The assessment and management of pain in cirrhosis

Opioid and Nonopioid Analgesic Prescribing Patterns of Hepatologists for Medicare Beneficiaries

INTRODUCTION

Opioids are commonly prescribed to patients with chronic liver disease, but little is known regarding medication prescribing patterns of hepatologists. Opioid use increased until national guidelines limited opioid prescriptions in early 2016. We aimed to describe rates of opioid and nonopioid analgesics to Medicare beneficiaries by hepatologists from 2013 to 2017 and identify demographic characteristics associated with higher prescribing.

METHODS

Prescription data from 2013 to 2017 by 761 hepatologists identified in the Centers for Medicare and Medicaid Services Part D Public Use File were analyzed. Annual prescription volumes were compared for providers with >10 annual prescriptions of a given drug type. Provider characteristics associated with opioid prescriptions were identified through multivariate logistic regression analyses.

RESULTS

The proportion of hepatologists prescribing >10 annual opioid prescriptions decreased from 29% to 20.6%. Median annual opioid prescriptions per hepatologist significantly decreased from 24 to 20. Tramadol remained the most prescribed analgesic. Nonopioid analgesic prescription volume did not increase significantly. Provider characteristics associated with increased opioid prescriptions included male sex, practice location in the South and Midwest (vs West), more years in practice, and a greater proportion of beneficiaries who are white or with low-income subsidy claims. Characteristics associated with fewer prescriptions included non-university-based practice, having a greater proportion of female beneficiaries, and later prescription year.

DISCUSSION

Hepatologists are prescribing less opioids. However, the prevalence of tramadol use and the lack of increase in nonopioid analgesic use highlights the need for advancing the science and training of pain management in chronic liver disease and targeted implementation of nonopioid treatment programs.

The burden of significant pain in the cirrhosis population: Risk factors, analgesic use, and impact on health care utilization and clinical outcomes

BACKGROUND

We aimed to characterize pain and analgesic use in a large contemporary cohort of patients with cirrhosis and to associate pain with unplanned health care utilization and clinical outcomes in this population.

METHODS

We included all patients with cirrhosis seen in UCSF hepatology clinics from 2013 to 2020. Pain severity and location were determined using documented pain scores at the initial visit; "significant pain" was defined as moderate or severe using established cutoffs. Demographic, clinical, and medication data were abstracted from electronic medical records. Associations between significant pain and our primary outcome of 1-year unplanned health care utilization (ie, emergency department visit or hospitalization) and our secondary outcomes of mortality and liver transplantation were explored in multivariable models.

RESULTS

Among 5333 patients with cirrhosis, 32% had a nonzero pain score at their initial visit and 25% had significant (ie moderate/severe) pain. Sixty percent of patients with significant pain used ≥1 analgesic; 34% used opioids. Patients with cirrhosis with significant pain had similar Model for End-Stage Liver Disease-Sodium scores (14 vs. 13), but higher rates of decompensation (65% vs. 55%). The most common pain location was the abdomen (44%). Patients with abdominal pain, compared to pain in other locations, were more likely to have decompensation (72% vs. 56%). Significant pain was independently associated with unplanned health care utilization (adjusted odds ratio: 1.3, 95% CI: 1.1-1.5) and mortality (adjusted hazard ratio: 1.4, 95% CI: 1.2-1.6).

CONCLUSIONS

Pain among patients with cirrhosis is often not well-controlled despite analgesic use, and significant pain is associated with unplanned health care utilization and mortality in this population. Effectively identifying and treating pain are essential in reducing costs and improving quality of life and outcomes among patients with cirrhosis.

Changing Prevalence of Medication Use in People with Cirrhosis: A Retrospective Cohort Study Using Pharmaceutical Benefits Scheme Data

BACKGROUND

Safe and appropriate use of medicines is essential to improve health outcomes in cirrhosis. However, little is known about the number and type of medicines dispensed to people with cirrhosis in Australia, as this predominantly occurs in the community. We aimed to characterise the prescriptions dispensed to people with cirrhosis and explore changes in the use of medication groups over time.

METHODS

Pharmaceutical Benefits Scheme data between 1 January 2016 and 30 June 2020 was extracted for consenting CirCare participants (multi-site, prospective, observational study). Prescriptions dispensed from cirrhosis diagnosis until liver transplant or death were included. Safety classifications for dispensed medicines were defined using published evidence-based recommendations. The pattern of medication use was analysed in 6-monthly time intervals. Generalised estimating equations models were used to estimate the change in consumption of medicines over time.

RESULTS

Five hundred twenty-two patients (mean age 60 years, 70% male, 34% decompensated at recruitment) were dispensed 89,615 prescriptions during the follow-up period, representing a median of 136 [interquartile range (IQR) 62-237] prescriptions and a median of 16 (IQR 11-23) unique medicines per patient (total n = 9306 medicines). The most commonly used medicines were proton pump inhibitors (PPIs) (dispensed at least once to 73% of patients), opioids (68%) and antibiotics (89%). Polypharmacy was prevalent, with 59-69% of observed participants in each time period dispensed five or more unique medicines. Prescription medication use increased over time (p < 0.001) independently of age, comorbidity burden and liver disease aetiology. The likelihood of taking PPIs, opioids, antidepressants and inhaled medicines also increased with each successive time period. Use of angiotensin therapies, metformin and statins differed over time between patients with compensated versus decompensated cirrhosis. General practitioners prescribed 69% of dispensed medicines, including a higher proportion of 'unsafe' and 'safety unknown' medicines compared with consultants/specialists (p < 0.001).

CONCLUSIONS

Polypharmacy is common in people with cirrhosis and some medication groups may be overused. Pharmacovigilance is required and future medication safety efforts should target high-risk prescribing practices and promote medication rationalisation in the community.

Low back pain in patients hospitalised with liver cirrhosis- a retrospective study

BACKGROUND

Lower back pain is a common issue, but little is known about the prevalence of pain in patients with liver cirrhosis during hospitalisation. Therefore, the objective of this study was to determine lower back pain in patients with liver cirrhosis.

METHODS

The sample consisted of patients with liver cirrhosis (n = 79; men n = 55; women n = 24; mean age = 55.79 ± 12.52 years). The hospitalised patients were mobile. The presence and intensity of pain were assessed in the lumbar spine during hospitalisation. The presence of pain was assessed using the visual analogue pain scale (0-10). The range of motion of the lower spine was assessed using the Schober and Stibor tests. Frailty was measured by Liver Frailty Index (LFI). The condition of liver disease was evaluated using The Model For the End-Stage Liver Disease (MELD) and Child-Pugh score (CPS) and ascites classification. Student's t test and Mann-Whitney test were used for analysis of the difference of group. Analysis of variance (ANOVA) with the Tukey post hoc test was used to test differences between categories of liver frailty index. The Kruskal-Wallis test was used to test pain distribution. Statistical significance was determined at the α-0.05 significance level.

RESULT

The prevalence of pain in patients with liver cirrhosis was 13.92% (n = 11), and the mean intensity of pain according to the visual analogue scale was 3.73 (± 1.90). Lower back pain was present in patients with ascites (15.91%; n = 7) and without ascites (11.43%; n = 4). The prevalence of lower back pain was not statistically significant between patients with and without ascites (p = 0,426). The base of Schober's assessment mean score was 3.74 cm (± 1.81), and based on Stibor's assessment mean score was 5.84 cm (± 2.23).

CONCLUSION

Lower back pain in patients with liver cirrhosis is a problem that requires attention. Restricted spinal mobility has been reported in patients with back pain, according to Stibor, compared to patients without pain. There was no difference in the incidence of pain in patients with and without ascites.

Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease

CONTEXT

Patients with end-stage liver disease (ESLD) commonly experience pain and other symptoms that result in a poor quality of life. Few studies have examined opioid usage, adverse events (AEs), and other outcomes in ESLD patients receiving opioid analgesia.

OBJECTIVES

This study aimed to compare outcomes in ESLD patients who received opioids to those who did not and to determine risk factors for AEs.

METHODS

This was a retrospective case-cohort study of 270 hospitalized patients with ESLD that used administrative and clinical data from the electronic medical record.

RESULTS

Two-thirds of patients with ESLD admitted during the study period received at least one opioid analgesic. Patients who received opioids presented with a greater number of liver related complications and higher rates of anxiety (32% vs. 17%, P= 0.007), had substantially worse initial and average pain scores (both P< 0.001), and received more palliative care consultations. The opioid group had somewhat more respiratory (22.2% vs. 11.1%, P= 0.02) and gastrointestinal (38.5% vs. 25.2%, P= 0.03) AEs, but no increase in CNS adverse events which included hepatic encephalopathy. Anxiety and disease severity (i.e., the number of liver related complications) but not opioid administration were risk factors for the number of AEs.

CONCLUSION

Opioid administration was not an independent risk factor for the number of AEs in hospitalized patients with ESLD, whereas anxiety and more liver-related complications increased AE risk. Our findings suggest that opioids have an appropriate and reasonably safe role in alleviation of pain in patients with ESLD.

Current vision on diagnosis and comprehensive care in hepatic encephalopathy

The first clinical guidelines on hepatic encephalopathy were published in 2009. Almost 14 years since that first publication, numerous advances in the field of diagnosis, treatment, and special condition care have been made. Therefore, as an initiative of the Asociación Mexicana de Gastroenterología A.C., we present a current view of those aspects. The manuscript described herein was formulated by 24 experts that participated in six working groups, analyzing, discussing, and summarizing the following topics: Definition of hepatic encephalopathy; recommended classifications; epidemiologic panorama, worldwide and in Mexico; diagnostic tools; conditions that merit a differential diagnosis; treatment; and primary and secondary prophylaxis. Likewise, these guidelines emphasize the management of certain special conditions, such as hepatic encephalopathy in acute liver failure and acute-on-chronic liver failure, as well as specific care in patients with hepatic encephalopathy, such as the use of medications and types of sedation, describing those that are permitted or recommended, and those that are not.

Palliative Care for Patients with End-Stage Liver Disease

End-stage liver disease (ESLD) is the culmination of progression of chronic liver disease to cirrhosis, decompensation, and chronic liver failure, featuring portal hypertension or hepatocellular failure-related complications. Liver transplantation offers improved long-term survival for these patients but is negatively influenced by donor availability, financial constraints in developing countries, active substance abuse, progression of disease or malignancy on wait-list, sepsis and extrahepatic organ involvement. In this context, palliative care (PC), an interdisciplinary medical practice that aim to prevent and relieve suffering, offers best possible quality of life and is not limited to end-of-life care. It also encompasses achievable goals such as symptom control and aggressive disease-modifying treatments or interventions that beneficially alter the natural course of the disease to offer curative intend. In this narrative review, we discuss the prognostic factors that define disease course in ESLD, various indications and challenges in PC for advanced cirrhosis and management options for major symptom burden in patients with ESLD based on evidence-based best practice.

Contemporary management of pain in cirrhosis: Toward precision therapy for pain

Chronic pain is highly prevalent in patients with cirrhosis and is associated with poor health-related quality of life and poor functional status. However, there is limited guidance on appropriate pain management in this population, and pharmacologic treatment can be harmful, leading to adverse outcomes, such as gastrointestinal bleeding, renal injury, falls, and hepatic encephalopathy. Chronic pain can be categorized mechanistically into three pain types: nociceptive, neuropathic, and nociplastic, each responsive to different therapies. By discussing the identification, etiology, and treatment of these three mechanistic pain descriptors with a focus on specific challenges in patients with cirrhosis, we provide a framework for better tailoring treatments, including nonpharmacologic therapies, to patients' needs.

Using Intervention Mapping to Develop a Novel Pain Self-Management Intervention for People with Cirrhosis

BACKGROUND

Chronic pain is common among patients with cirrhosis and is challenging to treat. While promising, pain self-management (PSM) interventions have not been tailored to this population's needs.

AIMS

To design a PSM intervention for patients with cirrhosis.

METHODS

Semi-structured interviews with 17 patients with cirrhosis, 12 hepatologists, and 6 administrators from two medical centers were conducted to inform a rigorous, structured intervention mapping (IM) process. Qualitative content analysis was guided by social cognitive theory (SCT) and the Consolidated Framework for Implementation Research (CFIR) and incorporated into intervention development. A planning group met regularly throughout the intervention, to reach consensus about how to use data and theory to develop the intervention through IM.

RESULTS

Participants described barriers to PSM behaviors, including the absence of simple, evidence-based interventions for pain for patients with cirrhosis, inadequate provider knowledge, time, and training, and lack of champions, funding, and communication. Patients described high motivation to treat pain using behavioral methods including meditation, prayer, and exercise. The intervention was designed to address barriers to PSM behaviors for patients with cirrhosis, using behavior change methods that address knowledge, self-efficacy, and outcome expectations. The LEAP (Liver Education About Pain) intervention is a 12-week, modular intervention delivered by phone via individual and group sessions with a health coach.

CONCLUSIONS

People with cirrhosis, hepatologists, and administrators informed this theory-driven, tailored PSM intervention, which was designed to be implementable in the real world.

Future liver remnant volume is associated with postoperative fentanyl consumption following open donor hepatectomy: a retrospective multivariate analysis

PURPOSE

Liver resection has a risk of postoperative hepatic dysfunction, including drug metabolism. Since fentanyl is primarily metabolized in the liver, liver resection requires exercising caution against fentanyl overdose in postoperative analgesia. The rationale for dose adjustment of fentanyl in the preoperative prescription for patients undergoing liver resection remains unclear. We examined whether postoperative fentanyl consumption is associated with the future liver remnant after liver resection and investigated factors influencing fentanyl consumption.

METHODS

In this retrospective study, 89 living liver donors undergoing open liver resection received intravenous patient-controlled analgesia with fentanyl 2 mg with thoracic epidural analgesia. The primary outcome was postoperative hourly consumption of intravenous patient-controlled analgesia with fentanyl. Future liver remnant volume (ml) and the ratio of future liver remnant volume to whole liver volume (%) were estimated by computed tomography volumetry and compared to determine which correlated more strongly with fentanyl hourly consumption. Multivariable analysis identified independent factors affecting fentanyl consumption, with adjustments for patient characteristics and intravenous patient-controlled analgesia setting.

RESULTS

Future liver remnant volume (ml) was significantly correlated more strongly than the ratio of future liver remnant (%) with postoperative fentanyl consumption (r = 0.53 vs. 0.36, p < 0.001). Larger future liver remnant volume (β = 0.25, p = 0.006) and age < 45 years (β = 0.24, p = 0.009) were independently associated with higher fentanyl consumption, while sex and weight were not.

CONCLUSIONS

Future liver remnant volume was significantly associated with postoperative fentanyl consumption. Smaller remnant liver volume and older age (≥ 45 years) were independent factors reducing postoperative fentanyl consumption in patients undergoing open donor hepatectomy.

Metamizole-Associated Risks in Decompensated Hepatic Cirrhosis

BACKGROUND

Because of the increased risk of acute renal failure (ARF), the use of cyclooxygenase (COX) inhibitors is not recommended in patients with decompensated hepatic cirrhosis. Metamizole is not a classic COX inhibitor, but there are insufficient data to support its safe use. In this study, we investigate the effect of metamizole on the risk of ARF in these patients.

METHODS

Metamizole use, ARF incidence, and patient mortality were examined in a large, retrospective, exploratory cohort and validated with data from a prospective registry.

RESULTS

523 patients were evaluated in the exploratory cohort. Metamizole use at baseline was documented in 110 cases (21%) and was independently associated with the development of ARF, severe (grade 3) ARF, and lower survival without liver transplantation at follow-up on day 28 (HR: 2.2, p < 0.001; HR: 2.8, p < 0.001; and HR: 2.6, p < 0.001, respectively). Interestingly, the risk of ARF depended on the dose of metamizole administered (HR: 1.038, p < 0.001). Compared to patients who were treated with opioids, the rate of ARF was higher in the metamizole group (49% vs. 79%, p = 0.014). An increased risk of ARF with metamizole use was also demonstrated in the independent validation cohort (p < 0.001).

CONCLUSION

Metamizole therapy, especially at high doses, should only be used with a high level of caution in patients with decompensated cirrhosis.

Hip Fractures in Patients With Liver Cirrhosis: Worsening Liver Function Is Associated with Increased Mortality

BACKGROUND

Liver cirrhosis is associated with osteoporosis, imbalance leading to falls, and subsequent fragility fractures. Knowing the prognosis of patients with liver cirrhosis of varying severity at the time of hip fracture would help physicians determine the course of treatment in this complex patient popultaion.

QUESTIONS/PURPOSES

(1) Is there an association between liver cirrhosis of varying severity and mortality in patients with hip fractures? (2) Is there an association between liver cirrhosis of varying severity and the in-hospital, 30-day, and 90-day postoperative complications of symptomatic thromboembolism and infections including wound complications, pneumonia, and urinary tract infections?

METHODS

Between 2015 and 2019, we identified 128 patients with liver cirrhosis who were treated for hip fractures at one of two Level I trauma centers. Patients younger than 18 years, those with incomplete medical records, fractures other than hip fractures or periprosthetic hip fractures, noncirrhotic liver disease, status after liver transplantation, and metastatic cancer other than hepatocellular carcinoma were excluded. Based on these exclusions, 77% (99 of 128) of patients were eligible; loss to follow-up was 0% within 1 year and 4% (4 of 99) at 2 years. The median follow-up duration was 750 days (interquartile range 232 to 1000). Ninety-four patients were stratified based on Model for End-stage Liver Disease (MELD) score subgroup (MELD scores of 6-9 [MELD6-9], 10-19 [MELD10-19], and 20-40 [MELD20-40]), and 99 were stratified based on compensation or decompensation status, both measures for liver cirrhosis severity. MELD scores combine laboratory parameters related to liver disease and are used to predict cirrhosis-related mortality based on metabolic abnormalities. Decompensation, however, is the clinical finding of acute deterioration in liver function characterized by ascites, hepatic encephalopathy, and variceal hemorrhage, associated with increased mortality. MELD analyses excluded 5% (5 of 99) of patients due to missing laboratory values. Median age at the time of hip fracture was 69 years (IQR 62 to 78), and 55% (54 of 99) of patients were female. The primary outcome of mortality was determined at 90 days, 1 year, and 2 years after surgery. Secondary outcomes were symptomatic thromboembolism and infections, defined as any documented surgical wound complications, pneumonia, or urinary tract infections requiring treatment. These were determined by chart review at three timepoints: in-hospital and within 30 days or 90 days after discharge. The primary outcome was assessed using a Cox proportional hazard analysis for the MELD score and compensation or decompensation classifications; secondary outcomes were analyzed using the Fisher exact test.

RESULTS

Patients in the MELD20-40 group had higher 90-day (hazard ratio 3.95 [95% CI 1.39 to 12.46]; p = 0.01), 1-year (HR 4.12 [95% CI 1.52 to 11.21]; p < 0.001), and 2-year (HR 3.65 [95% CI 1.68 to 7.93]; p < 0.001) mortality than those in the MELD6-9 group. Patients with decompensation had higher in-hospital (9% versus 0%; p = 0.04), 90-day (HR 3.35 [95% CI 1.10 to 10.25]; p = 0.03), 1-year (HR 4.39 [95% CI 2.02 to 9.54]; p < 0.001), and 2-year (HR 3.80 [95% CI 2.02 to 7.15]; p < 0.001) mortality than did patients with compensated disease. All in-hospital deaths were related to liver failure and within 30 days of surgery. The 1-year mortality was 55% for MELD20-40 and 53% for patients with decompensated disease, compared with 16% for patients with MELD6-9 and 15% for patients with compensated disease. In both the MELD and (de)compensation analyses, in-hospital and postdischarge 30-day symptomatic thromboembolic and infectious complications were not different among the groups (all p > 0.05). Ninety-day symptomatic thromboembolism was higher in the MELD20-40 group compared with the other two MELD classifications (13% for MELD20-40 and 0% for both MELD6-9 and MELD10-19; p = 0.02).

CONCLUSION

The mortality of patients with preexisting liver cirrhosis who sustain a hip fracture is high, and it is associated with the degree of cirrhosis and decline in liver function, especially in those with signs of decompensation, defined as ascites, hepatic encephalopathy, and variceal hemmorrhage. Patients with mild-to-moderate cirrhosis (MELD score < 20) and those with compensated disease may undergo routine fracture treatment based on their prognosis. Those with severe (MELD score > 20) or decompensated liver cirrhosis should receive multidisciplinary, individualized treatment, with consideration given to palliative and nonsurgical treatment given their high risk of death within 1 year after surgery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Characteristics of opioid prescribing to outpatients with chronic liver diseases: A call for action

Background

Chronic liver disease (CLD) is among the strongest risk factors for adverse prescription opioid-related events. Yet, the current prevalence and factors associated with high-risk opioid prescribing in patients with chronic liver disease (CLD) remain unclear, making it challenging to address opioid safety in this population. Therefore, we aimed to characterize opioid prescribing patterns among patients with CLD.

Methods

This retrospective cohort study included patients with CLD identified at a single medical center and followed for one year from 10/1/2015-9/30/2016. Multivariable, multinomial regression was used identify the patient characteristics, including demographics, medical conditions, and liver-related factors, that were associated with opioid prescriptions and high-risk prescriptions (≥90mg morphine equivalents per day [MME/day] or co-prescribed with benzodiazepines).

Results

Nearly half (47%) of 12,425 patients with CLD were prescribed opioids over a one-year period, with 17% of these receiving high-risk prescriptions. The baseline factors significantly associated with high-risk opioid prescriptions included female gender (adjusted incident rate ratio, AIRR = 1.32, 95% CI = 1.14–1.53), Medicaid insurance (AIRR = 1.68, 95% CI = 1.36–2.06), cirrhosis (AIRR = 1.22, 95% CI = 1.04–1.43) and baseline chronic pain (AIRR = 3.40, 95% CI = 2.94–4.01), depression (AIRR = 1.93, 95% CI = 1.60–2.32), anxiety (AIRR = 1.84, 95% CI = 1.53–2.22), substance use disorder (AIRR = 2.16, 95% CI = 1.67–2.79), and Charlson comorbidity score (AIRR = 1.27, 95% CI = 1.22–1.32). Non-alcoholic fatty liver disease was associated with decreased high-risk opioid prescriptions (AIRR = 0.56, 95% CI = 0.47–0.66).

Conclusion

Opioid medications continue to be prescribed to nearly half of patients with CLD, despite efforts to curtail opioid prescribing due to known adverse events in this population.

Hemoperitoneum From Bleeding Intra-Abdominal Varices: A Rare, Life-Threatening Cause of Abdominal Pain in a Patient With Cirrhosis

We report the case of a 54-year-old male with alcoholic cirrhosis who presented several times to the emergency department (ED) with right upper quadrant abdominal pain. Ten days after his initial presentation, the patient represented with hypotension and anemia. An abdominal CT angiogram identified hemorrhage from an ectopic varix successfully treated with emergent glue embolization of mesenteric, omental, and periumbilical varices. Intraperitoneal bleeding from ectopic varices in cirrhosis patients is a rare, life-threatening condition. Consideration and recognition of ectopic variceal hemorrhage in patients with cirrhosis can facilitate prompt life-saving treatment in a population susceptible to significant morbidity and mortality.

Medication Treatment of Active Opioid Use Disorder in Veterans With Cirrhosis

INTRODUCTION

Although opioid use disorder (OUD) is common in patients with cirrhosis, it is unclear how medication treatment for OUD (MOUD) is used in this population. We aimed to assess the factors associated with MOUD and mortality in a cohort of Veterans with cirrhosis and OUD.

METHODS

Within the Veterans Health Administration Corporate Data Warehouse, we developed a cohort of Veterans with cirrhosis and active OUD, using 2 outpatient or 1 inpatient International Classification of Diseases, ninth revision codes from 2011 to 2015 to define each condition. We assessed MOUD initiation with methadone or buprenorphine over the 180 days following the first OUD International Classification of Diseases, ninth revision code in the study period. We fit multivariable regression models to assess the association of sociodemographic and clinical factors with receiving MOUD and the associations between MOUD and subsequent clinical outcomes, including new hepatic decompensation and mortality.

RESULTS

Among 5,600 Veterans meeting criteria for active OUD and cirrhosis, 722 (13%) were prescribed MOUD over 180 days of follow-up. In multivariable modeling, MOUD was significantly, positively associated with age (adjusted odds ratio [AOR] per year: 1.04, 95% confidence interval (CI): 1.01-1.07), hepatitis C virus (AOR = 2.15, 95% CI = 1.37-3.35), and other substance use disorders (AOR = 1.47, 95% CI = 1.05-2.04) negatively associated with alcohol use disorder (AOR = 0.70, 95% CI = 0.52-0.95), opioid prescription (AOR = 0.51, 95% CI = 0.38-0.70), and schizophrenia (AOR = 0.59, 95% CI = 0.37-0.95). MOUD was not significantly associated with mortality (adjusted hazards ratio = 1.20, 95% CI = 0.95-1.52) or new hepatic decompensation (OR = 0.57, CI = 0.30-1.09).

DISCUSSION

Few Veterans with active OUD and cirrhosis received MOUD, and those with alcohol use disorder, schizophrenia, and previous prescriptions for opioids were least likely to receive these effective therapies.

Top Ten Tips Palliative Care Clinicians Should Know About End-Stage Liver Disease

End-stage liver disease (ESLD) is an increasingly prevalent condition with high morbidity and mortality, especially for those ineligible for liver transplantation. Patients with ESLD, along with their family caregivers, have significant needs related to their quality of life, and there is increasing attention being paid to integration of palliative care (PC) principles into routine care throughout the disease spectrum. To provide upstream care for these patients and their family caregivers, it is essential for PC providers to understand their complex psychosocial and physical needs and to be aware of the unique challenges around medical decision making and end-of-life care for this patient population. This article, written by a team of liver and PC experts, shares 10 high-yield tips to help PC clinicians provide better care for patients with advanced liver disease.

A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease

Background: Pain is a significant problem in adults living with advanced liver disease, having limited guidance available for its clinical management. While pain is considered a multidimensional experience, there have been limited reviews of the pain literature in advanced liver disease conducted with a multidimensional framework. Aims: The goal of this scoping review was to identify and map the multidimensional domains of pain in adults with advanced liver disease using the biopsychosocial model. Methods: We used Arksey and O'Malley's scoping framework. A search was conducted in MEDLINE, Embase, AMED, and CINAHL databases and the gray literature using specific eligibility criteria (1990-2019). Citation selection and data extraction were performed by two independent reviewers and in duplicate. Results: Of the 43 studies that met inclusion criteria, 51% were from North America and 93% utilized quantitative methods. The combined studies reported on 168,110 participants with ages ranging between 23 to 87 years. Only 9% reported an objective scoring system for liver disease severity. Few studies reported pain classification (9%) and intensity (16%). Pain prevalence ranged between 18% and 100%, with pain locations including joint, abdomen, back, head/neck, and upper/lower extremities. We identified and mapped 115 pain factors to the biopsychosocial model: physical (81%), psychological (65%), and sociocultural (5%). Only 9% measured pain using validated multidimensional tools. Pharmacological intervention (92%) prevailed among pain treatments. Conclusions: Pain is not well understood in patients with advanced liver disease, having limited multidimensional pain assessment and treatment approaches. There is a need to systematically examine the multidimensional nature of pain in this population.

Omega-3 derivatives, specialized pro-resolving mediators: Promising therapeutic tools for the treatment of pain in chronic liver disease

The main causes of liver injury are associated with inflammation and permanent damage. They can cause chronic liver disease (CLD), which is mainly related to viral hepatitis, alcohol consumption and non-alcoholic steatohepatitis, leading to fibrosis, cirrhosis and hepatocellular carcinoma. These conditions prevent the liver from working normally and make it begin to fail, which in turn may prompt a liver transplant. CLD and cirrhosis are the eleventh cause of death worldwide. At present, there are no approved pharmacological treatments to prevent, treat or resolve liver fibrosis. The prevalence of pain in the hepatic disease is elevated with ranges between 30% and 40%. Most of the pain drugs require hepatic function; therefore, the suitable control of pain is still a clinical challenge. Specialized pro-resolving mediators (SPM): lipoxins, resolvins, protectins and maresins, are potent endogenous molecules (nM concentrations) that modulate inflammatory body responses by reducing neutrophil infiltration, macrophage activity and pain sensitization. SPM have anti-inflammatory properties, stimulate tissue resolution, repair and regeneration, and exhibit anti-nociceptive actions. Furthermore, SPM were tried on different cellular, animal models and human observational data of liver injury, improving the pathogenesis of inflammation and fibrosis. In the present work, we will describe recent evidence that suggests that SPM can be used as a therapeutic option for CLD. Additionally, we will examine the role of SPM in the control of pain in pathologies associated with liver injury.

Neurobehavioral Consequences Associated with Long Term Tramadol Utilization and Pathological Mechanisms

:

Tramadol is a synthetic analog of codeine used to treat pain of moderate to severe intensity and is reported to have neurotoxic potential. At therapeutic dose, tramadol does not cause major side effects in comparison to other opioid analgesics, and is useful for the management of neurological problems like anxiety and depression. Long term utilization of tramadol is associated with various neurological disorders like seizures, serotonin syndrome, Alzheimer’s disease and Parkinson’s disease. Tramadol produces seizures through inhibition of nitric oxide, serotonin reuptake and inhibitory effects on GABA receptors. Extensive tramadol intake alters redox balance through elevating lipid peroxidation and free radical leading to neurotoxicity and produces neurobehavioral deficits. During Alzheimer’s disease progression, low level of intracellular signalling molecules like cGMP, cAMP, PKC and PKA affect both learning and memory. Pharmacologically tramadol produces actions similar to Selective Serotonin Reuptake Inhibitors (SSRIs), increasing the concentration of serotonin, which causes serotonin syndrome. In addition, tramadol also inhibits GABAA receptors in the CNS has been evidenced to interfere with dopamine synthesis and release, responsible for motor symptoms. The reduced level of dopamine may produce bradykinesia and tremors which are chief motor abnormalities in Parkinson’s Disease (PD).

Perioperative Opioid Use and Chronic Post-Surgical Pain after Liver Transplantation: A Single Center Observational Study

OBJECTIVES

To investigate the opioid requirements and prevalence of chronic postsurgical pain (CPSP) in liver transplant (LT) recipients and to evaluate the association of opioid use with postoperative survival.

DESIGN

Retrospective analysis.

SETTING

A large academic medical center.

PATIENTS

Cadaveric liver transplants recipients from 2008 to 2016.

INTERVENTIONS

Analysis of demographic, perioperative, and outcome data.

MEASUREMENTS AND MAIN RESULTS

This study measured the incidence and quantity of preoperative opioid use, postoperative opioid requirements, the incidence of CPSP, and survival in patients with and without CPSP. Opioid requirements were calculated in morphine milligram equivalents. In total, 322 LT recipients satisfied the inclusion criteria. The cohort of interest included 61 patients (18.9%) who were prescribed opioids before LT, compared to the control group of 261. Postoperative opioid requirements were significantly higher in the cohort of interest in the first 24 hours (205.9 ± 318.5 v 60.4 ± 33.6 mg, p < 0.0001) and at 7 days after transplant (57.0 ± 70.6 mg v 19.2 ± 15.4 mg, p < 0.0001). Incidence of CPSP was significantly higher in the cohort of interest at 3 months (70.5% v 45.5%, p < 0.0001), at 2 years (38% v 12%), and at 5 years (29.8% v 6.9%) postoperatively. CPSP was a significant risk factor for patient mortality after transplantation (p = 0.038, HR 1.26).

CONCLUSIONS

Opioid use is relatively frequent in patients waiting for LT. It significantly affects the postoperative opioid requirements and the incidence of CSPS. CPSP may significantly affect survival after LT.

Identifying and mapping biopsychosocial factors associated with pain in adults with advanced liver disease: protocol for a scoping review

INTRODUCTION

Pain is highly prevalent in the adult population diagnosed with liver disease. Those progressing to advanced liver disease often experience persistent pain and poor pain relief. There is presently limited guidance for the management of pain and associated symptoms in this population. The current literature lacks attention on how physical, psychological and social domains of liver disease modulate the pain experience. In this paper, we outline our scoping review protocol to systematically review the literature from academic bibliographic databases and grey sources to identify and map the biopsychosocial factors associated with pain in adults with advanced liver disease.

METHODS AND ANALYSIS

Arksey and O'Malley's methodology, and Tricco et al's Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, will guide the process for this scoping review. The literature search will include electronic and hand-searching methods using scholarly and grey sources. Scholarly databases include Medline, Embase, Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature. Grey databases will focus on research studies not captured in the scholarly databases including those by government agencies and professional organisations. Two members of the research team will independently screen the resulting publications following specific inclusion and exclusion criteria. Quality appraisal of the included research studies will employ the use of the Mixed Methods Appraisal Tool version 2018. Data collection and extraction of study characteristics will use a data extraction tool developed iteratively by the research team. Analysis of the factors associated with pain outcomes will be mapped and described according to the domains of the biopsychosocial model of pain.

ETHICS AND DISSEMINATION

The scoping review involves analysis of the published literature on pain and advanced liver disease and does not require ethics approval. The results will be shared with expert stakeholders to help establish clinical significance. We will disseminate the findings through publication in a scholarly journal: local, provincial, national and international scientific and professional conferences.

PROSPERO REGISTRATION NUMBER

CRD42019135677.