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Glancy M, Palmateer N, Yeung A, Hickman M, Macleod J, Bishop J, Barnsdale L, Trayner KM, Priyadarshi S, Wallace J, Hutchinson S, McAuley A. Risk of drug-related death associated with co-prescribing of gabapentinoids and Z-drugs among people receiving opioid-agonist treatment: A national retrospective cohort study. Psychiatry Res 2024; 339:116028. [PMID: 38917674 DOI: 10.1016/j.psychres.2024.116028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/28/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Prescribing of gabapentinoids and Z-drug-hypnotics has increased in the population and among people receiving opioid-agonist treatment (OAT) for opioid dependence. Evidence is mixed on whether co-prescribing of sedatives such as gabapentinoids and Z-drugs during OAT increases risk of drug-related death (DRD). METHODS We conducted a retrospective cohort study of individuals prescribed OAT between 2011 and 2020 in Scotland. Prescribing records were linked to mortality data and other healthcare datasets (sociodemographic, comorbidity). We identified episodes of treatment with gabapentinoids/Z-drugs and used multivariable quasi-Poisson regression to model associations between co-prescription and DRD risk. RESULTS Among 46,602 individuals with 304,783 person-years of follow-up, we found that co-prescription was common, with 25 % and 34 % ever being co-prescribed gabapentinoids and Z-drugs, respectively. Gabapentinoid exposure was strongly associated (adjusted hazard ratio (aHR)=2·18, 95 % CI=1·92, 2·46) and Z-drug exposure moderately associated (aHR=1·39, 95 % CI=1·15, 1·66) with elevated risk of DRD. Gabapentinoid exposure was associated with DRD risk on and off OAT; Z-drug exposure was less strongly associated with DRD risk when on OAT. CONCLUSIONS Co-prescription of gabapentinoids and Z-drugs is common among OAT patients. However, co-prescription is associated with increased risk of DRD. Alternatives to prescribing sedative medications to OAT patients and/or greater monitoring - if prescribed - are needed.
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Affiliation(s)
- Megan Glancy
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK.
| | - Norah Palmateer
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| | - Alan Yeung
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Macleod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Kirsten Ma Trayner
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| | - Saket Priyadarshi
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Glasgow Alcohol and Drug Recovery Services, NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | - Sharon Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| | - Andrew McAuley
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
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Jain L, Meeks TW, Blazes CK. Reconsidering the usefulness of long-term high-dose buprenorphine. Front Psychiatry 2024; 15:1401676. [PMID: 39114740 PMCID: PMC11303732 DOI: 10.3389/fpsyt.2024.1401676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/04/2024] [Indexed: 08/10/2024] Open
Abstract
Buprenorphine has been successfully used for decades in the treatment of opioid use disorder, yet there are complexities to its use that warrant attention to maximize its utility. While the package insert of the combination product buprenorphine\naloxone continues to recommend a maximum dose of 16 mg daily for maintenance, the emergence of fentanyl and synthetic analogs in the current drug supply may be limiting the effectiveness of this standard dose. Many practitioners have embraced and appropriately implemented novel practices to mitigate the sequelae of our current crisis. It has become common clinical practice to stabilize patients with 24 - 32 mg of buprenorphine daily at treatment initiation. Many of these patients, however, are maintained on these high doses (>16 mg/d) indefinitely, even after prolonged stability. Although this may be a necessary strategy in the short term, there is little evidence to support its safety and efficacy, and these high doses may be exposing patients to more complications and side effects than standard doses. Commonly known side effects of buprenorphine that are likely dose-related include hyperhidrosis, sedation, decreased libido, constipation, and hypogonadism. There are also complications related to the active metabolite of buprenorphine (norbuprenorphine) which is a full agonist at the mu opioid receptor and does not have a ceiling on respiratory suppression. Such side effects can lead to medical morbidity as well as decreased medication adherence, and we, therefore, recommend that after a period of stabilization, practitioners consider a trial of decreasing the dose of buprenorphine toward standard dose recommendations. Some patients' path of recovery may never reach this stabilization phase (i.e., several months of adherence to medications, opioid abstinence, and other clinical indicators of stability). Side effects of buprenorphine may not have much salience when patients are struggling for survival and safety, but for those who are fortunate enough to advance in their recovery, the side effects become more problematic and can limit quality of life and adherence.
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Affiliation(s)
- Lakshit Jain
- Department of Psychiatry, University of Connecticut, Farmington, CT, United States
| | - Thomas W. Meeks
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Christopher K. Blazes
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
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Rudolph KE, Williams NT, Diaz I, Forrest S, Hoffman KL, Samples H, Olfson M, Doan L, Cerda M, Ross RK. Pain Management Treatments and Opioid Use Disorder Risk in Medicaid Patients. Am J Prev Med 2024:S0749-3797(24)00248-4. [PMID: 39025248 DOI: 10.1016/j.amepre.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION People with chronic pain are at increased risk of opioid misuse. Less is known about the unique risk conferred by each pain management treatment, as treatments are typically implemented together, confounding their independent effects. This study estimated the extent to which pain management treatments were associated with risk of opioid use disorder (OUD) for those with chronic pain, controlling for baseline demographic and clinical confounding variables and holding other pain management treatments at their observed levels. METHODS Data were analyzed in 2024 from 2 chronic pain subgroups within a cohort of non-pregnant Medicaid patients aged 35-64 years, 2016-2019, from 25 states: those with (1) chronic pain and physical disability (CPPD) (N=6,133) or (2) chronic pain without disability (CP) (N=67,438). Nine pain management treatments were considered: prescription opioid (1) dose and (2) duration; (3) number of opioid prescribers; opioid co-prescription with (4) benzo- diazepines, (5) muscle relaxants, and (6) gabapentinoids; (7) nonopioid pain prescription, (8) physical therapy, and (9) other pain treatment modality. The outcome was OUD risk. RESULTS Having opioids co-prescribed with gabapentin or benzodiazepine was statistically significantly associated with a 37-45% increased OUD risk for the CP subgroup. Opioid dose and duration also were significantly associated with increased OUD risk in this subgroup. Physical therapy was significantly associated with an 18% decreased risk of OUD in the CP subgroup. DISCUSSION Coprescription of opioids with either gabapentin or benzodiazepines may substantially increase OUD risk. More positively, physical therapy may be a relatively accessible and safe pain management strategy.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
| | - Nicholas T Williams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Ivan Diaz
- Division of Biostatistics, New York University Grossman School of Medicine, New York, New York
| | - Sarah Forrest
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Katherine L Hoffman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Hillary Samples
- Rutgers Institute for Health, Rutgers University, New Brunswick, New Jersey
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Lisa Doan
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Grossman School of Medicine, New York, New York
| | - Magdalena Cerda
- Division of Epidemiology, New York University Grossman School of Medicine, New York, New York
| | - Rachael K Ross
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Ip VHY, Uppal V, Kwofie K, Shah U, Wong PBY. Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations. Can J Anaesth 2024; 71:898-920. [PMID: 38504037 DOI: 10.1007/s12630-024-02699-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 03/21/2024] Open
Abstract
PURPOSE Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways. SOURCE We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature. PRINCIPAL FINDINGS Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen. CONCLUSION Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.
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Affiliation(s)
- Vivian H Y Ip
- Department of Anesthesia, Perioperative and Pain Medicine, University of Calgary, Calgary, AB, Canada
| | - Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kwesi Kwofie
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ushma Shah
- Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada
| | - Patrick B Y Wong
- Department of Anesthesiology and Pain Medicine, University of Ottawa, 501 Smyth Rd, CCW 1401, Ottawa, ON, K1H 8L6, Canada.
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Blike GT, McGrath SP, Ochs Kinney MA, Gali B. Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients. Anesth Analg 2024; 138:955-966. [PMID: 38621283 DOI: 10.1213/ane.0000000000006840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.
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Affiliation(s)
- George T Blike
- From the Departments of Anesthesiology
- Community and Family Medicine, Geisel School of Medicine, Hanover, New Hampshire
- The Dartmouth Institute, Dartmouth College, Hanover, New Hampshire
- Surveillance Analytics Core, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Susan P McGrath
- From the Departments of Anesthesiology
- Surveillance Analytics Core, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michelle A Ochs Kinney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bhargavi Gali
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Rivera D, Muniz-Sarriera AB, Marcial J, Torres H, Colón-Rodríguez E, Crespo MJ. Acute Respiratory Failure Secondary to Low-Dose Opioid Administration in a Patient With Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome After Undergoing Trans-sphenoidal Tumor Resection. Cureus 2024; 16:e56973. [PMID: 38665747 PMCID: PMC11045160 DOI: 10.7759/cureus.56973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
We present a case of an obese 56-year-old male with obstructive sleep apnea (OSA), obesity hypoventilation syndrome (OHS), and pituitary macroadenoma, who underwent nasal endoscopic trans-sphenoidal resection. Surgery was performed under general anesthesia, uneventfully as planned. The patient experienced, however, delayed emergence despite receiving adequate neuromuscular blockade agent reversal. Extubation was performed and the patient was transferred to the recovery room on a Venturi mask (50% fraction of inspired oxygen, FIO2)and 93% saturation. Postoperatively, the patient was complaining of acute pain that did not resolve with non-opioid medications and a low morphine dose (0.035 mg/kg) for pain management was administered. Subsequently, he developed severe respiratory depression, requiring intubation. After three hours, the patient was extubated, transferred to the intensive care unit, and discharged five days later. Although the patient recovered favorably, this case highlights the risks of administering opioids to patients with OSA and OHS. To our knowledge, this is the first case reporting extreme respiratory depression secondary to the administration of a very low dose of morphine in patients with these comorbidities. Therefore, it is essential to be cautious with the use of opioids and to explore multimodal pain relief methods for these patients.
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Affiliation(s)
- Dennys Rivera
- Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, USA
| | | | - Joshua Marcial
- Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, USA
| | - Hector Torres
- Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, USA
| | | | - Maria J Crespo
- Physiology and Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, USA
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Billig JI, Bicket MC, Yazdanfar M, Gunaseelan V, Sears ED, Brummett CM, Waljee JF. Cohort study of new off-label gabapentin prescribing in chronic opioid users. Reg Anesth Pain Med 2024; 49:88-93. [PMID: 37380198 DOI: 10.1136/rapm-2023-104613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Gabapentin is commonly prescribed as an off-label adjunct to opioids because of its safer risk profile. Recent evidence has shown an increased risk of mortality when coprescribed with opioids. Therefore, we aimed to evaluate whether the addition of off-label gabapentin in patients with chronic opioid use is associated with a reduction in opioid dosage. METHODS We performed a retrospective cohort study of patients with chronic opioid use with a new off-label gabapentin prescription (2010-2019). Our primary outcome of interest was a reduction in opioid dosage measured via oral morphine equivalents (OME) per day after the addition of a new off-label gabapentin prescription. RESULTS In our cohort of 172,607 patients, a new off-label gabapentin prescription was associated with a decrease in opioid dosage in 67,016 patients (38.8%) (median OME/day reduction:13.8), with no change in opioid dosage in 24,468 patients (14.2%), and an increase in opioid dosage in 81,123 patients (47.0%) (median OME/day increase: 14.3). A history of substance/alcohol use disorders was associated with a decrease in opioid dosage after the addition of a new off-label gabapentin (aOR 1.20, 95% CI 1.16 to 1.23). A history of pain disorders was associated with a decrease in opioid dosage after the initiation of a new gabapentin prescription including arthritis (aOR 1.12, 95% CI 1.09 to 1.15), back pain (aOR 1.10, 95% CI 1.07 to 1.12), and other pain conditions (aOR 1.08, 95% CI 1.06 to 1.10). CONCLUSIONS In this study of patients with chronic opioid use, an off-label gabapentin prescription did not reduce opioid dosage in the majority of patients. The coprescribing of these medications should be critically evaluated to ensure optimal patient safety.
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Affiliation(s)
- Jessica I Billig
- Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Mark C Bicket
- Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Maryam Yazdanfar
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Vidhya Gunaseelan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Erika D Sears
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
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Kim E, Raji MA, Westra J, Wilkes D, Kuo YF. Comparative effectiveness of pain control between opioids and gabapentinoids in older patients with chronic pain. Pain 2024; 165:144-152. [PMID: 37561652 PMCID: PMC10838352 DOI: 10.1097/j.pain.0000000000003006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/16/2023] [Indexed: 08/12/2023]
Abstract
ABSTRACT Gabapentinoid (GABA) prescribing has substantially increased while opioid prescribing has decreased since the 2016 Centers for Disease Control and Prevention Guidelines restricted opioid prescribing for chronic pain. The shift to GABA assumes equal analgesic effectiveness to opioids, but no comparative analgesic effectiveness data exist to support this assumption. We compared GABA to opioids by assessing changes in pain interfering with activities (activity-limiting pain) over time in patients with chronic pain. We used 2017 to 2019 data from a 20% national sample of Medicare beneficiaries diagnosed with chronic pain who initiated a GABA or opioid prescription for ≥30 continuous days and received home health care in the study year. The main outcome was the difference in reduction in pain score from pre- to post-prescription assessments between the 2 groups. Within a 60-day window before-and-after drug initiation, our sample comprised 3208 GABA users and 2846 opioid users. Reduction in post-prescription scores of pain-related interference with activities to less-than-daily pain was 48.1% in the GABA group and 41.7% in the opioid group; this remained significant (odds ratio = 1.29, 95% confidence interval: 1.17-1.43, P < 0.0001) after adjustment for patient demographics and comorbidities. The adjusted difference in reduced pain-related interference score between the 2 groups was -0.10 points on a 0 to 4 scale ( P = 0.01). Gabapentinoid use had greater odds of less-than-daily pain post-prescription, in a dose-dependent manner. Thus, GABA use was associated with a larger reduction in chronic pain than opioids, with a larger effect at higher GABA dosage. Future research is needed on functional outcomes in patients with chronic pain prescribed GABA or opioids.
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Affiliation(s)
- Emily Kim
- School of Medicine, University of Texas Medical Branch, Galveston, TX, 77555
| | - Mukaila A Raji
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, 77555
- Department of Biostatistics & Data Science, University of Texas Medical Branch, Galveston, TX, 77555
| | - Jordan Westra
- Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, 77555
| | - Denise Wilkes
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, 77555
| | - Yong-Fang Kuo
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, 77555
- Department of Biostatistics & Data Science, University of Texas Medical Branch, Galveston, TX, 77555
- Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, 77555
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Bharat C, Gisev N, Barbieri S, Dobbins T, Larney S, Buizen L, Degenhardt L. Prescription opioid use among people with opioid dependence and concurrent benzodiazepine and gabapentinoid exposure: An analysis of overdose and all-cause mortality. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 123:104287. [PMID: 38088003 DOI: 10.1016/j.drugpo.2023.104287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Studies investigating mortality risk associated with use of opioid analgesics, benzodiazepines, gabapentinoids, and opioid agonist treatment (OAT) among people with opioid dependence (PWOD) are lacking. This study addresses this gap using a cohort of 37,994 PWOD initiating opioid analgesics between July 2003 and July 2018 in New South Wales, Australia. METHODS Linked administrative records provided data on dispensings, sociodemographics, clinical characteristics, OAT, and mortality. Cox proportional hazards models assessed associations between time-varying measures of individual and concurrent medicine use and OAT with all-cause mortality, accidental opioid overdose, non-drug induced accidents, and non-drug-induced suicide. Opioid analgesic dose effects, expressed as oral morphine equivalents (OMEs) per day, were also examined. OUTCOMES During the study period, 3167 individuals died. Compared with no use, all medicines of interest were associated with increased accidental opioid overdose risk; hazard ratios (HR) ranged from 1.33 (95 % CI: 1.05-1.68) for opioid analgesic use to 6.10 (95 % CI: 4.11-9.06) for opioid analgesic, benzodiazepine and gabapentinoid use. Benzodiazepine use was associated with increased non-drug-induced accidents and non-drug-induced suicides. For all-cause mortality, all combinations of benzodiazepines and gabapentinoids with opioid analgesics were associated with increased risk (aHRs ranged from 1.35 to 2.73). For most medicines/medicine combinations, all-cause mortality risk was reduced when in OAT compared to out of OAT. Higher opioid analgesic doses were associated with increased all-cause mortality (e.g., 90-199 mg vs 1-49 mg OME per day: HR 1.90 [95 % CI: 1.52-2.40]). INTERPRETATION The increased mortality risk associated with benzodiazepines and gabapentinoids among PWOD appear to be reduced when engaged in OAT. A greater focus on encouraging OAT engagement, providing overdose prevention education, and access and coverage of overdose antidotes is necessary to minimise the unintended consequences of medicines use in this population.
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Affiliation(s)
- Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | | | | | - Sarah Larney
- Université de Montréal and Centre de Recherche du CHUM, Montreal, Canada
| | - Luke Buizen
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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Ellis MS, Xu KY, Tardelli VS, Fidalgo TM, Buttram ME, Grucza RA. Gabapentin Use Among Individuals Initiating Buprenorphine Treatment for Opioid Use Disorder. JAMA Psychiatry 2023; 80:1269-1276. [PMID: 37672238 PMCID: PMC10483381 DOI: 10.1001/jamapsychiatry.2023.3145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/05/2023] [Indexed: 09/07/2023]
Abstract
Importance Gabapentin prescriptions have drastically increased in the US due to off-label prescribing in settings such as opioid use disorder (OUD) treatment to manage a range of comorbid conditions and withdrawal symptoms, despite a lack of evidence. Objective To assess the purpose and associated risks of off-label gabapentin use in OUD treatment. Design, Setting, and Participants This retrospective recurrent-event case-control study with a crossover design used administrative claims data from MarketScan Commercial and Multi-State Medicaid databases from January 1, 2006, to December 31, 2016. Individuals aged 12 to 64 years with an OUD diagnosis and filling buprenorphine prescriptions were included in the primary analysis conducted from July 1, 2022, through June 1, 2023. Unit of observation was the person-day. Exposures Days covered by filled gabapentin prescriptions. Main Outcomes and Measures Primary outcomes were receipt of gabapentin in the 90 days after initiation of buprenorphine treatment and drug-related poisoning. Drug-related poisonings were defined using codes from International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Results A total of 109 407 patients were included in the analysis (mean [SD] age, 34.0 [11.2] years; 60 112 [54.9%] male). Among the 29 967 patients with Medicaid coverage, 299 (1.0%) were Hispanic, 1330 (4.4%) were non-Hispanic Black, 23 112 (77.1%) were non-Hispanic White, and 3399 (11.3%) were other. Gabapentin was significantly less likely to be prescribed to Black or Hispanic patients, and more likely to be prescribed to female patients, those with co-occurring substance use or mood disorders, and those with comorbid physical conditions such as neuropathic pain. Nearly one-third of persons who received gabapentin (4336 [31.1%]) had at least 1 drug-related poisoning after initiating buprenorphine treatment, compared with 13 856 (14.5%) among persons who did not receive gabapentin. Adjusted analyses showed that days of gabapentin use were not associated with hospitalization for drug-related poisoning (odds ratio, 0.98 [95% CI, 0.85-1.13]). Drug-related poisoning risks did not vary based on dosage. Conclusions and Relevance Gabapentin is prescribed in the context of a myriad of comorbid conditions. Even though persons receiving gabapentin are more likely to have admissions for drug-related poisoning, these data suggest that gabapentin is not associated with an increased risk of drug-related poisoning alongside buprenorphine in adjusted analyses. More data on the safety profile of gabapentin in OUD settings are needed.
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Affiliation(s)
- Matthew S. Ellis
- Department of Psychiatry, Washington University in St Louis, School of Medicine, St Louis, Missouri
| | - Kevin Y. Xu
- Department of Psychiatry, Washington University in St Louis, School of Medicine, St Louis, Missouri
| | - Vitor S. Tardelli
- Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
- Translational Addictions Research Laboratory, Centre for Addictions and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Thiago M. Fidalgo
- Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mance E. Buttram
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville
| | - Richard A. Grucza
- Department of Family and Community Medicine, St Louis University, St Louis, Missouri
- Department of Health and Outcomes Research, St Louis University, St Louis, Missouri
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Maharjan S, Kertesz SG, Bhattacharya K, Markland A, McGwin G, Yang Y, Bentley JP, Ramachandran S. Coprescribing of opioids and psychotropic medications among Medicare-enrolled older adults on long-term opioid therapy. J Am Pharm Assoc (2003) 2023; 63:1753-1760.e5. [PMID: 37633452 DOI: 10.1016/j.japh.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Pressures to reduce opioid prescribing have potential to incentivize coprescribing of opioids (at lower dose) with psychotropic medications. Evidence concerning the extent of the problem is lacking. This study assessed trends in coprescribing and characterized coprescribing patterns among Medicare-enrolled older adults with chronic noncancer pain (CNCP) receiving long-term opioid therapy (LTOT). METHODS A cohort study was conducted using 2012-2018 5% National Medicare claims data. Eligible beneficiaries were continuously enrolled and had no claims for cancer diagnoses or hospice use, and ≥ 2 claims with diagnoses for CNCP conditions within a 30-day period in the 12 months before the index date (LTOT initiation). Coprescribing was defined as an overlap between opioids and any class of psychotropic medication (antidepressants, benzodiazepines, antipsychotics, anticonvulsants, muscle relaxants, and nonbenzodiazepine hypnotics) based on their prescription fill dates and days of supply in a given year. The occurrence of coprescribing, coprescribing intensity, and number of days of overlap with psychotropic medications were calculated for each calendar year. RESULTS The eligible study population of individuals on LTOT ranged from 2038 in 2013 to 1751 in 2018. The occurrence of coprescribing among eligible beneficiaries decreased from 73.41% in 2013 to 70.81% in 2015 and then increased slightly to 71.22% in 2018. Among eligible beneficiaries with at least one overlap day, the coprescribing intensity with any class of psychotropic medications showed minimal variation throughout the study period: 74.73% in 2013 and 72.67% in 2018. Across all the years, the coprescribing intensity was found to be highest with antidepressants (2013, 49.90%; 2018, 50.33%) followed by benzodiazepines (2013, 25.42%; 2018, 19.95%). CONCLUSION Coprescribing was common among older adults with CNCP who initiated LTOT but did not rise substantially in the period studied. Future research should investigate drivers behind coprescribing and safety of various patterns of use.
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Eide D, McDonald R, Hamina A, Clausen T, Odsbu I, Skurtveit S. Prescription high-risk polysubstance use among opioid maintenance treatment patients. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104196. [PMID: 37741700 DOI: 10.1016/j.drugpo.2023.104196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 08/01/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Among individuals receiving buprenorphine or methadone as opioid maintenance treatment (OMT), concomitant use of other central nervous system depressants, including prescription drugs, can increase risk of overdose. We aimed to 1) determine the prevalence of use of high-risk prescription drugs (opioid analgesics, benzodiazepines, benzodiazepine-related drugs, and gabapentinoids) among OMT patients, 2) calculate its associations with different mental health and pain-related diagnoses, and 3) compare prevalence of concomitant use with the general population. METHODS A national sample comprising all individuals filling at least one prescription of OMT drugs in Norway in 2019 was formed. Healthcare registry data were linked to investigate high-risk prescription drug use and different diagnoses. We calculated one-year prevalence of use, amount dispensed in defined daily doses (DDDs), and the number of prescribers for the different high-risk prescription drugs. Logistic regression was used to determine associations (adjusted odds ratios; aOR, 95% confidence intervals (CIs)) between diagnoses and use. Prevalence of use was calculated both in the OMT patient sample and the general population. RESULTS Among the OMT patient sample (n=7,299), 47.6% (n=3,476) filled prescriptions for benzodiazepines. For each high-risk prescription drug group, there was a median of 1-2 prescribers. Musculoskeletal diagnoses were the strongest factor for concomitant high-risk prescription drug use for both males (aOR 3.23, CI: 2.72-3.85) and females (aOR 3.07, CI: 2.42- 3.90). The 1-year prevalence of benzodiazepine use was 11.4 times higher for males and 7.1 times higher for females in OMT than the general population. The amount in DDDs was higher for every drug for OMT patients than the general population, particularly for benzodiazepines. CONCLUSIONS OMT patients frequently filled prescriptions for high-risk drugs, and in higher dosages than the general population. However, we found little evidence of 'doctor shopping.' Given that these prescription drugs carry overdose risk, particularly when combined with OMT drugs, our findings emphasize the continued need for education and caution to both prescribers and patients on their concomitant use with OMT.
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Affiliation(s)
- Desiree Eide
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway.
| | - Rebecca McDonald
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway
| | - Aleksi Hamina
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway
| | - Ingvild Odsbu
- Department of Chronic Diseases Norwegian Institute of Public Health, PO Box 222 Skøyen 0213 Oslo, Norway
| | - Svetlana Skurtveit
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway; Department of Chronic Diseases Norwegian Institute of Public Health, PO Box 222 Skøyen 0213 Oslo, Norway
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Nguyen AP, Glanz JM, Narwaney KJ, Zeng C, Wright L, Fairbairn LM, Binswanger IA. Update of a Multivariable Opioid Overdose Risk Prediction Model to Enhance Clinical Care for Long-term Opioid Therapy Patients. J Gen Intern Med 2023; 38:2678-2685. [PMID: 36944901 PMCID: PMC10506960 DOI: 10.1007/s11606-023-08149-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Clinical opioid overdose risk prediction models can be useful tools to reduce the risk of overdose in patients prescribed long-term opioid therapy (LTOT). However, evolving overdose risk environments and clinical practices in addition to potential harmful model misapplications require careful assessment prior to widespread implementation into clinical care. Models may need to be tailored to meet local clinical operational needs and intended applications in practice. OBJECTIVE To update and validate an existing opioid overdose risk model, the Kaiser Permanente Colorado Opioid Overdose (KPCOOR) Model, in patients prescribed LTOT for implementation in clinical care. DESIGN, SETTING, AND PARTICIPANTS The retrospective cohort study consisted of 33, 625 patients prescribed LTOT between January 2015 and June 2019 at Kaiser Permanente Colorado, with follow-up through June 2021. MAIN MEASURES The outcome consisted of fatal opioid overdoses identified from vital records and non-fatal opioid overdoses from emergency department and inpatient settings. Predictors included demographics, medication dispensings, substance use disorder history, mental health history, and medical diagnoses. Cox proportional hazards regressions were used to model 2-year overdose risk. KEY RESULTS During follow-up, 65 incident opioid overdoses were observed (111.4 overdoses per 100,000 person-years) in the study cohort, of which 11 were fatal. The optimal risk model needed to risk-stratify patients and to be easily interpreted by clinicians. The original 5-variable model re-validated on the new study cohort had a bootstrap-corrected C-statistic of 0.73 (95% CI, 0.64-0.85) compared to a C-statistic of 0.80 (95% CI, 0.70-0.88) in the updated model and 0.77 (95% CI, 0.66-0.87) in the final adapted 7-variable model, which was also well-calibrated. CONCLUSIONS Updating and adapting predictors for opioid overdose in the KPCOOR Model with input from clinical partners resulted in a parsimonious and clinically relevant model that was poised for integration in clinical care.
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Affiliation(s)
- Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
| | - Leslie Wright
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
| | | | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
- Colorado Permanente Medical Group, Denver, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA
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Azizad O, Joshi GP. Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns. Best Pract Res Clin Anaesthesiol 2023; 37:317-330. [PMID: 37938079 DOI: 10.1016/j.bpa.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.
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Affiliation(s)
- Omaira Azizad
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Zammit A, Coquet J, Hah J, el Hajouji O, Asch SM, Carroll I, Curtin CM, Hernandez-Boussard T. Postoperative opioid prescribing patients with diabetes: Opportunities for personalized pain management. PLoS One 2023; 18:e0287697. [PMID: 37616195 PMCID: PMC10449216 DOI: 10.1371/journal.pone.0287697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/12/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Opioids are commonly prescribed for postoperative pain, but may lead to prolonged use and addiction. Diabetes impairs nerve function, complicates pain management, and makes opioid prescribing particularly challenging. METHODS This retrospective observational study included a cohort of postoperative patients from a multisite academic health system to assess the relationship between diabetes, pain, and prolonged opioid use (POU), 2008-2019. POU was defined as a new opioid prescription 3-6 months after discharge. The odds that a patient had POU was assessed using multivariate logistic regression controlling for patient factors (e.g., demographic and clinical factors, as well as prior pain and opiate use). FINDINGS A total of 43,654 patients were included, 12.4% with diabetes. Patients with diabetes had higher preoperative pain scores (2.1 vs 1.9, p<0.001) and lower opioid naïve rates (58.7% vs 68.6%, p<0.001). Following surgery, patients with diabetes had higher rates of POU (17.7% vs 12.7%, p<0.001) despite receiving similar opioid prescriptions at discharge. Patients with Type I diabetes were more likely to have POU compared to other patients (Odds Ratio [OR]: 2.22; 95% Confidence Interval [CI]:1.69-2.90 and OR:1.44, CI: 1.33-1.56, respectively). INTERPRETATION In conclusion, surgical patients with diabetes are at increased risk for POU even after controlling for likely covariates, yet they receive similar postoperative opiate therapy. The results suggest a more tailored approach to diabetic postoperative pain management is warranted.
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Affiliation(s)
- Alban Zammit
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- Institute for Computational & Mathematical Engineering, Stanford University, Stanford, California, United States of America
| | - Jean Coquet
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Jennifer Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Oualid el Hajouji
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- Institute for Computational & Mathematical Engineering, Stanford University, Stanford, California, United States of America
| | - Steven M. Asch
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Ian Carroll
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Catherine M. Curtin
- Department of Surgery, VA Palo Alto Health Care System, Menlo Park, California, United States of America
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Biomedical Data Science, Stanford University, Stanford, California, United States of America
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Biomedical Data Science, Stanford University, Stanford, California, United States of America
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16
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Khambaty M, Devalapalli AP, Silbert RE, Kashiwagi DT, Regan DW, Sundsted KK, Mauck KF. Practice Changing Updates in Perioperative Medicine Literature 2022. A Systematic Review. Am J Med 2023; 136:753-762.e1. [PMID: 37148994 DOI: 10.1016/j.amjmed.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023]
Abstract
Perioperative medicine is a rapidly growing multidisciplinary field with significant advances published each year. In this review, we highlight important perioperative publications in 2022. A multi-database literature search from January to December of 2022 was undertaken. Original research articles, systematic reviews, meta-analyses, and guidelines were included. Abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature were excluded. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont, Canada). A modified Delphi technique was used to identify 8 practice-changing articles. We identified another 10 articles for tabular summaries. We highlight why these articles have the potential to change clinical perioperative practice and areas where more information is needed.
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Affiliation(s)
- Maleka Khambaty
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Aditya P Devalapalli
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Richard E Silbert
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Deanne T Kashiwagi
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; Department of Internal Medicine, Sheikh Shakhbout Medical City in partnership with Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Dennis W Regan
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Karna K Sundsted
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
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Powell D, Shetty KD, Peet ED. Trends in overdose deaths involving gabapentinoids and Z-drugs in the United States. Drug Alcohol Depend 2023; 249:109952. [PMID: 37301069 PMCID: PMC10332434 DOI: 10.1016/j.drugalcdep.2023.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/10/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION As policies have been implemented to limit access to prescription opioids, other drugs have been prescribed off-label, sometimes concurrently with opioids, to manage pain. There are concerns about the use of gabapentinoids and "Z-drugs" with opioids. As the opioid crisis transitions to illicit opioids and polysubstance use, little work quantifies the concurrent involvement of non-opioid prescription drugs and illicit opioids in overdose deaths. METHODS Data from the census of deaths in the United States for 1999-2020 were used to understand trends in deaths involving gabapentinoids/Z-drugs and opioid co-involvement. These trends were studied overall and by sex, race, age, and education. RESULTS Per capita overdose deaths involving gabapentinoids/Z-drugs increased almost continuously since 1999, averaging 15.8% annual growth. This rate increased to 32% in 2020, primarily due to overdoses involving synthetic opioids. Women typically had higher rates of overdose deaths involving both opioids and gabapentinoids/Z-drugs, though this disparity disappeared in 2020. White Americans and American Indians/Alaskan Natives historically had higher rates than other racial groups; however, Black Americans experienced over 60% annual growth in recent years. Low education groups have been disproportionately impacted. The age incidence tends to be older than overdoses involving opioids more generally. CONCLUSION Overdose deaths involving opioids and gabapentinoids/Z-drugs have tended to disproportionately affect women and older age groups compared to all opioid-involved overdoses. As deaths involving synthetic opioids likely reflect use of illicitly-obtained opioids, there may be less of a role for policies targeting the concurrent prescribing of gabapentinoids/Z-drugs with opioids to reduce these deaths.
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Affiliation(s)
- David Powell
- RAND, 1200 S. Hayes St, Arlington, VA22202, United States.
| | | | - Evan D Peet
- RAND, 4570 Fifth Ave, Pittsburgh, PA15213, United States
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18
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Smith S, Tucker SB, Yunusa I. Comment: "Co-Prescribing of Central Nervous System-Active Medications for COPD Patients: Impact on Emergency Room Visits and Hospitalization". Ann Pharmacother 2023; 57:993-994. [PMID: 36373627 DOI: 10.1177/10600280221136254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Affiliation(s)
- Sloan Smith
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Sarah Beth Tucker
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Ismaeel Yunusa
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
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19
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Kazemi SM, Kouhestani E, Hosseini SM. The effect of pregabalin on postoperative pain after anterior cruciate ligament reconstruction: A systematic review of randomized clinical trials. Br J Pain 2023; 17:332-341. [PMID: 37538943 PMCID: PMC10395387 DOI: 10.1177/20494637231152967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023] Open
Abstract
Background Despite the enormous success of anterior cruciate ligament (ACL) reconstruction, acute neuropathic pain can develop postoperatively and is both distressing and difficult to treat once established. Pregabalin, an anticonvulsant agent that selectively affects the nociceptive process, has been used as a pain relief agent. The purpose of this systematic review of randomized controlled trials (RCTs) was to evaluate the pain control effect of pregabalin versus placebo after ACL reconstruction. Method A search of the literature was performed from inception to June 2022, using PubMed, Scopus, Google Scholar, Web of Science, Cochrane and EBSCO. Studies considered for inclusion were RCTs that reported relevant outcomes (postoperative pain scores, cumulative opioid consumption, adverse events) following administration of pregabalin in patients undergoing ACL reconstruction. Result Five placebo-controlled RCTs involving 272 participants met the inclusion criteria. 75 mg and 150 mg oral pregabalin was used in included trials. Two studies used a single dose of pregabalin one hour before anesthesia induction. Two studies used pregabalin 1 hour before anesthesia induction and 12 hours after. One study used daily pregabalin 7 days before and 7 days after surgery. Out of five papers, three papers found significantly lower pain intensity and cumulative opioid consumption in pregabalin group compared with placebo group. However, a decrease in pain scores was found in all trials. Pregabalin administration was associated with dizziness and nausea. Conclusion The use of pregabalin may be a valuable asset in pain management after ACL reconstruction. However, future studies with larger sample size and longer follow-up period are required.
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Affiliation(s)
- Seyyed Morteza Kazemi
- Department of Orthopaedic Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Bone Joint and Related Tissues Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Emad Kouhestani
- Department of Orthopaedic Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Bone Joint and Related Tissues Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyed Mehdi Hosseini
- Department of Orthopaedic Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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20
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Chiang LJ, Lai PC, Huang YT. Effectiveness and Adverse Events of Gabapentinoids as Analgesics for Patients with Burn Injuries: A Systematic Review with Meta-Analysis and Trial Sequential Analysis. J Clin Med 2023; 12:5042. [PMID: 37568444 PMCID: PMC10420087 DOI: 10.3390/jcm12155042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
(1) Background: Pain after a burn injury is difficult to endure, and emerging studies aim to ascertain the effects of gabapentin and pregabalin as non-opioid treatment options. (2) Methods: We searched for randomised controlled trials (RCTs) in six databases. The risk of bias was assessed using the RoB 2.0 tool. We performed meta-analysis and trial sequential analysis and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology for judging the certainty of evidence (CoE). (3) Results: Five RCTs were included. Compared with placebo, gabapentinoids significantly decreased the pain intensity within 24 h (mean difference (MD) = -1.06, 95% confidence interval (CI): -1.47--0.65) and from 72 h to 9 days (MD = -0.82, 95% CI: -1.16--0.48), but not after 3 weeks (MD = -0.44, 95% CI: -1.31-0.42). Opioid consumption (mg/day) was reduced within 24 h (MD = -13.34, 95% CI: -22.16--4.52) and from 72 h to 9 days (MD = -7.87, 95% CI: -14.82--0.91). Increased risks of drowsiness (risk ratio (RR) = 3.255, 95% CI: 1.135-9.335) and dizziness (RR = 3.034, 95% CI: 1.006-9.147) were observed, but sensitivity analysis using the Bayesian method showed no increased risk. All endpoints were judged as low to very low CoE. (4) Conclusions: Gabapentinoids offer modest analgesic benefits as a component of multimodal pain management for burn injuries of less than 3 weeks. The adverse effects should be carefully monitored. Large-scale RCTs are warranted for the reinforcement of CoE in clinical use.
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Affiliation(s)
- Liang-Jui Chiang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
| | - Pei-Chun Lai
- Education Centre, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
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Powell D, Peet ED, Pacula RL. Understanding the rise in overdose deaths involving opioids and non-opioid prescription drugs in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104104. [PMID: 37422359 PMCID: PMC10770297 DOI: 10.1016/j.drugpo.2023.104104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/11/2023] [Accepted: 06/13/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Previous studies demonstrate that the reformulation of OxyContin in the U.S. in 2010 induced substitution to illicit opioids, causing illicit opioid markets to grow disproportionately fast in states more exposed to the reformulation. In this paper, we examine if this shift to the illicit market also led to a rise in polysubstance overdose deaths involving non-opioid prescription drugs, including gabapentinoids and "Z-drugs" and, separately, benzodiazepines. METHODS Using a difference-in-differences framework, the relationship between exposure to reformulation and overdose death rates including specific substances was studied in each year from 1999 to 2020 while accounting for fixed differences across states, common nationwide shocks, and state-level differences in pain reliever misuse prior to reformulation. Exposure to reformulation was measured as the pre-reformulation rate of OxyContin misuse. RESULTS Exposure to reformulation predicted growth in overdose deaths involving gabapentinoids and Z-drugs. There is less evidence that it predicted growth in overdose deaths involving benzodiazepines. However, for all substances, there is strong evidence that pre-reformulation OxyContin misuse rates predicted post-reformulation growth in overdose deaths concurrently involving synthetic opioids. DISCUSSION The opioid crisis has changed in radical ways. This study links a major supply-side intervention to the increase in polysubstance overdose deaths involving non-opioid prescription drugs, specifically gabapentinoids and Z-drugs.
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Affiliation(s)
- David Powell
- RAND Corporation, 1200 South Hayes Street, Arlington, VA 22202 USA.
| | - Evan D Peet
- RAND Corporation, 4570 Fifth Ave, Pittsburgh, PA 15213 USA
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Bongiovanni T, Gan S, Finlayson E, Ross JS, Harrison JD, Boscardin WJ, Steinman MA. Trends in the Use of Gabapentinoids and Opioids in the Postoperative Period Among Older Adults. JAMA Netw Open 2023; 6:e2318626. [PMID: 37326989 PMCID: PMC10276300 DOI: 10.1001/jamanetworkopen.2023.18626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Importance In response to the opioid epidemic, recommendations from some pain societies have encouraged surgeons to embrace multimodal pain regimens with the intent of reducing opioid use in the postoperative period, including by prescribing gabapentinoids. Objective To describe trends in postoperative prescribing of both gabapentinoids and opioids after a variety of surgical procedures by examining nationally representative Medicare data and further understand variation by procedure. Design, Setting, and Participants This serial cross-sectional study of gabapentinoid prescribing from January 1, 2013, through December 31, 2018, used a 20% US Medicare sample. Gabapentinoid-naive patients 66 years or older undergoing 1 of 14 common noncataract surgical procedures performed in older adults were included. Data were analyzed from April 2022 to April 2023. Exposure One of 14 common surgical procedures in older adults. Main Outcomes and Measures Rate of postoperative prescribing of gabapentinoids and opioids, defined as a prescription filled between 7 days before the procedure and 7 days after discharge from surgery. Additionally, concomitant prescribing of gabapentinoids and opioids in the postoperative period was assessed. Results The total study cohort included 494 922 patients with a mean (SD) age of 73.7 (5.9) years, 53.9% of whom were women and 86.0% of whom were White. A total of 18 095 patients (3.7%) received a new gabapentinoid prescription in the postoperative period. Of those receiving a new gabapentinoid prescription, 10 956 (60.5%) were women and 15 529 (85.8%) were White. After adjusting for age, sex, race and ethnicity, and procedure type in each year, the rate of new postoperative gabapentinoid prescribing increased from 2.3% (95% CI, 2.2%-2.4%) in 2014 to 5.2% (95% CI, 5.0%-5.4%) in 2018 (P < .001). While there was variation between procedure types, almost all procedures saw an increase in both gabapentinoid and opioid prescribing. In this same period, opioid prescribing increased from 56% (95% CI, 55%-56%) to 59% (95% CI, 58%-60%) (P < .001). Concomitant prescribing also increased from 1.6% (95% CI, 1.5%-1.7%) in 2014 to 4.1% (95% CI, 4.0%-4.3%) in 2018 (P < .001). Conclusions and Relevance The findings of this cross-sectional study of Medicare beneficiaries suggest that new postoperative gabapentinoid prescribing increased without a subsequent downward trend in the proportion of patients receiving postoperative opioids and a near tripling of concurrent prescribing. Closer attention needs to be paid to postoperative prescribing for older adults, especially when using multiple types of medications, which can have adverse drug events.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California, San Francisco, School of Medicine
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, School of Medicine
- Northern California Institute for Research and Education, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, School of Medicine
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - James D. Harrison
- Division of Hospital Medicine, University of California, San Francisco, School of Medicine
| | - W. John Boscardin
- Department of Medicine, University of California, San Francisco, School of Medicine
- Department of Epidemiology and Biostatistics, University of California, San Francisco, School of Medicine
| | - Michael A. Steinman
- Division of Geriatrics, University of California, San Francisco, School of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Hurley ET, Danilkowicz RM, Toth AP. Editorial Commentary: Postoperative Pain Management After Anterior Cruciate Ligament Reconstruction Can Minimize Opioid Use and Allow Early Rehabilitation. Arthroscopy 2023; 39:1296-1298. [PMID: 37019539 DOI: 10.1016/j.arthro.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 04/07/2023]
Abstract
Effective analgesia is essential after anterior cruciate ligament (ACL) reconstruction to control pain while minimizing opioid consumption and allowing early rehabilitation. Orthopaedic surgeons write the third-largest number of opioid prescriptions, which are responsible for 1/10th of all opioid prescriptions, and one-third of patients with ACL injury use opioids preoperatively, a risk factor for postoperative abuse. Pain management after ACL reconstruction using variety of analgesic regimens including various permutations of nerve blocks, nerve block adjuncts, intra-articular injections, intravenous and oral medications, cryotherapy, compression stockings, and transcutaneous electrical nerve stimulation units, based on multidisciplinary collaboration between surgeons and anesthesiologists, can minimize opioid consumption. A recent meta-analysis shows that combined femoral-sciatic nerve block may be a top-ranked analgesic technique. Femoral and adductor canal nerve blocks are also effective alternatives and most common. Femoral and femoral sciatic nerve blocks may risk quadriceps strength deficits, whereas an advantage of adductor canal nerve is that the saphenous nerve is purely sensory. We recommend longer-acting nerve blockade (72 hours) using continuous anesthetic delivery via a pump/catheter with ropivacaine or the use of a slow-release preparation such as bupivacaine liposome injectable suspension.
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Gupta S, Dhawan A, Dhawan J, McColl MA, Smith KM, McColl A. Potentially harmful drug-drug interactions in the therapeutic regimens of persons with spinal cord injury. J Spinal Cord Med 2023:1-9. [PMID: 36972222 DOI: 10.1080/10790268.2023.2185399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023] Open
Abstract
OBJECTIVES Individuals with spinal cord injury deal with multiple health complications that require them to use many medications. The purpose of this paper was to find the most common potentially harmful drug-drug interactions (DDIs) in therapeutic regimens of persons with spinal cord injury, and the risk factors associated with it. We further highlight the relevance of each of the DDIs specific to spinal cord injury population. DESIGN Observational design and cross-sectional analysis. SETTING Community; Canada. PARTICIPANTS Individuals with spinal cord injury (n = 108). MAIN OUTCOME MEASURES/ANALYSIS The main outcome was the presence of one or more potential DDIs that can lead to an adverse outcome. All the reported drugs were classified as per the World Health Organization's Anatomical Therapeutic Chemical Classification system. Twenty potential DDIs were selected for the analysis based on the most common medications prescribed to people with spinal cord injury and severity of clinical consequences. The medication lists of study participants were analyzed for selected DDIs. RESULTS Among the 20 potential DDIs analyzed in our sample, the top 3 prevalent DDIs were Opioids + Skeletal Muscle Relaxants, Opioids + Gabapentinoids, and Benzodiazepines + ≥ 2 other central nervous system (CNS)-active drugs. Of the total sample of 108 respondents, 31 participants (29%) were identified with having at least one potential DDI. The risk of having a potential DDI was highly associated with polypharmacy, though no associations were found between the presence of a drug interaction and age, sex, level of injury, time since injury, or cause of injury among the study sample. CONCLUSION Almost three out of ten individuals with spinal cord injury were at risk of having a potentially harmful drug interaction. Clinical and communication tools are needed that facilitate identification and elimination of harmful drug combinations in the therapeutic regimens of patients with spinal cord injury.
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Affiliation(s)
- Shikha Gupta
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Alaina Dhawan
- Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Jillian Dhawan
- Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Mary Ann McColl
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Karen M Smith
- Department of Physical Medicine and Rehabilitation, School of Medicine, Queen's University, Kingston, Canada
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25
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van Veenendaal N, Foss NB, Miserez M, Pawlak M, Zwaans WAR, Aasvang EK. A narrative review on the non-surgical treatment of chronic postoperative inguinal pain: a challenge for both surgeon and anaesthesiologist. Hernia 2023; 27:5-14. [PMID: 36315351 PMCID: PMC9931782 DOI: 10.1007/s10029-022-02693-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic pain is one of the most frequent clinical problems after inguinal hernia surgery. Despite more than two decades of research and numerous publications, no evidence exists to allow for chronic postoperative inguinal pain (CPIP) specific treatment algorithms. METHODS This narrative review presents the current knowledge of the non-surgical management of CPIP and makes suggestions for daily practice. RESULTS There is a paucity for high-level evidence of non-surgical options for CPIP. Different treatment options and algorithms have been published for chronic pain patients in the last decades. DISCUSSION AND CONCLUSION It is suggested that non-surgical treatment is introduced in the management of all CPIP patients. The overall approach to interventions should be pragmatic, tiered and multi-interventional, starting with least invasive and only moving to more invasive procedures upon lack of effect. Evaluation should be multidisciplinary and should take place in specialized centres. We strongly suggest to follow general guidelines for treatment of persistent pain and to build a database allowing for establishing CPIP specific evidence for optimal analgesic treatments.
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Affiliation(s)
- N van Veenendaal
- Department of Anesthesiology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - N B Foss
- Department of Anaesthesia and Intensive Care, Hvidovre University Hospital, Copenhagen, Denmark
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - M Pawlak
- North Devon Comprehensive Hernia Centre, North Devon District Hospital, Royal Devon University Healthcare NHS Foundation Trust, Barnstaple, UK
| | - W A R Zwaans
- Department of General Surgery, Máxima Medical Center, Veldhoven, Eindhoven, The Netherlands.,SolviMáx Center of Excellence for Abdominal Wall and Groin Pain, Eindhoven, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - E K Aasvang
- Department of Anesthesiology, Center for Cancer and Organ Diseases, Rigshopitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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26
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Jivraj NK, Ladha KS, Goel A, Hill A, Wijeysundera DN, Bateman BT, Neuman M, Wunsch H. Nonopioid Analgesic Prescriptions Filled after Surgery among Older Adults in Ontario, Canada: A Population-based Cohort Study. Anesthesiology 2023; 138:195-207. [PMID: 36512729 PMCID: PMC10411646 DOI: 10.1097/aln.0000000000004443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The objective was to assess changes over time in prescriptions filled for nonopioid analgesics for older postoperative patients in the immediate postdischarge period. The authors hypothesized that the number of patients who filled a nonopioid analgesic prescription increased during the study period. METHODS The authors performed a population-based cohort study using linked health administrative data of 278,366 admissions aged 66 yr or older undergoing surgery between fiscal year 2013 and 2019 in Ontario, Canada. The primary outcome was the percentage of patients with new filled prescriptions for nonopioid analgesics within 7 days of discharge, and the secondary outcome was the analgesic class. The authors assessed whether patients filled prescriptions for a nonopioid only, an opioid only, both opioid and nonopioid prescriptions, or a combination opioid/nonopioid. RESULTS Overall, 22% (n = 60,181) of patients filled no opioid prescription, 2% (n = 5,534) filled a nonopioid only, 21% (n = 59,608) filled an opioid only, and 55% (n = 153,043) filled some combination of opioid and nonopioid. The percentage of patients who filled a nonopioid prescription within 7 days postoperatively increased from 9% (n = 2,119) in 2013 to 28% (n = 13,090) in 2019, with the greatest increase for acetaminophen: 3% (n = 701) to 20% (n = 9,559). The percentage of patients who filled a combination analgesic prescription decreased from 53% (n = 12,939) in 2013 to 28% (n = 13,453) in 2019. However, the percentage who filled both an opioid and nonopioid prescription increased: 4% (n = 938) to 21% (n = 9,880) so that the overall percentage of patients who received both an opioid and a nonopioid remained constant over time 76% (n = 18,642) in 2013 to 75% (n = 35,391) in 2019. CONCLUSIONS The proportion of postoperative patients who fill prescriptions for nonopioid analgesics has increased. However, rather than a move to use of nonopioids alone for analgesia, this represents a shift away from combination medications toward separate prescriptions for opioids and nonopioids. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Naheed K Jivraj
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Akash Goel
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Andrea Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Mark Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah Wunsch
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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27
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Bonnet U, Kanti AK, Scherbaum N, Specka M. The Role of Gabapentinoids in the Substance Use Pattern of Adult Germans Seeking Inpatient Detoxification Treatment - A Pilot Study. J Psychoactive Drugs 2023; 55:102-111. [PMID: 35290159 DOI: 10.1080/02791072.2022.2050858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
To shed more light on the addictive power of the gabapentinoids (GPTs) gabapentin and pregabalin, we performed a structured face-to-face interview with GPT-users about DSM-IV-dependence-criteria (sedatives), consume-motives and cessation-needs. Among 100 patients consecutively admitted to a detoxification-ward, fifteen (15%) reported lifetime GPT-use (18-50 years old, 2 females): seven (7%) used gabapentin, twelve (12%) pregabalin and four had lifetime experiences with both GPTs. Of the seven gabapentin-users, three patients were dependent including one person with a spontaneous remission. Of the 12 pregabalin-users, five were dependent, including two persons with a spontaneous remission. Fourteen of fifteen cases reported GPT-use side-by-side with an opioid-use, mostly for sparing opioids. Twelve GPT-users additionally co-used benzodiazepines. In no case, a GPT was the reason for detoxification treatment or reported to be involved in an emergency event. Altogether, every 7th patient (n = 15) of our inpatient detoxification-seeking sample reported GPT-use including 50% (n = 8) who were dependent. Among them, 35% (3/8) had been already spontaneously remitted. As GPT-users reported no cession-need and the vast majority were primarily affected by co-occurring opioid- and benzodiazepine-addiction, we assume that GPTs more likely played a bystander-role than mediating the addictive behavior of this population with multiple recreational drug use experience.
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Affiliation(s)
- Udo Bonnet
- Head of the Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Evangelisches Krankenhaus Castrop-Rauxel, Academic Teaching Hospital of the University of Duisburg/Essen and Professor, University of Duisburg/Essen, Essen, Germany
| | - Ann-Kristin Kanti
- Resident Physician at the Department of Internal Medicine, Evangelisches Krankenhaus Castrop-Rauxel, Academic Teaching Hospital of the University of Duisburg/Essen, Castrop-Rauxel, Germany
| | - Norbert Scherbaum
- Head of the Department of Psychiatry and Psychotherapy, LVR-Hospital Essen, Faculty of Medicine, University of Duisburg/Essen and Professor, University of Duisburg/Essen, Essen, Germany
| | - Michael Specka
- Senior psychologist and researcher in the Department of Psychiatry and Psychotherapy, Faculty of Medicine, LVR Hospital Essen, University of Duisburg-Essen and Doctor rerum medicarum of the University of Duisburg/Essen, Essen, Germany
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28
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Billig JI, Gunaseelan V, Yazdanfar M, Sears ED, Iwashyna TJ, Chang T, Waljee JF. Gabapentinoid Prescribing for Carpal Tunnel Syndrome. Hand (N Y) 2023; 18:106S-113S. [PMID: 35225033 PMCID: PMC9896291 DOI: 10.1177/15589447211063544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gabapentinoids, including gabapentin and pregabalin, are commonly prescribed for neuropathic pain, but robust evidence recommends against using gabapentinoids for the treatment of carpal tunnel syndrome (CTS). We aimed to quantify national prescribing patterns of gabapentinoids for CTS. METHODS We performed a retrospective population-based cohort study using claims data of gabapentinoid-naïve patients with a new diagnosis of CTS (2009-2016). Our primary outcome was a new gabapentinoid fill for CTS. We assessed temporal trends and characteristics associated with a gabapentinoid fill. Multivariable logistic regression was used to evaluate the association between patient-level factors and a new gabapentinoid fill for CTS. RESULTS Of the 248 324 previously gabapentinoid-naïve patients with CTS, 9589 patients (4%) filled a gabapentinoid prescription. Sixty-one percent were prescribed by primary care providers or medical subspecialists. Patients with a history of neck pain (odds ratio [OR]: 1.31, 95% confidence interval [CI], 1.25-1.38), back pain (OR: 1.25, 95% CI, 1.20-1.31), arthritis (OR: 1.25, 95% CI, 1.18-1.31), and other pain conditions (OR: 1.26, 95% CI, 1.20-1.31) were associated with an increased odds of a new gabapentinoid fill. In addition, patients with a history of alcohol or substance use disorder were significantly associated with a new gabapentinoid prescription fill (OR: 1.33, 95% CI, 1.20-1.47). CONCLUSIONS Despite evidence recommending against the use of gabapentinoids for CTS, gabapentinoids were frequently initiated among those with higher risk for misuse, including substance use disorders. Given the effectiveness of bracing or surgery for CTS and the risks associated with gabapentinoids, efforts aimed at disseminating evidence-based treatment for CTS are critical to minimize the harms of gabapentinoid misuse.
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Affiliation(s)
| | | | | | - Erika D. Sears
- University of Michigan, Ann Arbor,
USA
- VA Ann Arbor Healthcare System, MI,
USA
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29
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Ellis MS, Qureshi R, Buttram ME. Understanding motivations and use typologies of gabapentin with opioid agonist medications. Drug Alcohol Depend 2023; 242:109713. [PMID: 36462231 DOI: 10.1016/j.drugalcdep.2022.109713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prior research suggests a potential relationship between the nonmedical use of gabapentin and use of opioid agonist medications (OAMs), buprenorphine and methadone. However, this research has been limited in scope and understanding despite increases in gabapentin prescribing in opioid use disorder (OUD) treatment settings and increased detection in opioid overdose fatalities. METHODS Data were analyzed for 346 participants of a follow-up program to an ongoing national opioid surveillance program of new entrants to treatment for opioid use disorder. Data were sourced from a cross-sectional online survey distributed in July/August 2021. RESULTS Lifetime exposure to gabapentin was reported by 60.0 % of the sample, while lifetime history of nonmedical use was reported by 43.2 %. Of those nonmedically using gabapentin, 50.0 % did so while also on a dosage of either buprenorphine or methadone, with 28.4 % engaged in concurrent nonmedical use of both gabapentin and OATs. Motivations for concurrent nonmedical use included high-seeking (38.6 %), self-management of pain/physical symptoms (33.3 %), and self-management of OUD (22.2 %). CONCLUSIONS Gabapentin exposure in treatment-seeking persons with OUD appears to be quite common, and use, both medically and nonmedically, frequently occurs alongside OAMs. Motivations for concurrent nonmedical use of gabapentin and OATs mirrors motivations for off-label prescribing by healthcare providers, but may also serve as a form of self-management of OUD when OAM regimens are interrupted, insufficiently prescribed or prescribed at insufficient dosages. Further research should seek to understand the risks versus benefits of gabapentin in OAM treatment settings.
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Affiliation(s)
- Matthew S Ellis
- Washington University in St. Louis, School of Medicine, Department of Psychiatry. St. Louis, MO, USA.
| | - Rida Qureshi
- Washington University in St. Louis, St. Louis, MO, USA
| | - Mance E Buttram
- University of Arkansas, Department of Health, Human Performance & Recreation, Fayetteville, AR, USA
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30
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Russo M, Graham B, Santarelli DM. Gabapentin-Friend or foe? Pain Pract 2023; 23:63-69. [PMID: 36300903 PMCID: PMC10092611 DOI: 10.1111/papr.13165] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/19/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Gabapentin is a recommended first-line agent for treating neuropathic pain; however, its efficacy rate is reportedly low, and the risk of adverse events is high. A plausible explanation for this lies with its wide range of actions, the entirety of which have yet to be fully elucidated. METHODS A review of the literature was conducted on gabapentin's known and proposed analgesic mechanisms of action, as well as potentially opposing or detrimental actions. RESULTS Gabapentin's classical analgesic mechanisms involve direct attenuation of excitatory neurotransmission in the spinal cord via inhibition of neuronal ion channels, while indirect mechanisms include descending inhibition and block of injury-evoked synaptogenesis. Glial effects have also been reported; however, whether they are neuroprotective or detrimental is unknown. Furthermore, data from animal models do not reflect clinical outcomes. CONCLUSIONS Gabapentin's clinical use should be reconsidered according to the net effects of its numerous assumed actions, including the tripartite synapse and oligodendrocyte effects. Whether it is doing more harm than good, especially in the scenarios of incomplete or loss of response, warrants consideration when prescribing gabapentin.
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Affiliation(s)
- Marc Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia.,Genesis Research Services, Broadmeadow, New South Wales, Australia.,School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Brett Graham
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
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Hoffmann AT, Dillenhöfer S, Lücke T, Maier C, Brinkmann F. [The challenges of managing thoracic pain in cystic fibrosis (CF)]. Schmerz 2022; 36:422-428. [PMID: 34762202 PMCID: PMC9674729 DOI: 10.1007/s00482-021-00603-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is a rare genetic multisystemic disorder with progressive abdominal and pulmonary involvement. Pain is still an underestimated symptom in CF patients. METHODS A comprehensive review of guidelines and scientific literature on the topic was performed and combined with findings from pain management in a young CF patient with progressive thoracic pain. RESULTS German CF guidelines do not cover diagnosis and management of pain in these patients. Studies from Europe and the United States report interactions between intensity of pain and mortality in CF, but do not include data on the efficacy of pain management. These data and clinical observations of a CF patient with episodes of intense thoracic pain are used to illustrate the specific challenges in pain relief. CONCLUSION Pain management in CF requires meticulous monitoring as well as an interdisciplinary approach and should be implemented in the German CF guidelines. The authors also want to suggest recommendations for the treatment of thoracic pain in CF. The range and severity of organ involvement complicates the use both of opioids and non-opioids. Especially opioid treatment carries the risk of hypoxia and opioid-induced constipation (OIC) and needs close medical supervision.
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Affiliation(s)
- A T Hoffmann
- Universitätsklinik für Kinder- und Jugendmedizin, Ruhr-Universität Bochum, Alexandrinenstraße 5, 44791, Bochum, Deutschland
| | - S Dillenhöfer
- Universitätsklinik für Kinder- und Jugendmedizin, Ruhr-Universität Bochum, Alexandrinenstraße 5, 44791, Bochum, Deutschland
| | - T Lücke
- Universitätsklinik für Kinder- und Jugendmedizin, Ruhr-Universität Bochum, Alexandrinenstraße 5, 44791, Bochum, Deutschland
| | - C Maier
- Universitätsklinik für Kinder- und Jugendmedizin, Ruhr-Universität Bochum, Alexandrinenstraße 5, 44791, Bochum, Deutschland
| | - F Brinkmann
- Universitätsklinik für Kinder- und Jugendmedizin, Ruhr-Universität Bochum, Alexandrinenstraße 5, 44791, Bochum, Deutschland.
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Keyhani S, Leonard S, Byers AL, Zaman T, Krebs E, Austin PC, Moss-Vazquez T, Austin C, Sandbrink F, Bravata DM. Association of a Positive Drug Screening for Cannabis With Mortality and Hospital Visits Among Veterans Affairs Enrollees Prescribed Opioids. JAMA Netw Open 2022; 5:e2247201. [PMID: 36525274 PMCID: PMC9856228 DOI: 10.1001/jamanetworkopen.2022.47201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Cannabis has been proposed as a therapeutic with potential opioid-sparing properties in chronic pain, and its use could theoretically be associated with decreased amounts of opioids used and decreased risk of mortality among individuals prescribed opioids. OBJECTIVE To examine the risks associated with cannabis use among adults prescribed opioid analgesic medications. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among individuals aged 18 years and older who had urine drug screening in 2014 to 2019 and received any prescription opioid in the prior 90 days or long-term opioid therapy (LTOT), defined as more than 84 days of the prior 90 days, through the Veterans Affairs health system. Data were analyzed from November 2020 through March 2022. EXPOSURES Biologically verified cannabis use from a urine drug screen. MAIN OUTCOMES AND MEASURES The main outcomes were 90-day and 180-day all-cause mortality. A composite outcome of all-cause emergency department (ED) visits, all-cause hospitalization, or all-cause mortality was a secondary outcome. Weights based on the propensity score were used to reduce confounding, and hazard ratios [HRs] were estimated using Cox proportional hazards regression models. Analyses were conducted among the overall sample of patients who received any prescription opioid in the prior 90 days and were repeated among those who received LTOT. Analyses were repeated among adults aged 65 years and older. RESULTS Among 297 620 adults treated with opioids, 30 514 individuals used cannabis (mean [SE] age, 57.8 [10.5] years; 28 784 [94.3%] men) and 267 106 adults did not (mean [SE] age, 62.3 [12.3] years; P < .001; 247 684 [92.7%] men; P < .001). Among all patients, cannabis use was not associated with increased all-cause mortality at 90 days (HR, 1.07; 95% CI, 0.92-1.22) or 180 days (HR, 1.00; 95% CI, 0.90-1.10) but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.01-1.07) and 180 days (HR, 1.04; 95% CI, 1.01-1.06). Among 181 096 adults receiving LTOT, cannabis use was not associated with increased risk of all-cause mortality at 90 or 180 days but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.02-1.09) and 180 days (HR, 1.05; 95% CI, 1.02-1.09). Among 77 791 adults aged 65 years and older receiving LTOT, cannabis use was associated with increased 90-day mortality (HR, 1.55; 95% CI, 1.17-2.04). CONCLUSIONS AND RELEVANCE This study found that cannabis use among adults receiving opioid analgesic medications was not associated with any change in mortality risk but was associated with a small increased risk of adverse outcomes and that short-term risks were higher among older adults receiving LTOT.
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Affiliation(s)
- Salomeh Keyhani
- Department of Medicine, University of California, San Francisco
- San Francisco VA Medical Center, San Francisco, California
| | - Samuel Leonard
- Northern California Institute for Research and Education, San Francisco
| | - Amy L. Byers
- Department of Medicine, University of California, San Francisco
- San Francisco VA Medical Center, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Tauheed Zaman
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Addiction Recovery and Treatments Services, San Francisco VA Health Care System, San Francisco, California
| | - Erin Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
| | - Peter C. Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | | | - Charles Austin
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Friedhelm Sandbrink
- National Pain Management, Opioid Safety and Prescription Drug Monitoring Program, Veterans Health Administration, Washington, District of Columbia
- Department of Neurology, George Washington University, Washington District of Columbia
| | - Dawn M. Bravata
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis
- Regenstreif Institute, Indianapolis Indiana
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Bongiovanni T, Gan S, Finlayson E, Ross J, Harrison JD, Boscardin J, Steinman MA. Prolonged use of newly prescribed gabapentin after surgery. J Am Geriatr Soc 2022; 70:3560-3569. [PMID: 36000860 PMCID: PMC9771946 DOI: 10.1111/jgs.18005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/05/2022] [Accepted: 07/24/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgeons have made substantial efforts to decrease postoperative opioid prescribing, largely because it can lead to prolonged use. These efforts include adoption of non-opioid pain medication including gabapentin. Like opioids, gabapentin use may be prolonged, increasing the risk of altered mental status and even overdose and death when taken concurrently with opioids. However, little is known about postoperative prolonged use of gabapentin in older adults. METHODS We merged a 20% sample of Medicare Carrier, MedPAR and Outpatient Files with Part D for 2013-2018. We included patients >65 years old without prior gabapentinoid use who underwent common non-cataract surgical procedures. We defined new postoperative gabapentin as fills for 7 days before surgery until 7 days after discharge. We excluded patients whose discharge disposition was hospice or death. The primary outcome was prolonged use of gabapentin, defined as a fill>90 days after discharge. To identify risk factors for prolonged use, we constructed logistic regression models, adjusted for procedure and patient characteristics, length of stay, disposition location, and care complexity. RESULTS Overall, 17,970 patients (3% of all eligible patients) had a new prescription for gabapentin after surgery. Of these, the mean age was 73 years old and 62% were female. The most common procedures were total knee (45%) and total hip (21%) replacements. Prolonged use occurred in 22%. Those with prolonged use were more likely to be women (64% vs. 61%), be non-White (14% vs. 12%), have concurrent prolonged opioid use (44% vs. 18%), and have undergone emergency surgery (8% vs. 4%). On multivariable analysis, being female, having a higher Charlson comorbidity score, having an opioid prescription at discharge and at >90 days and having a higher care complexity were associated with prolonged use of gabapentin. CONCLUSIONS More than one-fifth of older adults prescribed gabapentin postoperatively filled a prescription >90 days after discharge, especially among patients with more comorbidities and concurrent prolonged opioid use, increasing the risk of adverse drug events and polypharmacy.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Siqi Gan
- University of California San Francisco Pepper Center, San Francisco, California, USA
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Joseph Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
| | - James D Harrison
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - John Boscardin
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
- Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA
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Murnion B, Schaffer A, Cairns R, Brett J. Gabapentinoids: repeating mistakes of the past? Addiction 2022; 117:2969-2971. [PMID: 35715932 DOI: 10.1111/add.15970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Bridin Murnion
- Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Andrea Schaffer
- Medicines Policy Research Unit, UNSW, Sydney, NSW, Australia
| | - Rose Cairns
- School of Pharmacy, University of Sydney, NSW Poisons Information Centre, Sydney, NSW, Australia
| | - Jonathan Brett
- Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,Medicines Policy Research Unit, UNSW, Sydney, NSW, Australia
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Chen C, Tighe PJ, Lo-Ciganic WH, Winterstein AG, Wei YJ. Perioperative Use of Gabapentinoids and Risk for Postoperative Long-Term Opioid Use in Older Adults Undergoing Total Knee or Hip Arthroplasty. J Arthroplasty 2022; 37:2149-2157.e3. [PMID: 35577053 PMCID: PMC9588599 DOI: 10.1016/j.arth.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Gabapentinoids are recommended by guidelines as a component of multimodal analgesia to manage postoperative pain and reduce opioid use. It remains unknown whether perioperative use of gabapentinoids is associated with a reduced or increased risk of postoperative long-term opioid use (LTOU) after total knee or hip arthroplasty (TKA/THA). METHODS Using Medicare claims data from 2011 to 2018, we identified fee-for-service beneficiaries aged ≥ 65 years who were hospitalized for a primary TKA/THA and had no LTOU before the surgery. Perioperative use of gabapentinoids was measured from 7 days preadmission through 7 days postdischarge. Patients were required to receive opioids during the perioperative period and were followed from day 7 postdischarge for 180 days to assess postoperative LTOU (ie, ≥90 consecutive days). A modified Poisson regression was used to estimate the relative risk (RR) of postoperative LTOU in patients with versus without perioperative use of gabapentinoids, adjusting for confounders through propensity score weighting. RESULTS Of 52,788 eligible Medicare older beneficiaries (mean standard deviation [SD] age 72.7 [5.3]; 62.5% females; 89.7% White), 3,967 (7.5%) received gabapentinoids during the perioperative period. Postoperative LTOU was 3.8% in patients with and 4.0% in those without perioperative gabapentinoids. After adjusting for confounders, the risk of postoperative LTOU was similar comparing patients with versus without perioperative gabapentinoids (RR = 1.07; 95% confidence interval [CI] = 0.91-1.26, P = .408). Sensitivity and bias analyses yielded consistent results. CONCLUSION Among older Medicare beneficiaries undergoing a primary TKA/THA, perioperative use of gabapentinoids was not associated with a reduced or increased risk for postoperative LTOU.
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Affiliation(s)
- Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida
| | - Patrick J Tighe
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida; Department of Epidemiology, University of Florida Colleges of Medicine and Public Health and Health Professions, Gainesville, Florida
| | - Yu-Jung Wei
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
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Evaluation of Concurrent Benzodiazepine and Opioid Prescribing Patterns with a Focus on Acute Muscle Spasms Indication at Hospital Discharge. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Miano TA, Wang L, Leonard CE, Brensinger CM, Acton EK, Dawwas GK, Bilker WB, Soprano SE, Nguyen TPP, Woody G, Yu E, Neuman M, Li L, Hennessy S. Identifying Clinically Relevant Drug-Drug Interactions With Methadone and Buprenorphine: A Translational Approach to Signal Detection. Clin Pharmacol Ther 2022; 112:1120-1129. [PMID: 35881659 PMCID: PMC10015595 DOI: 10.1002/cpt.2717] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/18/2022] [Indexed: 11/11/2022]
Abstract
Methadone and buprenorphine have pharmacologic properties that are concerning for a high risk of drug-drug interactions (DDIs). We performed high-throughput screening for clinically relevant DDIs with methadone or buprenorphine by combining pharmacoepidemiologic and pharmacokinetic approaches. We conducted pharmacoepidemiologic screening via a series of self-controlled case series studies (SCCS) in Optum claims data from 2000 to 2019. We included persons 18 years or older who experienced an outcome of interest during target drug treatment. Exposures were all overlapping medications (i.e., the candidate precipitants) during target drug treatment. Outcomes were opioid overdose, non-overdose adverse effects, and cardiac arrest. We used conditional Poisson regression to calculate rate ratios, accounting for multiple comparisons with semi-Bayes shrinkage. We explored the impact of key study design choices in analyses that varied the exposure definitions of the target drugs and the candidate precipitant drugs. Pharmacokinetic screening was conducted by incorporating published data on CYP enzyme metabolism into an equation-based static model. In SCCS analysis, 1,432 events were included from 248,069 new users of methadone or buprenorphine. In the primary analysis, statistically significant DDIs included gabapentinoids with either methadone or buprenorphine; baclofen with methadone; and benzodiazepines with methadone. In sensitivity analysis, additional statistically significant DDIs included methocarbamol, quetiapine, or simvastatin with methadone. Pharmacokinetic screening identified two moderate-to-strong potential DDIs (clonidine and fluconazole with buprenorphine). The combination of clonidine and buprenorphine was also associated with a significantly increased risk of opioid overdose in pharmacoepidemiologic screening. These DDI signals may be the most important targets for future confirmation studies.
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Affiliation(s)
- Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lei Wang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ghadeer K. Dawwas
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samantha E. Soprano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thanh Phuong Pham Nguyen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Woody
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elmer Yu
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lang Li
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:716-734. [PMID: 36288110 DOI: 10.1097/spv.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery. METHODS A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs. CONCLUSIONS The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.
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Park CM, Inouye SK, Marcantonio ER, Metzger E, Bateman BT, Lie JJ, Lee SB, Levin R, Kim DH. Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery. JAMA Intern Med 2022; 182:1117-1127. [PMID: 36121671 PMCID: PMC9486639 DOI: 10.1001/jamainternmed.2022.3680] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/03/2022] [Indexed: 12/14/2022]
Abstract
Importance Gabapentin has been increasingly used as part of a multimodal analgesia regimen to reduce opioid use in perioperative pain management. However, the safety of perioperative gabapentin use among older patients remains uncertain. Objective To examine in-hospital adverse clinical events associated with perioperative gabapentin use among older patients undergoing major surgery. Design, Setting, and Participants This retrospective cohort study using data from the Premier Healthcare Database included patients aged 65 years or older who underwent major surgery at US hospitals within 7 days of hospital admission from January 1, 2009, to March 31, 2018, and did not use gabapentin before surgery. Data were analyzed from June 14, 2021, to May 23, 2022. Exposures Gabapentin use within 2 days after surgery. Main Outcomes and Measures The primary outcome was delirium, identified using diagnosis codes, and secondary outcomes were new antipsychotic use, pneumonia, and in-hospital death between postoperative day 3 and hospital discharge. To reduce confounding, 1:1 propensity score matching was performed. Risk ratios (RRs) and risk differences (RDs) with 95% CIs were estimated. Results Among 967 547 patients before propensity score matching (mean [SD] age, 76.2 [7.4] years; 59.6% female), the rate of perioperative gabapentin use was 12.3% (119 087 patients). After propensity score matching, 237 872 (118 936 pairs) gabapentin users and nonusers (mean [SD] age, 74.5 [6.7] years; 62.7% female) were identified. Compared with nonusers, gabapentin users had increased risk of delirium (4040 [3.4%] vs 3148 [2.6%]; RR, 1.28 [95% CI, 1.23-1.34]; RD, 0.75 [95% CI, 0.75 [0.61-0.89] per 100 persons), new antipsychotic use (944 [0.8%] vs 805 [0.7%]; RR, 1.17 [95% CI, 1.07-1.29]; RD, 0.12 [95% CI, 0.05-0.19] per 100 persons), and pneumonia (1521 [1.3%] vs 1368 [1.2%]; RR, 1.11 [95% CI, 1.03-1.20]; RD, 0.13 [95% CI, 0.04-0.22] per 100 persons), but there was no difference in in-hospital death (362 [0.3%] vs 354 [0.2%]; RR, 1.02 [95% CI, 0.88-1.18]; RD, 0.00 [95% CI, -0.04 to 0.05] per 100 persons). Risk of delirium among gabapentin users was greater in subgroups with high comorbidity burden than in those with low comorbidity burden (combined comorbidity index <4 vs ≥4: RR, 1.20 [95% CI, 1.13-1.27] vs 1.40 [95% CI, 1.30-1.51]; RD, 0.41 [95% CI, 0.28-0.53] vs 2.66 [95% CI, 2.08-3.24] per 100 persons) and chronic kidney disease (absence vs presence: RR, 1.26 [95% CI, 1.19-1.33] vs 1.38 [95% CI, 1.27-1.49]; RD, 0.56 [95% CI, 0.42-0.69] vs 1.97 [95% CI, 1.49-2.46] per 100 persons). Conclusion and Relevance In this cohort study, perioperative gabapentin use was associated with increased risk of delirium, new antipsychotic use, and pneumonia among older patients after major surgery. These results suggest careful risk-benefit assessment before prescribing gabapentin for perioperative pain management.
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Affiliation(s)
- Chan Mi Park
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Edward R. Marcantonio
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Eran Metzger
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jessica J. Lie
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Hahn J, Jo Y, Yoo SH, Shin J, Yu YM, Ah YM. Risk of major adverse events associated with gabapentinoid and opioid combination therapy: A systematic review and meta-analysis. Front Pharmacol 2022; 13:1009950. [PMID: 36304170 PMCID: PMC9593000 DOI: 10.3389/fphar.2022.1009950] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/12/2022] [Indexed: 07/29/2023] Open
Abstract
Background: The use of opioid-gabapentinoid combinations has increased, raising several safety concerns. However, meta-analysis studies focusing on this issue are limited. Objective: To evaluate the risk of central nervous system (CNS) depression, gastrointestinal (GI) adverse events, and mortality of combination therapy compared with those of opioid therapy and to explore the differences in the results according to study design and indications. Methods: Relevant studies were selected (published before 30 January 2022) by searching the MEDLINE, Embase, and CENTRAL databases. The pooled odds ratios (OR) with 95% confidence intervals (CI) of the outcomes were estimated using the Mantel-Haenszel method. Subgroup and meta-regression analyses were performed according to study characteristics. Quality assessment was conducted using the Risk of Bias 2 tool for randomized controlled trials (RCTs) and Cochrane Collaboration's Risk of Bias in non-RCTs tool for non-randomized trials. Results: Adverse events were reported in 26 RCTs and 7 non-RCTs, and mortality was reported in 10 non-RCTs. Compared to opioid therapy, dizziness, cognitive dysfunction, and respiratory depression in combination therapy significantly increased in non-RCTs (OR 3.26, 95% CI 1.82-5.85; OR 3.13, 95% CI 1.51-6.50; OR 1.71, 95% CI 1.31-2.24, respectively), and a similar trend for dizziness and cognitive dysfunction was also identified in the RCT analysis, although the difference was not significant. Combination therapy for cancer pain was associated with the highest risk of sedation in subgroup analysis. Combination therapy significantly decreased the risk of GI adverse events, including nausea, vomiting, and constipation. The mortality risk associated with combination therapy was higher than that associated with opioid therapy (OR 2.76, 95% CI 1.26-6.05). Conclusion: Opioid-gabapentinoid combination therapy could be associated with an increased risk of CNS depression and mortality, despite tolerable GI adverse events. These data suggest that combination therapy requires close monitoring of CNS depression, especially in cancer patients. Caution is needed in interpreting the clinical meanings owing to the lack of risk difference in respiratory depression in the RCT-only analysis and the absence of RCT or prospective studies investigating mortality.
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Affiliation(s)
- Jongsung Hahn
- School of Pharmacy, Jeonbuk National University, Jeonju, Jeonbuk, South Korea
- KIURI Research Center, Ajou University, Suwon, South Korea
| | - Youngkwon Jo
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, South Korea
| | - So Hee Yoo
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, South Korea
| | - Jaekyu Shin
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, San Francisco, CA, United States
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, South Korea
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, South Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsan, Gyeongsangbuk-do, South Korea
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41
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AUGS-IUGA Joint clinical consensus statement on enhanced recovery after urogynecologic surgery. Int Urogynecol J 2022; 33:2921-2940. [DOI: 10.1007/s00192-022-05223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 10/14/2022]
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Nakano Y, Mandai S, Genma T, Akagi Y, Fujiki T, Ando F, Susa K, Mori T, Iimori S, Naito S, Sohara E, Uchida S, Fushimi K, Rai T. Nationwide mortality associated with perioperative acute dialysis requirement in major surgeries. Int J Surg 2022; 104:106816. [DOI: 10.1016/j.ijsu.2022.106816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/22/2022] [Accepted: 07/30/2022] [Indexed: 02/07/2023]
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Effect of a Multimodal Analgesic Protocol on Short-Term and Long-Term Opioid Use After Orthopaedic Trauma. J Orthop Trauma 2022; 36:326-331. [PMID: 34999625 DOI: 10.1097/bot.0000000000002346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether the use of a multimodal analgesic protocol reduced short-term and long-term opioid use in patients hospitalized after orthopaedic trauma. DESIGN Retrospective pre-post intervention study. SETTING Regional, academic, Level 1 trauma center in Central Kentucky. PATIENTS/PARTICIPANTS Patients were hospitalized after orthopaedic injury before (n = 393) and after (n = 378) the implementation of a multimodal analgesic protocol. INTERVENTION The intervention involved a multimodal analgesic protocol consisting of acetaminophen, ibuprofen/ketorolac, gabapentinoids, skeletal muscle relaxants, and standardized doses of opioids plus standardized pain management education before hospital discharge. MAIN OUTCOME MEASUREMENTS End points included discharge opioid prescription, days' supply and daily morphine milligram equivalent (MME), and long-term opioid use after hospitalization. Opioid use in the 90 days before and after hospitalization was assessed using state prescription drug monitoring program data. RESULTS Discharge opioid prescription rates were similar in the intervention and control cohorts [79.9% vs. 78.4%, odds ratio (OR) 1.30 (0.83-2.03), P = 0.256]. Patients in the intervention cohort received a shorter days' supply [5.7 ± 4.1 days vs. 8.1 ± 6.2 days, rate ratio 0.70 (0.65-0.76), P < 0.001] and lower average daily MME [34.8 ± 24.9 MME vs. 51.5 ± 44.0 MME, rate ratio 0.68 (0.62-0.75), P < 0.001]. The incidence of long-term opioid use was also significantly lower in the intervention cohort [7.7% vs. 12.0%, OR 0.53 (0.28-0.98), P = 0.044]. CONCLUSIONS Implementation of a multimodal analgesic protocol was associated with reductions in both short-term and long-term opioid use, including long-term opioid therapy, after orthopaedic trauma. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Opioid Sparing Analgesics in Spine Surgery. Adv Orthop 2022; 2022:1026547. [PMID: 35942400 PMCID: PMC9356873 DOI: 10.1155/2022/1026547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/17/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022] Open
Abstract
Combinations of various nonopioid analgesics have been used to decrease pain and opioid consumption postoperatively allowing for faster recovery, improved patient satisfaction, and decreased morbidity. These opioid alternatives include acetaminophen, NSAIDs, COX-2 specific inhibitors, gabapentinoids, local anesthetics, dexamethasone, and ketamine. Each of these drugs presents its own advantages and disadvantages which can make it difficult to implement universally. In addition, ambiguous administration guidelines for these nonopioid analgesics lead to a difficult implementation of standardization protocols in spine surgery. A focus on the efficacy of different pain modalities specifically within spine surgery was implemented to assist with this standardized protocol endeavor and to educate surgeons on limiting opioid prescribing in the postoperative period. The purpose of this review article is to investigate the various opioid sparing medications that have been used to decrease morbidity in spine surgery and better assist surgeons in managing postoperative pain. Methods. A narrative review of published literature was conducted using the search function in Google scholar and PubMed was used to narrow down search criteria. The keywords “analgesics,” “spine,” and “pain” were used.
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Suvada K, Zimmer A, Soodalter J, Malik JS, Kavalieratos D, Ali MK. Coprescribing of opioids and high-risk medications in the USA: a cross-sectional study with data from national ambulatory and emergency department settings. BMJ Open 2022; 12:e057588. [PMID: 35710252 PMCID: PMC9207755 DOI: 10.1136/bmjopen-2021-057588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Describe trends in opioid plus high-risk medication coprescribing in the USA. DESIGN Analyses of serial, cross-sectional, nationally representative data of the National Ambulatory Medical Care Survey (NAMCS) over 2007-2016 and the National Hospital Ambulatory Medical Care Survey (NHAMCS) over 2007-2018. SETTING US ambulatory (NAMCS) and emergency department (ED, NHAMCS) settings. PARTICIPANTS Patient visits in which the patient was 18 years and older with an opioid prescription in the NAMCS or NHAMCS databases. PRIMARY AND SECONDARY OUTCOME MEASURES Frequency of opioid plus high-risk medication coprescribing. RESULTS From a combined sample of 700 499 visits over 2007-2018, there were 105 720 visits (15.1%) where opioids were prescribed. n=31 825 were from NAMCS and n=73 895 were from NHAMCS. The mean prevalence of coprescription of opioids and high-risk medications for the combined NAMCS and NHAMCS sample was 18.4% in 2007, peaked at 33.2% in 2014 and declined to 23.8% in 2016. Compared with adults receiving opioid prescriptions alone, those coprescribed opioids and high-risk medications were older, more likely female, white and using private or Medicare insurance (p<0.0001). CONCLUSIONS Coprescribing is more common in ambulatory than ED settings and has been declining, yet one in four patient visits where opioids were prescribed resulted in coprescribed, high-risk medications in 2016. Efforts and research to help lower the rates of high-risk prescribing are needed.
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Affiliation(s)
- Kara Suvada
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Anna Zimmer
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Jesse Soodalter
- Division of Palliative Medicine, Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Jimi S Malik
- Division of Palliative Medicine, Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Mohammed K Ali
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
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Waterloo M, Rozic M, Knauss G, Jackson S, Karuga D, Zimmerman DE, Montepara CA, Covvey JR, Nemecek BD. Gabapentin initiation in the inpatient setting: A characterization of prescribing. Am J Health Syst Pharm 2022; 79:S65-S73. [DOI: 10.1093/ajhp/zxac140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Disclaimer
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
Purpose
Gabapentin is a widely prescribed analgesic with increased popularity over recent years. Previous studies have characterized use of gabapentin in the outpatient setting, but minimal data exist for its initiation in the inpatient setting. The objective of this study was to characterize the prescribing patterns of gabapentin when it was initiated in the inpatient setting.
Methods
This was a retrospective cohort study of a random sample of adult patients who received new-start gabapentin during hospital admission. Patients for whom gabapentin was prescribed as a home medication, with one-time, on-call, or as-needed orders, or who died during hospital admission were excluded. The primary outcome was characterization of the gabapentin indication; secondary outcomes included the starting and discharge doses, the number of dose titrations, the rate of concomitant opioid prescribing, and pain clinic follow-up. Patients were stratified by surgical vs nonsurgical status.
Results
A total of 464 patients were included, 283 (61.0%) of whom were surgical and 181 (39.0%) of whom were nonsurgical. The cohort was 60% male with a mean (SD) age of 56 (18) years; surgical patients were younger and included more women. The most common indications for surgical patients were multimodal analgesia (161; 56.9%), postoperative pain (53; 18.7%), and neuropathic pain (26; 9.2%), while those for nonsurgical patients were neuropathic pain (72; 39.8%) and multimodal analgesia (53; 29.3%). The mean starting dose was similar between the subgroups (613 mg for surgical patients vs 560 mg for nonsurgical patients; P = 0.196). A total of 51.6% vs 81.8% of patients received gabapentin at discharge (P < 0.0001), while referral/follow-up to a pain clinic was minimal and similar between the subgroups (1.1% vs 3.9%; P = 0.210).
Conclusion
Inpatients were commonly initiated on gabapentin for generalized indications, with approximately half discharged on gabapentin. Further studies are needed to assess the impact of this prescribing on chronic utilization.
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Affiliation(s)
- Marissa Waterloo
- Hackensack Meridian Health Riverview Medical Center, Red Bank, NJ, USA
| | - Matthew Rozic
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Gionna Knauss
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Simran Jackson
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Dellon Karuga
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - David E Zimmerman
- Division of Pharmacy Practice, UPMC Mercy Hospital, Pittsburgh, PA
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Courtney A Montepara
- Division of Pharmacy Practice, Allegheny General Hospital, Pittsburgh, PA
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Jordan R Covvey
- Division of Pharmaceutical, Administrative, and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Branden D Nemecek
- Division of Pharmacy Practice, UPMC Mercy Hospital, Pittsburgh, PA
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
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Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies. Plast Reconstr Surg Glob Open 2022; 10:e4310. [PMID: 35572190 PMCID: PMC9094416 DOI: 10.1097/gox.0000000000004310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 12/13/2022]
Abstract
Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control. Methods A review study based on multimodal analgesia was conducted. Results We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices. Conclusion This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.
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Prabhakar NK, Chadwick AL, Nwaneshiudu C, Aggarwal A, Salmasi V, Lii TR, Hah JM. Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review. Int J Gen Med 2022; 15:4535-4549. [PMID: 35528286 PMCID: PMC9075013 DOI: 10.2147/ijgm.s292698] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Perioperative pain management is a unique challenge in patients undergoing spine surgery due to the increased incidence of both pre-existing chronic pain conditions and chronic postsurgical pain. Peri-operative planning and counseling in spine surgery should involve an interdisciplinary approach that includes consideration of patient-level risk factors, as well as pharmacologic and non-pharmacologic pain management techniques. Consideration of psychological factors and patient focused education as an adjunct to these measures is paramount in developing a personalized perioperative pain management plan. Understanding the currently available body of knowledge surrounding perioperative opioid management, management of opioid use disorder, regional/neuraxial anesthetic techniques, ketamine/lidocaine infusions, non-opioid oral analgesics, and behavioral interventions can be useful in developing a comprehensive, multi-modal treatment plan among patients undergoing spine surgery. Although many of these techniques have proved efficacious in the immediate postoperative period, long-term follow-up is needed to define the impact of such approaches on persistent pain and opioid use. Future techniques involving the use of precision medicine may help identify phenotypic and physiologic characteristics that can identify patients that are most at risk of developing persistent postoperative pain after spine surgery.
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Affiliation(s)
- Nitin K Prabhakar
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Andrea L Chadwick
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Chinwe Nwaneshiudu
- Department of Anesthesiology, Perioperative and Pain Management, Mount Sinai Hospital, Icahn School of Medicine, New York, NY, USA
| | - Anuj Aggarwal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Vafi Salmasi
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Theresa R Lii
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jennifer M Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
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Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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Schaffer AL, Brett J, Buckley NA, Pearson SA. Trajectories of pregabalin use and their association with longitudinal changes in opioid and benzodiazepine use. Pain 2022; 163:e614-e621. [PMID: 34382609 DOI: 10.1097/j.pain.0000000000002433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/11/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Concomitant use of pregabalin with opioids and/or benzodiazepines is common, despite the increased risks. However, clinical trials suggest pregabalin can have an opioid-sparing effect when treating acute postoperative pain. We explored how opioid and benzodiazepine use changed over time in people initiating pregabalin, using dispensing claims data for a 10% sample of Australians (2013-19). Among 142,776 people initiating pregabalin (median age = 61 years, 57% female), we used group-based trajectory modelling to identify 6 pregabalin dose trajectories in the first year postinitiation. Two trajectories involved discontinuation: after one dispensing (49%), and after 6 months of treatment (14%). Four trajectories involved persistent use with variable estimated median daily doses of 39 mg (16%), 127 mg (14%), 276 mg (5%), and 541 mg (2%). We quantified opioid and benzodiazepine use in the year before and after pregabalin initiation using generalised linear models. Over the study period, 71% were dispensed opioids and 34% benzodiazepines, with people on the highest pregabalin dose having highest rates of use. Opioid use increased postpregabalin initiation. Among people using both opioids and pregabalin, the geometric mean daily dose in oral morphine equivalents increased after pregabalin initiation in all trajectories, ranging from +5.9% (99% confidence interval 4.8%-7.0%) to +39.8% (99% confidence interval 38.3%-41.5%) in people on the highest daily pregabalin dose. Among people using both pregabalin and benzodiazepines, the dose remained constant over time for people in all trajectories. Notwithstanding its reputation as opioid-sparing, in this outpatient setting, we observed that people using opioids tended to use higher opioid daily doses after pregabalin initiation, especially those on high pregabalin doses.
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Affiliation(s)
- Andrea L Schaffer
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
| | - Jonathan Brett
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
| | - Nicholas A Buckley
- Biomedical Informatics and Digital Health, University of Sydney, Sydney, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
- Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
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