditions (89.2%) and no chronic disease per pediatric medical complexity algorithm (51.5%). For the primary outcome, adults, relative to pediatric patients, who presented to the pediatric ED with nephrolithiasis had higher adjusted odds of receiving computerized tomography (CT) scans (Odds Ratio [OR] 1.43 [95% Confidence Interval [CI] 1.29-1.59]) and opioid analgesics (OR 1.45 [95%CI 1.33-1.58]) (Summary Figure). Secondary outcomes showed that adults, relative to pediatric patients, had lower adjusted odds of hospital admissions, 90-day ED revisits, and 90-day readmissions. DISCUSSION Our results suggest that certain pediatric safety and quality principles, such as limiting ionizing radiation exposure and opioid analgesic prescriptions, are not being equally applied to pediatric and adult patients who present to pediatric EDs with nephrolithiasis. The mechanism of these findings remains to be elucidated. CONCLUSIONS Variations in care for individuals with nephrolithiasis reflect an opportunity for quality improvement in pediatric EDs and inform work exploring optimal care pathways for all patients presenting to the pediatric ED with nephrolithiasis.
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Affiliation(s)
- Ryan F Walton
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Chen Yeh
- Northwestern University, Department of Preventive Medicine, Division of Biostatistics, Chicago, IL, USA.
| | - Rachel Shannon
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Ilina Rosoklija
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - James T Rague
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Emilie K Johnson
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Elizabeth R Alpern
- Northwestern University, Department of Pediatrics, Division of Emergency Medicine, Chicago, IL, USA.
| | - Jonathan S Ellison
- Children's Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.
| | | | | | - David I Chu
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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25
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Bailey J, Gill S, Poole R. Long-term, high-dose opioid prescription for chronic non-cancer pain in primary care: an observational study. BJGP Open 2022; 6:BJGPO. [PMID: 35728819 DOI: 10.3399/BJGPO.2021.0217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 05/23/2022] [Accepted: 06/16/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Opioid prescriptions for chronic pain have risen sharply over the last 25 years; harms associated with these drugs are related to dose and length of use. AIM The main aim of this study was to identify patients prescribed long-term, high-dose (LTHD) opioids in the community and to assess the prevalence of such use. DESIGN & SETTING An observational study of opioid prescribing in two demographically dissimilar GP practices in North Wales, UK. METHOD Details of opioid prescriptions were collected for 22 841 patients, of whom 1488 (6.5%) were being prescribed opioids on the census date. Exhaustive examination of the data identified all patients who were prescribed oral morphine equivalent doses of ≥120 mg/day for ≥1 year. RESULTS All these patients were being prescribed ≥120 mg/day, as a single drug, morphine, oxycodone, fentanyl, or buprenorphine, irrespective of opioid polypharmacy. Across both practices, 1.71/1000 patients were identified as LTHD users of opioid medication for chronic non-cancer pain (CNCP). Prevalence was similar in the two practices. Repetition of the process until January 2021 showed no change in the pattern. CONCLUSION This study offers confirmation that a significant group of patients are prescribed long-term opioid medication for chronic pain at doses that are unlikely to be effective in reducing pain, but are likely to have harmful consequences. The findings offer a simple, reliable, and practical method of data extraction to identify these patients individually from routinely collected prescribing data, which will help in monitoring and treating individuals and establishing the problem prevalence.
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26
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Bailey J, Nafees SB, Gill S, Jones L, Poole R. Patterns of prescribing in primary care leading to high-dose opioid regimens: a mixed-method study. BJGP Open 2022; 6:BJGPO. [PMID: 36229069 DOI: 10.3399/BJGPO.2022.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/06/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND There are concerns about continuing increases in the number of patients prescribed long-term opioids and the prescribing of 'strong' opioids for chronic pain. Little is known about patients who are prescribed these long-term, high-dose drugs. AIM To understand patterns of opioid prescribing that lead to long-term, high-dose use. DESIGN & SETTING A mixed-method study of the opioid prescription histories of patients using high doses in a North Wales GP practice. METHOD All patients on high-dose opioids during the census week were identified. Summary graphs of the prescription histories were prepared. Qualitative analysis was conducted individually by four researchers. A workshop was held to arrive at a consensus about common features and to inform further quantitative analysis. RESULTS A quarter of high-dose regimens were initiated outside the practice, either in a different primary care practice or in secondary care. The majority of the remaining patients showed a pattern of dose increases to high levels over a short period (median 3.5 months). None showed a pattern of gradual increases over a longer timescale. Most of the patients remained on high doses continuously once a daily dose of ≥120 mg oral morphine equivalent (OME) was reached. CONCLUSION These findings suggest that high-dose opioid regimens develop quickly in response to unknown clinical factors. An expected insidious upward drift in dose was not seen. The findings have implications for the prevention of potentially dangerous long-term, high-dose opioid prescribing. A dose of 60 mg OME or more is suggested as a useful 'red flag'.
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27
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Elshazly M, EL-Halafawy YM, Mohamed DZ, Wahab KAE, Mohamed TMK. Feasibility and efficacy of erector spinae plane block versus transversus abdominis plane block in laparoscopic bariatric surgery: a randomized comparative trial. Korean J Anesthesiol 2022; 75:502-509. [PMID: 35581710 PMCID: PMC9726464 DOI: 10.4097/kja.22169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/16/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Overweight and obesity are growing public health concerns worldwide. Bariatric surgery is a modality of weight reduction; however, postoperative pain can increase the length of hospital stay, with all the associated consequences. While regional anesthesia is an available option, the feasibility of performing abdominal wall blocks on patients with obesity is questionable. METHODS Sixty adult patients with a body mass index of 40-50 kg/m2 undergoing laparoscopic bariatric surgery were randomly assigned to receive either an ultrasound-guided transversus abdominis plane (TAP) or erector spinae plane (ESP) block. The primary outcome was the analgesic effect in the first 24 h postoperatively, assessed using the mean visual analog scale (VAS) score. Secondary outcomes were the time required for a successful block, incidence of complications, time to first rescue analgesia, time to flatus or stool passage, and total opioid consumption. RESULTS The mean VAS score during the first 24 h was higher with the TAP block than with the ESP block (2.78 ± 0.34 vs. 2.32 ± 0.12, P < 0.001). Additionally, the time to first rescue analgesia was greater with the ESP block (P = 0.001) and the time required for a successful block was higher with the TAP block (P = 0.001). However, the incidence of complications, total opioid consumption, and other secondary outcomes was similar between the groups. CONCLUSIONS Compared with the TAP block, the bilateral ESP block is a more feasible and effective method for intra- and postoperative analgesia in patients undergoing laparoscopic bariatric surgery.
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Affiliation(s)
- Mohamed Elshazly
- Department of Anesthesia, Surgical ICU, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt,Corresponding author: Mohamed Elshazly, M.D. Department of Anesthesia, Surgical ICU, and Pain Management, Faculty of Medicine, Cairo University, Al-Saray Street, El Manial Cairo 11956, EgyptTel: +20-1016109777Fax: +20-236997165
| | - Yasser Mohamed EL-Halafawy
- Department of Anesthesia, Surgical ICU, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dina Zakaria Mohamed
- Department of Anesthesia, Surgical ICU, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Khaled Abd El Wahab
- Department of Anesthesia, Surgical ICU, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Tamer Mohamed Kheir Mohamed
- Department of Anesthesia, Surgical ICU, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
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Lépine B, Debin M, Dassieu L, Gimenez L, Palmaro A, Ponté C, Swital M, Lapeyre-Mestre M, Blanchon T, Dupouy J. Prescribing buprenorphine for opioid use disorder in primary care: A survey of French general practitioners in the Sentinelles network. J Subst Abuse Treat 2022; 143:108891. [PMID: 36215914 DOI: 10.1016/j.jsat.2022.108891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/05/2022] [Accepted: 09/12/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Although opioid substitution coverage in France is high and patient care with buprenorphine is mainly managed by general practitioners (GPs), buprenorphine sales have been decreasing since 2011, suggesting that French GPs are prescribing less buprenorphine. Yet this possible change in GP practices has not yet been investigated. This study aimed to examine primary care GPs' opinions about buprenorphine and habits related to prescribing buprenorphine. METHODS The study team conducted a cross-sectional survey from March 2021 to July 2021 among a sample of GPs in the Sentinelles network, a French epidemiologic surveillance system based on primary care practitioners. The study collected information about substance use disorder (SUD) training, opinions on buprenorphine, and habits related to buprenorphine prescription were collected (initiation and renewal within the past two years). FINDINGS Among the 237 participants (34 % response rate), 15.2 % reported having had specific training for SUD management. A majority reported a very positive (16 %) or positive (63.7 %) opinion of buprenorphine. Most participants agreed (61.2 %) or strongly agreed (31.2 %) that buprenorphine was efficacious in the treatment of illicit opioid use disorder. Of the 206 GPs who reported having treated patients with opioid use disorder in the past two years, 47 (22.8 %) had initiated a buprenorphine prescription, whereas 177 (85.9 %) had renewed a buprenorphine prescription. Previous SUD training was associated with initiating buprenorphine (OR 4.66; 95 % CI [2.15-10.08]), while female gender was associated with not initiating buprenorphine prescribing (OR 0.46; 95 % CI [0.22-0.98]). CONCLUSION A sample of French GPs who work in primary care has a positive view of buprenorphine, but the absence of SUD training among this population may be a barrier to their prescribing buprenorphine.
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Affiliation(s)
- Barbara Lépine
- Département Universitaire de Médecine Générale, Université de Toulouse, Faculté de Médecine, 133 route de Narbonne, 31063 Toulouse, France
| | - Marion Debin
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, 75012 Paris, France
| | - Lise Dassieu
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, 850 rue Saint Denis, Montréal, QC H2X0A9, Canada
| | - Laetitia Gimenez
- Département Universitaire de Médecine Générale, Université de Toulouse, Faculté de Médecine, 133 route de Narbonne, 31063 Toulouse, France; MSPU La Providence, 1 avenue Louis Blériot, 31500 Toulouse, France; CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Aurore Palmaro
- Département Universitaire de Médecine Générale, Université de Toulouse, Faculté de Médecine, 133 route de Narbonne, 31063 Toulouse, France
| | - Camille Ponté
- CEIP-Addictovigilance, CIC 1436, Service de Pharmacologie Médicale et Clinique, Faculté de Médecine, 37 allées Jules Guesde, 31000 Toulouse, France
| | - Morgane Swital
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, 75012 Paris, France
| | - Maryse Lapeyre-Mestre
- CEIP-Addictovigilance, CIC 1436, Service de Pharmacologie Médicale et Clinique, Faculté de Médecine, 37 allées Jules Guesde, 31000 Toulouse, France
| | - Thierry Blanchon
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, 75012 Paris, France
| | - Julie Dupouy
- Département Universitaire de Médecine Générale, Université de Toulouse, Faculté de Médecine, 133 route de Narbonne, 31063 Toulouse, France; CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France; MSPU de Pins Justaret, 1 chemin de la gare, 31860 Pins Justaret, France.
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Yu X, Zhao L, Song B. Impact of opioid analgesics on the efficacy of immune checkpoint inhibitors in a lung cancer population. BMC Pulm Med 2022; 22:431. [PMID: 36411438 PMCID: PMC9677634 DOI: 10.1186/s12890-022-02210-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/31/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE A retrospective clinical study was conducted to compare the prognosis between the opioid analgesic (OA) treated and OA-untreated groups and to evaluate the effect of opioid analgesics on the efficacy of immune checkpoint inhibitors (ICIs) in the treatment of advanced lung cancer patients. In addition, a subgroup analysis of the clinical characteristics of the enrolled patients was performed to explore possible influencing factors. METHODS This study reviewed the medical records of eligible patients who received ICIs at our institution. The clinicopathological features and clinical outcomes were compared. Also, the use of OA was collected. Patient survival, the incidence of immune-related adverse events (irAEs), and other baseline variables were examined in both cohorts according to whether OA was used. RESULTS A total of 132 patients were included in the study. Of them, 39 (29.5%) were in the OA-treated group. No significant differences in baseline characteristics were observed between the OA-treated and untreated groups. The combined application of OA treatment significantly shortened progression-free survival (PFS) (P < 0.001) and overall survival (OS) (P = 0.002). However, both groups experienced similar incidences and gradations of irAEs. According to multivariate analysis, OA treatment resulted in significantly worse PFS (HR = 4.994, 95% CI 3.217-7.753, P < 0.001) and OS (HR = 3.618, 95% CI 2.030-6.240, P < 0.001). CONCLUSIONS Clinical outcomes of ICIs were significantly diminished in a cohort of Chinese patients with advanced lung cancer receiving OA therapy.
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Affiliation(s)
- Xiaoyuan Yu
- grid.452461.00000 0004 1762 8478First Hospital of Shanxi Medical University, Taiyuan, China
| | - Li Zhao
- grid.470966.aThird Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032 China
| | - Bin Song
- grid.470966.aThird Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032 China
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Rueter M, Baricault B, Lapeyre-Mestre M. Patterns of opioid analgesic prescribing in cancer outpatients during the last year of life in France: A pharmacoepidemiological cohort study based on the French health insurance database. Therapie 2022; 77:703-711. [PMID: 35697537 DOI: 10.1016/j.therap.2022.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 01/05/2022] [Accepted: 01/24/2022] [Indexed: 12/15/2022]
Abstract
Cancer pain management with adequate analgesics for cancer outpatients can be particularly challenging. This representative retrospective cohort study aimed to investigate the prevalence and timing of weak and strong opioid analgesic prescriptions in cancer outpatients during their last year of life, with a focus on factors associated to potential late strong opioid initiation. Factors associated with late strong opioid initiation were investigated through multivariate logistic regression analyses stratified by place of death. A retrospective cohort of cancer outpatients, who died between 2014 and 2016, was identified from the general sample of beneficiaries. Among N=4704 cancer patients (median age 76 years, 42.7% women), 3002 (63.8%) were prescribed and dispensed ≥1 weak or strong opioid analgesic during their last year of life; of whom, 2458 (52.3%) received ≥1 weak opioid analgesic (tramadol as single-ingredient accounting for 25.9%) and 1733 (36.8%) ≥1 strong opioid analgesic dispensation (fentanyl 21.6%). Median interval between the first prescription for any strong opioid and death was 18 weeks (interquartile range: 8-38), and for weak opioids 33 weeks (interquartile range: 20-47). Among weak opioid users, 1229 (50.0%) patients had received ≥1 weak opioid analgesic dispensation during the year n-2 before death. Among strong opioid users, 986 (56.9%) patients had received ≥1 weak opioid analgesic dispensation during the year n-2 before death and 381 (21.9%) patients ≥1 strong opioid analgesic dispensation. Patients with an outpatient death were more likely to have a late strong opioid initiation compared to patients with an inpatient death. Late strong opioid initiation (<18 weeks before death) was significantly associated with a lower number of hospitalization days and prior weak opioid exposure for patients with an inpatient death and, with older age, social, prior weak opioid exposure, and a prescription initiation by general practitioner for patients with an outpatient death. Our gained knowledge of opioid prescribing patterns in cancer patients during the last year of life might help to progress opioid analgesic treatment and to improve patient outcomes.
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Affiliation(s)
- Manuela Rueter
- Medical and Clinical Pharmacology Unit, University Hospital Centre Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; Clinical Investigation Center (CIC) 1436, University Hospital Centre Toulouse, 31059 Toulouse cedex 9, France; Equipe Pharmacologie en Population, cohorteS, biobanqueS, PEPPS, Toulouse University, 31000 Toulouse, France.
| | - Bérangère Baricault
- Medical and Clinical Pharmacology Unit, University Hospital Centre Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France
| | - Maryse Lapeyre-Mestre
- Medical and Clinical Pharmacology Unit, University Hospital Centre Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; Clinical Investigation Center (CIC) 1436, University Hospital Centre Toulouse, 31059 Toulouse cedex 9, France; Equipe Pharmacologie en Population, cohorteS, biobanqueS, PEPPS, Toulouse University, 31000 Toulouse, France
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Kang M, Seo M. Factors Affecting Nurses' Performance of Cancer Pain Management in a Tertiary Hospital. J Hosp Palliat Care 2022; 25:99-109. [PMID: 37674907 PMCID: PMC10179990 DOI: 10.14475/jhpc.2022.25.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/13/2022] [Accepted: 05/22/2022] [Indexed: 09/08/2023]
Abstract
Purpose More than 60% of patients with advanced cancer experience pain, and uncontrolled pain reduces the quality of life. Nurses are the closest healthcare providers to the patient and are suitable for managing cancer pain using pharmacological and non-pharmacological interventions. This study aimed to identify factors affecting the performance of cancer pain management among nurses. Methods This study was conducted among 155 participating nurses working at a tertiary hospital who had experience with cancer pain management. Data collection was performed between October 18, 2021 and October 25, 2021. Data analysis was conducted using descriptive statistics, the independent-sample t-test, one-way analysis of variance, and hierarchical regression analysis. Results There were 110 subjects (71.0%) who had no experience of cancer pain management education. The results of regression analysis indicated that barriers included medical staff, patients, and the hospital system for cancer pain management (β=0.28, P<0.001). The performance of cancer pain management was also affected by experience of cancer pain management training (β=0.22, P=0.007), and cancer pain management knowledge (β=0.21, P=0.006). The explanatory power of the variable was 16.6%. Conclusion It is crucial to assess system-related obstacles, as well as patients and medical staff, in order to improve nurses' cancer pain management performance. A systematic approach incorporating multidisciplinary interventions from interprofessional teams is required for effective pain management. Furthermore, pain management education is required both for cancer ward nurses and nurses in other wards.
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Affiliation(s)
- Minhwa Kang
- Department of Nursing, Gyeongsang National University Hospital, Jinju, Korea
| | - Minjeong Seo
- College of Nursing, Gyeongsang National University, Jinju, Korea
- Gerontological Health Research Center in Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
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Zeliadt SB, Douglas JH, Gelman H, Coggeshall S, Taylor SL, Kligler B, Bokhour BG. Effectiveness of a whole health model of care emphasizing complementary and integrative health on reducing opioid use among patients with chronic pain. BMC Health Serv Res 2022; 22:1053. [PMID: 35978421 PMCID: PMC9387037 DOI: 10.1186/s12913-022-08388-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/28/2022] [Indexed: 12/21/2022] Open
Abstract
Background The opioid crisis has necessitated new approaches to managing chronic pain. The Veterans Health Administration (VHA) Whole Health model of care, with its focus on patient empowerment and emphasis on nonpharmacological approaches to pain management, is a promising strategy for reducing patients’ use of opioids. We aim to assess whether the VHA’s Whole Health pilot program impacted longitudinal patterns of opioid utilization among patients with chronic musculoskeletal pain. Methods A cohort of 4,869 Veterans with chronic pain engaging in Whole Health services was compared with a cohort of 118,888 Veterans receiving conventional care. All patients were continuously enrolled in VHA care from 10/2017 through 3/2019 at the 18 VHA medical centers participating in the pilot program. Inverse probability of treatment weighting and multivariate analyses were used to adjust for observable differences in patient characteristics between exposures and conventional care. Patients exposed to Whole Health services were offered nine complementary and integrative health therapies alone or in combination with novel Whole Health services including goal-setting clinical encounters, Whole Health coaching, and personal health planning. Main measures The main measure was change over an 18-month period in prescribed opioid doses starting from the six-month period prior to qualifying exposure. Results Prescribed opioid doses decreased by -12.0% in one year among Veterans who began complementary and integrative health therapies compared to similar Veterans who used conventional care; -4.4% among Veterans who used only Whole Health services such as goal setting and coaching compared to conventional care, and -8.5% among Veterans who used both complementary and integrative health therapies combined with Whole Health services compared to conventional care. Conclusions VHA’s Whole Health national pilot program was associated with greater reductions in prescribed opioid doses compared to secular trends associated with conventional care, especially when Veterans were connected with complementary and integrative health therapies. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08388-2.
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Affiliation(s)
- Steven B Zeliadt
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA. .,Department of Health Services, School of Public Health, University of Washington, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA.
| | - Jamie H Douglas
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Hannah Gelman
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Scott Coggeshall
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.,Department of General Internal Medicine and Department of Health Policy and Management, UCLA, Los Angeles, CA, USA
| | - Benjamin Kligler
- Department of Family and Community Medicine, Icahn School of Medicine at Mount Sinai, Brooklyn, NY, USA.,US Department of Veterans Affairs Office of Patient Centered Care and Cultural Transformation, Washington, DC, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Hruschak V, Flowers KM, Patton M, Merchantz V, Schwartz E, Edwards R, Kaptchuk T, Kang J, Dossett M, Schreiber K. Experiences of Patients Taking Conditioned Open-Label Placebos for Reduction of Postoperative Pain and Opioid Exposure After Spine Surgery. Int J Behav Med 2022. [PMID: 35915346 DOI: 10.1007/s12529-022-10114-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pain after spine surgery is difficult to manage, often requiring the use of opioid analgesics. While traditional "deceptive" or concealed placebo has been studied in trials and laboratory experiments, the acceptability and patient experience of taking honestly prescribed placebos, such as "open-label" placebo (non-deceptive placebo), or conditioned placebo (pairing placebo with another active pharmaceutical) is relatively unexamined. METHODS Qualitative thematic analysis was performed using semi-structured, post-treatment interviews with spine surgery patients (n = 18) who had received conditioned open-label placebo (COLP) during the first 2-3 weeks after surgery as part of a RCT. Interview transcripts were reviewed by 3 investigators using an immersion/crystallization approach, followed by iterative large-group discussions with additional investigators, to identify, refine, and codify emergent themes. RESULTS Patients' experiences and perceptions of COLP efficacy varied widely. Some emergent themes included the power of the mind over pain, how COLP might provide distraction from or agency over pain, bandwidth required and engagement with COLP, and its modulation of opioid tapering, as well as negative attitudes toward opioids and pill taking in general. Other themes included uncertainty about COLP efficacy, observations of how personality may relate to COLP efficacy, and a recognition of the greater impact of COLP on reduction of opioid use rather than on pain itself. Interestingly, participant uncertainty, disbelief, and skepticism were not necessarily associated with greater opioid consumption or worse pain. CONCLUSION Participants provided insights into the experience of COLP which may help to guide its future utilization to manage acute pain and tapering from opioids.
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Rodriguez-Monguio R, Lun Z, Kehr K, Agustin JP, San Agustin-Nordmeier K, Huynh C, Reisner L. Hospital admission medication reconciliation in high-risk prescription opioid users. Res Social Adm Pharm 2022; 18:3379-3385. [PMID: 34972641 DOI: 10.1016/j.sapharm.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 11/01/2021] [Accepted: 11/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND No studies have assessed the clinical significance of medication reconciliation in surgical patients using high-risk extended-release/long-acting (ER/LA) opioid medications. OBJECTIVES We assessed differences in the perioperative use of opioid analgesics in patients who underwent medication reconciliation upon hospital admission compared to patients who did not and identified predictors of perioperative use of opioids. METHODS Retrospective observational quasi-experimental study including adult non-cancer patients who underwent elective surgery at UCSF Medical Center in the period January 2017 through December 2019 and received at least one opioid analgesic during surgical hospitalization. The primary study outcome was perioperative use of opioids measured in daily oral morphine equivalents (OME). Secondary outcomes were predictors of perioperative use of opioids after adjusting for baseline differences between groups. RESULTS We identified 402 patients. Of them, 59.5% were female. The mean patient age was 58.5 years. Most patients underwent neurological or orthopedic surgery (each 40.8%). Over 94.3% of our patients underwent medication reconciliation upon hospital admission, with 78.4% completed by a pharmacy staff. Medication reconciliation evidenced that 5.5% patients were not taking the ER/LA opioids on their medication history list. Inactive ER/LA opioids were discontinued during hospitalization. None of the patients with inactive ER/LA opioids had those opioids restarted at hospital discharge. In addition, patients (26.9%) were successfully converted from ER/LA to SA opioids. After adjusting for patients' demographic and clinical characteristics, surgical procedure type and post-operative pain, opioid formulation conversion was the main predictor of perioperative use of opioids per hospitalization day. Switching patients from ER/LA to SA opioids reduced the mean daily use of OME by 66.03 units (p < 0.02) without adversely impacting postoperative pain. CONCLUSIONS Medication reconciliation upon hospital admission reduced unnecessary exposure to opioids in hospitalized surgical patients.
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Affiliation(s)
- Rosa Rodriguez-Monguio
- Department of Clinical Pharmacy, University of California San Francisco (UCSF), USA; Medication Outcomes Center, University of California San Francisco (UCSF), USA; Philip R. Lee Institute for Health Policy Studies at the University of California San Francisco (UCSF), USA.
| | - Zhixin Lun
- Medication Outcomes Center, University of California San Francisco (UCSF), USA
| | - Kendall Kehr
- Department of Clinical Pharmacy, University of California San Francisco (UCSF), USA
| | - Janelle P Agustin
- Department of Clinical Pharmacy, University of California San Francisco (UCSF), USA
| | | | - Christine Huynh
- Department of Clinical Pharmacy, University of California San Francisco (UCSF), USA
| | - Lori Reisner
- Department of Pharmaceutical Services, University of California San Francisco (UCSF) Medical Center, USA
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Cordray H, Alfonso K, Brown C, Evans S, Goudy S, Govil N, Landry AM, Raol N, Smith K, Prickett KK. Sustaining standardized opioid prescribing practices after pediatric tonsillectomy. Int J Pediatr Otorhinolaryngol 2022; 159:111209. [PMID: 35749955 DOI: 10.1016/j.ijporl.2022.111209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/19/2022] [Accepted: 06/09/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes. METHODS A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure. RESULTS From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28). CONCLUSION An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.
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Affiliation(s)
- Holly Cordray
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kristan Alfonso
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Clarice Brown
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean Evans
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven Goudy
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Nandini Govil
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - April M Landry
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikhila Raol
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathleen Smith
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Kara K Prickett
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
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Townsend TN, Salz T, Haffajee RL, Caram MEV, Chino F, Bohnert ASB. Has Declining Opioid Dispensing to Cancer Patients Been Tailored to Risk of Opioid Harms? J Pain Symptom Manage 2022; 63:179-188. [PMID: 34656655 PMCID: PMC8816811 DOI: 10.1016/j.jpainsymman.2021.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/15/2021] [Accepted: 09/18/2021] [Indexed: 02/03/2023]
Abstract
CONTEXT Opioid prescribing to cancer patients is declining, but it is unknown whether reductions have been tailored to those at highest risk of opioid-related harms. OBJECTIVES Examine whether declines in opioid dispensing to patients receiving active cancer treatment are sharper in patients with substance use disorder (SUD) or mental health diagnoses. METHODS We used 2008-2018 national, commercial healthcare claims data to examine adjusted and unadjusted trends in opioid dispensing (receipt of ≥1 fill; average daily dosage; receipt of high-dose opioids; receipt of concurrent opioids and benzodiazepines) to patients ages ≥18 receiving treatment for one of four cancer types (breast; colorectal; head and neck; sarcoma; N = 324,789 patients). To compare declines across subgroups with varying risk of opioid-related harms, we stratified by SUD and mental health diagnosis. To address potential confounding, we estimated subgroup-specific trends using generalized estimating equations, adjusting for covariates. RESULTS Across groups, rate of ≥1 opioid fill per quarter fell 32.5% (95% CI: 31.8%-33.2%) from 2008 to 2018; daily dose among those receiving opioids fell 37.6% (95% CI: 36.7%-38.6%). In most cases, these declines were not sharper in subgroups at greater risk of opioid-related harms. For example, patients with opioid use disorder experienced the smallest declines in dispensing frequency, and there was no evidence that declines were sharper in patients with mental health diagnoses. CONCLUSION Sharp declines in opioid prescribing during the drug overdose crisis have affected a wide range of patients undergoing cancer treatment and may not have been sufficiently tailored to patient characteristics. Research on implications for opioid-related harms and pain management is needed.
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Affiliation(s)
- Tarlise N Townsend
- University of Michigan, Department of Health Management and Policy (T.N.T., R.L.H.), Ann Arbor, Michigan, USA; NYU Rory Meyers College of Nursing (T.N.T.), New York, New York, USA; Center for Opioid Epidemiology and Policy (T.N.T.), NYU Grossman School of Medicine Department of Population Health, New York, New York, USA.
| | - Talya Salz
- Memorial Sloan Kettering Cancer Center Health Outcomes Research Group (T.S.), New York, New York, USA
| | - Rebecca L Haffajee
- University of Michigan, Department of Health Management and Policy (T.N.T., R.L.H.), Ann Arbor, Michigan, USA; RAND Corporation (R.L.H.), Boston, Massachusetts, USA
| | - Megan E V Caram
- University of Michigan Department of Internal Medicine (M.E.V.C), Ann Arbor, Michigan, USA; VA Center for Clinical Management Research (M.E.V.C., A.S.B.B.), Ann Arbor, Michigan, USA
| | - Fumiko Chino
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology (F.C.), New York, New York, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research (M.E.V.C., A.S.B.B.), Ann Arbor, Michigan, USA; University of Michigan, Department of Anesthesiology (A.S.B.B.), Ann Arbor, Michigan, USA
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Oh SK, Lim BG, Won YJ, Lee DK, Kim SS. Analgesic efficacy of erector spinae plane block in lumbar spine surgery: A systematic review and meta-analysis. J Clin Anesth 2022; 78:110647. [PMID: 35030493 DOI: 10.1016/j.jclinane.2022.110647] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 12/02/2021] [Accepted: 01/02/2022] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Erector spinae plane block (ESPB) has gained popularity for perioperative analgesia in various surgeries. However, its efficacy in lumbar surgery remains unclear. This review aimed to determine whether ESPB could improve analgesic efficacy in lumbar spine surgery. DESIGN A meta-analysis of randomized controlled trials. SETTING Perioperative setting. PATIENTS Patients undergoing lumbar spine surgery under general anesthesia. INTERVENTIONS We searched the databases including PubMed, Cochrane Library, EMBASE, Web of Science etc. for published eligible controlled trials comparing ESPB with control (no block/sham block) in lumbar spine surgery. MEASUREMENTS The primary outcome was opioid consumption in the first 24 h after surgery. MAIN RESULTS Twelve studies comprising 665 participants were included. Compared to the control, ESPB reduced the opioid (morphine milligram equivalents) consumption significantly 24 h after surgery [mean difference (MD) = -14.55; 95% confidence interval (CI), -21.03 to -8.07; P < 0.0001] and lowered the pain scores at various time points (at rest or during movement) for 48 h after surgery. ESPB increased the patient satisfaction score (0-10) (MD = 2.38; 95% CI, 2.10 to 2.66; P < 0.0001), decreased the postoperative nausea and vomiting [risk ratio (RR) = 0.36; 95% CI, 0.20 to 0.67; P = 0.001], and minimized the length of hospital stay (MD = -1.24 days; 95% CI, -2.31 to -0.18; P = 0.02). Furthermore, subgroup analysis revealed additional reduction in opioid consumption by the block approach at the vertebral level of incision/operation than that at the fixed thoracic/lumbar level. However, considerable heterogeneity and low-grade quality of evidence were observed. CONCLUSIONS ESPB provided effective postoperative analgesia resulting in better patient satisfaction and recovery with decreased postoperative nausea and vomiting in patients undergoing lumbar surgery compared to the control. However, the low-grade quality of evidence compromised the findings, therefore further high-quality of evidence is required. PROSPERO registration number: CRD42021233362.
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Santo T, Campbell G, Gisev N, Degenhardt L. Exposure to childhood trauma increases risk of opioid use disorder among people prescribed opioids for chronic non-cancer pain. Drug Alcohol Depend 2022; 230:109199. [PMID: 34875576 DOI: 10.1016/j.drugalcdep.2021.109199] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little is known about childhood trauma exposure and Opioid Use Disorder (OUD) among people prescribed opioids for chronic non-cancer pain (CNCP). We aimed to (1) describe childhood trauma exposure among this population, and (2) examine if childhood trauma exposure was an independent risk factor for OUD among people prescribed opioids for CNCP. METHODS This study used baseline data from 1514 people prescribed opioids for CNCP in Australia. We used latent class analysis to characterise participants by five indicators of childhood trauma exposure and logistic regression to characterise class membership. We used discrete-time survival analysis to determine whether there was an independent association between childhood trauma exposure and risk of OUD according to adjusted odds ratios (AOR). RESULTS We identified three classes of childhood trauma exposure: (1) 'low exposure' (n = 765; 54.0%), (2) 'emotional & sexual abuse' (n = 324; 22.9%), and (3) 'high all' (n = 329; 23.2%). 'Emotional & sexual abuse' or 'high all' childhood trauma exposure class membership was associated with higher rates of pain difficulties, mental disorders, and substance use disorders, compared to 'low exposure' class membership. After we adjusted for previously identified OUD risk factors, participants in the 'emotional & sexual abuse' (AOR 1.51; 95%CI 1.09-2.12; p = 0.016) and 'high all' (AOR 1.77; 95%CI 1.28-2.45; p = 0.001) childhood trauma exposure classes were at increased risk of OUD. CONCLUSIONS Among people prescribed opioids for CNCP, childhood trauma exposure was a common, independent risk factor for OUD. Availability of trauma-informed services for those prescribed opioids for CNCP may reduce risk of transition to OUD.
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Affiliation(s)
- Thomas Santo
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia.
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; University of Sunshine Coast, Sunshine Coast, QLD, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
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Moreira de Barros GA, Baradelli R, Rodrigues DG, Toffoletto O, Domingues FS, Gayoso MV, Lopes A, Barros Afiune J, Nunes Guimarães GM. Use of methadone as an alternative to morphine for chronic pain management: a noninferiority retrospective observational study. Pain Rep 2021; 6:e979. [PMID: 34938934 DOI: 10.1097/PR9.0000000000000979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/14/2021] [Accepted: 10/26/2021] [Indexed: 12/21/2022] Open
Abstract
Methadone administration for outpatient was noninferior to morphine as analgesic on chronic pain. In addition, it was associated with lesser side effects. Introduction: Chronic pain causes disability and is prevalent in the general population. Opioids are a part of a multimodal strategy for pain management. Methadone, a cheap and long-acting synthetic opioid, may represent an option for those who have limited access to the aforementioned class of analgesics. We aimed to provide a real-world evidence for the analgesic use of methadone, compared with morphine. Methods: We conducted a noninferiority, retrospective observational single center study of patients with chronic pain, managed with either methadone or morphine at an outpatient specialized clinic. We extracted data from the electronic health records of patients who underwent an active treatment between August 2012 and January 2020 and were examined for at least 2 consecutive medical visits, after the administration of one of the aforementioned drugs. Data were analyzed using a generalized additive model with random-effects mixed linear method to account for the individual-related, time-related, and drug-related variations. The numeric verbal scale (0–10) was used to assess the pain severity. Results: From the database of 3373 patients, we included 262 patients (175 methadone and 87 morphine). In an unadjusted analysis, methadone was superior to morphine, and the mean worst pain was 0.86 points lower (95% confidence interval, −1.29 to −0.43). Moreover, methadone was superior to morphine in the adjusted analysis, with the worst pain mean being 1.24 points lower. This provided evidence for the noninferiority of methadone than morphine. Conclusion: Methadone was superior to morphine in a 20% noninferiority margin for reducing worst pain.
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Lin N, Mandel D, Chuck CC, Kalagara R, Doelfel SR, Zhou H, Dandapani H, Mahmoud LN, Stretz C, Mac Grory BC, Wendell LC, Thompson BB, Furie KL, Mahta A, Reznik ME. Risk Factors for Opioid Utilization in Patients with Intracerebral Hemorrhage. Neurocrit Care 2021; 36:964-973. [PMID: 34931281 DOI: 10.1007/s12028-021-01404-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Headache is a common presenting symptom of intracerebral hemorrhage (ICH) and often necessitates treatment with opioid medications. However, opioid prescribing patterns in patients with ICH are not well described. We aimed to characterize the prevalence and risk factors for short and longer-term opioid use in patients with ICH. METHODS We conducted a retrospective cohort study using data from a single-center registry of patients with nontraumatic ICH. This registry included data on demographics, ICH-related characteristics, and premorbid, inpatient, and postdischarge medications. After excluding patients who died or received end-of-life care, we used multivariable regression models adjusted for premorbid opioid use to determine demographic and ICH-related risk factors for inpatient and postdischarge opioid use. RESULTS Of 468 patients with ICH in our cohort, 15% (n = 70) had premorbid opioid use, 53% (n = 248) received opioids during hospitalization, and 12% (n = 53) were prescribed opioids at discharge. The most commonly used opioids during hospitalization were fentanyl (38%), oxycodone (30%), morphine (26%), and hydromorphone (7%). Patients who received opioids during hospitalization were younger (univariate: median [interquartile range] 64 [53.5-74] vs. 76 [67-83] years, p < 0.001; multivariable: odds ratio [OR] 0.96 per year, 95% confidence interval [CI] 0.94-0.98) and had larger ICH volumes (univariate: median [interquartile range] 10.1 [2.1-28.6] vs. 2.7 [0.8-9.9] cm3, p < 0.001; multivariable: OR 1.05 per cm3, 95% CI 1.03-1.08) than those who did not receive opioids. All patients who had external ventricular drain placement and craniotomy/craniectomy received inpatient opioids. Additional risk factors for increased inpatient opioid use included infratentorial ICH location (OR 4.8, 95% CI 2.3-10.0), presence of intraventricular hemorrhage (OR 3.9, 95% CI 2.2-7.0), underlying vascular lesions (OR 3.0, 95% CI 1.1-8.1), and other secondary ICH etiologies (OR 7.5, 95% CI 1.7-32.8). Vascular lesions (OR 4.0, 95% CI 1.3-12.5), malignancy (OR 5.0, 95% CI 1.5-16.4), vasculopathy (OR 10.0, 95% CI 1.8-54.2), and other secondary etiologies (OR 7.2, 95% CI 1.8-29.9) were also risk factors for increased opioid prescriptions at discharge. Among patients who received opioid prescriptions at discharge, 43% (23 of 53) continued to refill their prescriptions at 3 months post discharge. CONCLUSIONS Inpatient opioid use in patients with ICH is common, with some risk factors that may be mechanistically connected to primary headache pathophysiology. However, the lower frequency of opioid prescriptions at discharge suggests that inpatient opioid use does not necessarily lead to a high rate of long-term opioid dependence in patients with ICH.
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Affiliation(s)
- Nelson Lin
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Daniel Mandel
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Carlin C Chuck
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | | | - Savannah R Doelfel
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Helen Zhou
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Hari Dandapani
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Leana N Mahmoud
- Department of Pharmacy, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Brown University, 593 Eddy St, APC 712, Providence, RI, USA
| | - Christoph Stretz
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Brian C Mac Grory
- Department of Neurology, Duke University School of Medicine, Duke University, Durham, NC, USA
| | - Linda C Wendell
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA.,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Bradford B Thompson
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA.,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Karen L Furie
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Ali Mahta
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA.,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA. .,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA.
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Henry SG, Shev AB, Crow D, Stewart SL, Wintemute GJ, Fenlon C, Wirtz SJ. Impacts of prescription drug monitoring program policy changes and county opioid safety coalitions on prescribing and overdose outcomes in California, 2015-2018. Prev Med 2021; 153:106861. [PMID: 34687731 DOI: 10.1016/j.ypmed.2021.106861] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/05/2021] [Accepted: 10/14/2021] [Indexed: 11/30/2022]
Abstract
In 2015, California received funding to implement the Prescription Drug Overdose Prevention Initiative, a 4-year program to reduce deaths involving prescription opioids by 1) leveraging improvements to California's prescription drug monitoring program (PDMP) (i.e., mandatory PDMP registration for prescribers and pharmacists), and 2) supporting county opioid safety coalitions. We used statewide data from 2011 to 2018 to evaluate the Initiative's impact on opioid prescribing and overdose rates. Prescribing data were obtained from California's PDMP; fatal and non-fatal overdose data were obtained from the California Department of Public Health. Outcomes were monthly opioid prescribing rates and opioid overdose rates, modeled using generalized linear mixed models. Exposures were mandatory PDMP registration, presence of county coalitions, and Initiative support for county coalitions. Mandatory PDMP registration was associated with a 25% decrease (95%CI, 0.71-0.79) in opioid prescribing rates after 24 months. Having a county coalition was associated with a 2% decrease (95%CI, 0.96-0.99) in the opioid prescribing rate; receiving Initiative support was associated with an additional 2% decrease (95%CI, 0.97-0.98). Mandatory PDMP registration and county coalitions were associated with a 35% decrease (95%CI, 0.43-0.97) and a 21% decrease (95% CI, 0.70-0.90), respectively in prescription opioid overdose deaths. Both interventions were also associated with significantly fewer deaths involving any opioid but had no significant association with non-fatal overdose rates. Findings add to the knowledge available to guide policy to prevent high-risk prescribing and opioid overdoses. While further study is needed, coalitions and mandatory PDMP registration may be important components in such efforts.
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Affiliation(s)
- Stephen G Henry
- Department of Internal Medicine, University of California Davis, 4150 V St Suite 2400, Sacramento, CA 95817, USA.
| | - Aaron B Shev
- Violence Prevention Research Program, University of California Davis, 2315 Stockton Blvd, Sacramento, CA 95817, USA
| | - David Crow
- Substance and Addiction Prevention Branch, California Department of Public Health, 1616 Capitol Ave MS 8701, Sacramento, CA 95814, USA
| | - Susan L Stewart
- Department of Public Health Sciences, University of California Davis, Medical Sciences 1-C, One Shields Ave, Davis, CA 95616, USA
| | - Garen J Wintemute
- Violence Prevention Research Program, University of California Davis, 2315 Stockton Blvd, Sacramento, CA 95817, USA
| | - Christine Fenlon
- Substance and Addiction Prevention Branch, California Department of Public Health, 1616 Capitol Ave MS 8701, Sacramento, CA 95814, USA
| | - Stephen J Wirtz
- Injury and Violence Prevention Branch, California Department of Public Health, 1616 Capitol Ave, Suite 74.436 MS 7214, Sacramento, CA 95814, USA
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Zhao L, Li Z, Fang L, Kim MJ, Nallani SC, Sahajwalla CG, Calderon SN, Roca RA, Feng K, Zineh I, Lionberger R. Association of partial systemic exposure and abuse potential for opioid analgesics with abuse deterrence labeling claims supporting product-specific guidance. EClinicalMedicine 2021; 41:101135. [PMID: 34585126 PMCID: PMC8455721 DOI: 10.1016/j.eclinm.2021.101135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Over the past decade, U.S. FDA has approved 10 opioid analgesics in abuse-deterrent formulations (ADFs). ADFs are intended to reduce abuse of a prescription opioid through manipulation of the product to use one or more routes of abuse. Although it is critically needed for evaluation of the abuse deterrent properties of an opioid product, the relationship between systemic exposure and likelihood of abuse of the opioid has not been fully characterized. To fill the current knowledge gap, we have evaluated the association of subjective measures predictive of abuse potential (e.g., scores of "drug liking," "take drug again"), which are referred to as 'pharmacodynamic (PD)' responses for measuring abuse potential, with systemic exposure of the opioid using the data from all the clinical abuse potential trials submitted to FDA in support of the approval of innovator ADFs. METHODS Extensive pharmacokinetic (PK) and subjective response data from 11 clinical abuse potential trials in recreational opioid users following oral and nasal administration of intact and manipulated oxycodone, hydrocodone and morphine products from the FDA internal database were utilized for the present analysis. This retrospective study used data collected from January 11th, 2010 until March 25th, 2015. The potential relationship between PK metrics, especially those for early exposure measures, and the subjective measures of drug liking and take drug again as PD metrics of abuse potential were explored using linear and logistic regression analyses. Heterogeneity analysis was conducted to assess study-to-study variation and multi-level logistic regression analysis was used to affirm the identified PK-PD relationship based on pooled data. FINDINGS Following oral and nasal administration of intact and manipulated opioids, the maximum visual analogue scale (VAS) for Drug Liking was generally achieved no later than the time to peak plasma drug concentration. Both heterogeneity analysis and multi-level logistic regression indicated insignificant inter study variability for the evaluated PK-PD relationships. Duration of Drug Liking response (i.e., VAS ≥ 65) lasted for 2 to 4 h after drug administration. The early portion of the systemic area under the plasma concentration-time curve (AUC), e.g., partial AUCs in the first 3 h and 4 h were found to be associated with abuse potential measures including maximum Drug Liking VAS and maximum Taking Drug Again VAS. Neither a formulation factor (e.g., immediate-release vs. extended-release, intact vs. manipulated) nor a route of administration was identified as a significant factor together with early partial AUCs to predict the probability of maximum Drug Liking or maximum Take Drug Again responses being greater than or equal to 65. INTERPRETATION Our assessment indicates that the measure of early systemic drug exposure of opioids is the best predictor of the abuse potential response in recreational opioid users following oral or nasal administration of a single dose of an intact or manipulated abuse deterrent opioids. Our findings support FDA's recommendation of comparative PK studies with early partial AUCs as a supportive PK metric for the assessment of abuse deterrent properties of generic opioid drug products in the general and product-specific guidance's of ADFs. FUNDING The study was partially funded by Fiscal Year 2017 Critical Path of the Center for Drug Evaluation and Research at the U.S. Food and Drug Administration.
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Affiliation(s)
- Liang Zhao
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave., Silver Spring, MD 20993, USA
- Corresponding author.
| | - Zhichuan Li
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave., Silver Spring, MD 20993, USA
| | - Lanyan Fang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave., Silver Spring, MD 20993, USA
| | - Myong-Jin Kim
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave., Silver Spring, MD 20993, USA
| | - Srikanth C. Nallani
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Chandrahas G. Sahajwalla
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Silvia N. Calderon
- Controlled Substance Staff, Controlled Substance Program, Office of the Center Director, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rigoberto A. Roca
- Division of Anesthesia, Analgesia, and Addiction Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993, USA
| | - Kairui Feng
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave., Silver Spring, MD 20993, USA
| | - Issam Zineh
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Lionberger
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave., Silver Spring, MD 20993, USA
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Balbale SN, Cao L, Trivedi I, Stulberg JJ, Suda KJ, Gellad WF, Evans CT, Lambert BL, Jordan N, Keefer LA. High-Dose Opioid Use Among Veterans with Unexplained Gastrointestinal Symptoms Versus Structural Gastrointestinal Diagnoses. Dig Dis Sci 2021; 66:3938-50. [PMID: 33385263 DOI: 10.1007/s10620-020-06742-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND In a cohort of Veterans dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D, we sought to describe high-dose daily opioid use among Veterans with unexplained gastrointestinal (GI) symptoms and structural GI diagnoses and examine factors associated with high-dose use. METHODS We used linked national patient-level data from the VA and Centers for Medicare and Medicaid Services (CMS). We grouped patients into 3 subsets: those with unexplained GI symptoms (e.g., chronic abdominal pain); structural GI diagnoses (e.g., chronic pancreatitis); and those with a concurrent unexplained GI symptom and structural GI diagnosis. High-dose daily opioid use levels were examined as a binary variable [≥ 100 morphine milligram equivalents (MME)/day] and as an ordinal variable (50-99 MME/day, 100-119 MME/day, or ≥ 120 MME/day). RESULTS We identified 141,805 chronic GI patients dually enrolled in VA and Part D. High-dose opioid use was present in 11% of Veterans with unexplained GI symptoms, 10% of Veterans with structural GI diagnoses, and 15% of Veterans in the concurrent GI group. Compared to Veterans with only an unexplained GI symptom or structural diagnosis, concurrent GI patients were more likely to have higher daily opioid doses, more opioid days ≥ 100 MME, and higher risk of chronic use. Factors associated with high-dose use included opioid receipt from both VA and Part D, younger age, and benzodiazepine use. CONCLUSIONS A significant subset of chronic GI patients in the VA are high-dose opioid users. Efforts are needed to reduce high-dose use among Veterans with concurrent GI symptoms and diagnoses.
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Paula M, Vappu R, Hannu K, Juhani VL, Kari P. Opioid use frequency in early axial spondyloarthritis in Finland - a pharmacoepidemic register study. Joint Bone Spine 2021; 89:105302. [PMID: 34687895 DOI: 10.1016/j.jbspin.2021.105302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 10/03/2021] [Accepted: 10/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate opioid use among incident axial spondyloarthritis (axSpA) patients compared to general population. METHODS From the national register, we identified all adult patients with axSpA (ICD-10 codes M45-46), who between 2010 and 2014 (index date, ID) were for the first time granted special reimbursement for any disease-modifying anti-rheumatic drugs (DMARDs). Three matched population controls were identified for each patient. Drug purchases were evaluated between 2009-15, and opioid use was analyzed for one year before and after the ID. The Defined Daily Dose (DDD) was used as a tool to assess the opioid consumption before and after the biological (b) DMARD initiation. RESULTS We identified 3,577 axSpA patients and 10,573 controls. Of these patients, 97.2% started a conventional synthetic (cs) DMARD during a year after ID and 23.4% switched later to a self-injected bDMARD between the ID and 31 Dec 2015 (median follow-up 3.4 years). Opioids were purchased at least once by 29.8% and 21.7% of the patients in the years before and after the ID, respectively, compared to 8.1% and 7.8% of the controls. The proportion of opioid-using patients was greatest during the last quarter before the ID [relative risk (RR) 4.72 (95% CI 4.14 to 5.39)] compared to controls, and it remained higher [RR 2.84 (2.59 to 3.11)] also after the start of csDMARDs. DDD of opioid consumption decreased from 7.7 to 1.6/1,000 inhabitants after bDMARD initiation. CONCLUSION Considerably more axSpA patients than population controls used opioids. The opioid consumption by dose decreased clearly after bDMARD initiation.
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Affiliation(s)
- Muilu Paula
- Department of Internal Medicine, Centre for Rheumatic Diseases, Tampere University Hospital, Tampere, Finland.
| | - Rantalaiho Vappu
- Department of Internal Medicine, Kanta-Hame Central Hospital, Hameenlinna, Finland; Department of Internal Medicine, Centre for Rheumatic Diseases, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kautiainen Hannu
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland; Folkhälsan Research Center, Helsinki, Finland
| | - Virta Lauri Juhani
- Research Department, Social Insurance Institution of Finland, Turku, Finland
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Svensson CJ, Lundberg CE, Sandström TZ, Andrell P, Thörn SE, Rosengren A, Wolf A. Opioid consumption in patients undergoing Roux-en-Y bariatric surgery compared with population controls with and without obesity. Surg Obes Relat Dis 2021; 18:107-116. [PMID: 34493454 DOI: 10.1016/j.soard.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/24/2021] [Accepted: 08/08/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Patients with obesity are prescribed more opioids than the general population. OBJECTIVES To compare opioid consumption in patients with obesity who underwent Roux-en-Y bariatric surgery (RYGB) with population controls with and without obesity, not undergoing bariatric surgery, and to identify characteristics associated with opioid use. SETTING This study included all patients with a principal diagnosis of obesity, aged 18-72 years, with a RYGB surgical code in the Swedish Patient Register between 2007 and 2013. METHODS RYGB patients (n = 23,898) were age- and sex-matched with 1 control patient with obesity (n = 23,898) and 2 population controls without obesity (n = 46,064). Participants were classified as nonconsumers and consumers based on their opioid dispensations during the 12 months before baseline. Opioid consumption was assessed for 24 months. RESULTS Nonconsumers. Within 24 months, a significantly higher proportion of RYGB patients (16.6%) started using opioids compared with the controls with obesity (14.3%, P < .0001) and population controls (5.4%, P < .0001). RYGB patients and controls with obesity had higher median daily intake of opioid morphine equivalent (MEQ) (2.8 mg/d) than population controls (2.5 mg/d, P < .0001). Consumers. Within 24 months, the proportion of RYGB patients and controls with obesity that was using opioids were similar (53.1% and 53.4%), but higher compared to population controls (38.0%, P < .0001). The median daily opioid MEQ was higher among RYGB patients than in population controls (10.5 versus 7.8 mg/d, P < .0001). RYGB patients, overall, had higher incidence of bowel surgery and cholecystectomy compared with controls with obesity and population controls, leading to prolonged opioid use in this group. Opioid consumption in general was associated with chronic pain and psychiatric disorder, which were more common in patients with obesity than in the population controls. CONCLUSION RYGB surgery increased the risk of prolonged opioid use in patients with obesity who were nonconsumers before surgery but had no effect on overall opioid use among prior consumers. RYGB-associated complications requiring surgery influenced opioid use for both nonconsumers and consumers. Regular reassessments of pain mechanisms and specific treatment owing to type of pain could prevent unnecessary opioid use in this patient group.
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Affiliation(s)
- Carl Johan Svensson
- Department of Anaesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden; Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Christina E Lundberg
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tatiana Zverkova Sandström
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Paulin Andrell
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sven-Egron Thörn
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine Geriatrics and Emergency Medicine/Östra, Gothenburg, Sweden
| | - Axel Wolf
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Abstract
In recent years the prescription opioid overdose epidemic has decreased, but has been more than offset by increases in overdose caused by fentanyl and fentanyl analogues. Opioid overdose patients should receive naloxone if they have significant respiratory depression and/or loss of protective airway reflexes. Patients who receive naloxone should be observed for recurrent opioid effects. Patients with opioid overdose may be admitted to the intensive care unit for naloxone infusions, treatment of noncardiogenic pulmonary edema, autonomic instability, or sequelae of hypoxia-ischemia or cardiac arrest. Primary and secondary prevention are important to reduce the number of people with life-threatening opioid overdose.
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Khan M, Joyce E, Horn J, Scoville JP, Ravindra V, Menacho ST. Postoperative bowel complications after non-shunt-related neurosurgical procedures: case series and review of the literature. Neurosurg Rev 2021; 45:275-283. [PMID: 34297261 DOI: 10.1007/s10143-021-01609-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/02/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
Postoperative bowel complications after non-shunt-related neurosurgical procedures are relatively rare. In an effort to identify the primary risk factors, we evaluated postoperative bowel complications in cranial, endovascular, and spinal procedures in neurosurgery patients using our own institutional case series along with a literature review.We identified severe postoperative bowel complications that occurred at our institution after non-shunt-related neurosurgical procedures between July 2016 and December 2018. We also completed a systematic review of PubMed/MEDLINE using search terms related to bowel complications.At our institution, 7 patients (average age 49.7 ± 9.5 years, range 34-60; no apparent sex predilection) had severe postoperative bowel complications after undergoing a total of 10 neurosurgical procedures. Diagnosis was on average 1 week postoperatively (range 5-13 days), and the time between radiographic/clinical diagnosis and either surgery or death was 1.3 ± 1.4 days (range 0-4 days). Bowel perforation occurred in 4 patients. Five of the patients died, 3 as a direct result of the bowel complication. In the literature review, we identified 6487 spine and 66 cranial and/or endovascular bowel complications after neurosurgical procedures.Our case series and literature review demonstrate that severe postoperative bowel complications after non-shunt-related neurosurgical procedures, while rare, carry significant morbidity/mortality despite prompt and aggressive management. These can also happen without direct injury to bowel tissue, instead occurring as sequelae of inflammatory processes, as well as from delayed mobility, extended use of opiate narcotics, and lack of standardized protocols to ensure early bowel movements that likely stems from unfamiliarity with this potentially devastating complication.
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Affiliation(s)
- Majid Khan
- University of Nevado, Reno School of Medicine, Reno, NV, USA
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Jeffrey Horn
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Jonathan P Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Vijay Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Sarah T Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT, 84132, USA.
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Wang X, Narayan SW, Penm J, Johnstone C, Patanwala AE. Gastrointestinal Adverse Events in Hospitalized Patients Following Orthopedic Surgery: Tapentadol Immediate Release Versus Oxycodone Immediate Release. Pain Physician 2021; 24:E309-E315. [PMID: 33988952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Tapentadol has relatively less effect on mu-opioid receptors compared with other opioids. This has the potential to reduce the occurrence of gastrointestinal (GI) adverse drug events (ADEs). OBJECTIVES To compare the GI ADEs during hospitalization between tapentadol immediate release (IR) and oxycodone IR following orthopedic surgeries. STUDY DESIGN Retrospective cohort study. SETTING A major metropolitan tertiary referral hospital in Australia. METHODS Data for adult orthopedic surgery patients receiving postoperative tapentadol IR or oxycodone IR during hospitalization between January 1, 2018 and June 30, 2019, were collected from electronic medical records. The primary outcome was the occurrence of postoperative GI ADEs occurring during hospitalization. This was defined as a composite of nausea, vomiting, or constipation. RESULTS The study cohort included 199 patients. Of these, 99 patients received tapentadol IR and 100 patients received oxycodone IR for postoperative pain during hospitalization. The mean age was 66 ± 12 years, and 111 patients (56%) were women. There was no significant difference between groups on the occurrence of GI ADEs (53% in oxycodone group and 51% in tapentadol group, difference 2%, 95% confidence interval [CI], -11% to 16%; P = 0.777). After adjusting for potential confounders, the use of tapentadol IR was not associated with a significant reduction of GI ADEs (odds ratio, 0.62; 95% CI, 0.32-1.20; P = 0.154). LIMITATIONS This was a single-center study and should be extrapolated with caution. As this was a retrospective study, the accuracy and availability of data were dependent on documentation in electronic medical records. CONCLUSIONS Tapentadol IR is associated with similar GI ADE occurrence compared with oxycodone IR in patients with orthopedic postoperative pain during hospitalization.
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Affiliation(s)
- Xinyi Wang
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia
| | - Sujita W Narayan
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia
| | - Jonathan Penm
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia
| | - Charlotte Johnstone
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Asad E Patanwala
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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de Araújo IDT, de Sousa Santos K, das Neves Peixoto TVO, Costa MJF, de Assunção IV, Borges BCD. The combined use of systemic analgesic/anti-inflammatory drugs and a bioactive topical desensitizer for reduced in-office bleaching sensitivity without jeopardizing the hydrogen peroxide efficacy: a randomized, triple blinded, split-mouth clinical trial. Clin Oral Investig 2021. [PMID: 33884504 DOI: 10.1007/s00784-021-03948-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the effect of combined systemic administration of paracetamol 500 mg/codeine phosphate 30 mg (PACO) and postoperative topical application of a bioactive desensitizer on in-office bleaching sensitivity and tooth color change. MATERIALS AND METHODS A randomized, triple-blind, split-mouth clinical trial was conducted. Forty volunteers ingested PACO (n = 20) or placebo (PLA) (n = 20). Their left/right hemiarches received topical application of a bioactive desensitizer [Nano-P™(NP)] and prophylactic paste (PAS), generating four treatment approaches: PACO/NP, PACO/PAS, PLA/NP, and PLA/PAS. Two bleaching sessions (35% hydrogen peroxide) were performed, and the PAS/NP were applied after the procedure. Sensitivity was obtained since the first bleaching session up to 7 days post-bleaching. The color change was evaluated using CIEDE2000 and whiteness index parameters up to 7 days post-bleaching. Data were analyzed using one- and two-way ANOVA/Tukey post hoc tests (p < 0.05). RESULTS The PLA/PAS showed a sensitivity average of at least two times higher than the PACO/NP. The treatment approaches promoted statistically similar bleaching patterns (p > 0.05). CONCLUSION The combined approach of systemic administration of PACO and postoperative topical application of NP reduced the level of in-office bleaching sensitivity without jeopardizing hydrogen peroxide efficacy. CLINICAL RELEVANCE Professionals can adopt the combined approach of systemic administration of analgesic/anti-inflammatory drugs and topical application of a bioactive desensitizer for decreased bleaching sensitivity caused by 35% hydrogen peroxide in-office.
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Fernandez AC, Lin LA, Bazzi AR, Boissoneault J, Borsari B, Blow F. Beliefs about Perioperative Opioid and Alcohol Use among Elective Surgical Patients Who Report Unhealthy Drinking: A Qualitative Study. Pain Med 2021; 22:2384-2392. [PMID: 33892495 PMCID: PMC8500720 DOI: 10.1093/pm/pnab104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Elective surgical patients with unhealthy alcohol use have unique pain management needs and addiction risk factors that are relevant to surgical preparation and recovery. This descriptive qualitative study sought to better understand patients' beliefs and behaviors related to opioid use, alcohol use, and pain management in the perioperative context. DESIGN We conducted individual semi-structured interviews between July 2017 and March 2018. SETTING A large Midwestern academic health system. SUBJECTS Participants were elective surgical patients meeting unhealthy alcohol use criteria, recruited from the health system's preoperative anesthesia clinic. METHOD Semi-structured interview guides explored beliefs and behaviors relating to alcohol and opioid use, health status, and surgical care. Interview recordings were transcribed and coded for thematic analysis. RESULTS Among 20 elective surgical patients (25% female), we identified three key themes regarding alcohol use, opioid use, and their co-use before and after surgery. First, desires and intentions to use opioids for postoperative pain management varied widely, even before opioids were prescribed. Second, some participants described alcohol as a preferred pain management strategy. Third, participants held a range of beliefs about the risks and benefits of alcohol and opioid co-use. CONCLUSION Appropriate assessment of beliefs and intentions regarding opioid and alcohol use could help identify patients most vulnerable to new opioid problems and unhealthy alcohol use in the context of perioperative surgical pain. These findings have important implications for perioperative pain management.
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Affiliation(s)
- Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
- Correspondence to: Anne C. Fernandez, PhD, Department of Psychiatry, University of Michigan. North Campus Research Complex, 2800 PlymouthRoad, Building 16, Ann Arbor, MI 48109, USA. Tel: 734-232-0313; Fax: 734-764-7932; E-mail:
| | - Lewei A Lin
- Department of Psychiatry, University of Michigan and Center for Clinical Management Research, HSR&D, Veterans Affairs Health Care System, Ann Arbor, Michigan
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California
| | - Jeff Boissoneault
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Brian Borsari
- Department of Psychiatry and Behavioral Sciences, San Francisco Veterans Affairs Health Care System, University of California San Francisco, San Francisco, California, USA
| | - Frederic Blow
- Department of Psychiatry, University of Michigan and Center for Clinical Management Research, HSR&D, Veterans Affairs Health Care System, Ann Arbor, Michigan
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