A Brief History of the Opioid Epidemic and Strategies for Pain Medicine

Inside "Operation Change Agent": Mallinckrodt's Plan for Capturing the Opioid Market

CONTEXT

The United States is deeply entangled in an opioid crisis that began with the overuse of prescription painkillers. At the height of the prescription opioid crisis (2006-2012), Mallinckrodt Pharmaceuticals was the nation's largest opioid manufacturer. This study explores Mallinckrodt's strategies for expanding its market share by promoting a new opioid.

METHODS

The authors used the Opioid Industry Document Archive to analyze the incentive structures, sales contests, and rhetorical strategy behind Mallinckrodt's "Operation Change Agent," a campaign to switch patients from OxyContin to Mallinckrodt-manufactured painkillers. A structured search of the archive in October 2022 retrieved 464 documents dated between 2010 and 2020.

FINDINGS

The authors identified a range of Mallinckrodt's sales force motivational techniques, including hypertargeting high-decile prescribers, providing free trial kits, using emotion-based language to connect with prescribers, and strategies for opposing prescriber resistance. Throughout, managers used specific incentivization metaphors to frame strategies in terms of sport and ultramarathons.

CONCLUSIONS

This research on internal corporate strategy joins the growing challenges to industry claims that opioid sales teams simply educated providers and helped fill existing demand for their products. It has important implications for regulatory policy and consumer protections that can better protect health in the face of competitive market forces.

Dynamics of combatting market-driven epidemics: Insights from U.S. reduction of cigarette, sugar, and prescription opioid consumption

Misuse and overconsumption of certain consumer products have become major global risk factors for premature deaths, with their total costs in trillions of dollars. Progress in reducing such deaths has been slow and difficult. To address this challenge, this review introduces the definition of market-driven epidemics (MDEs), which arise when companies aggressively market products with proven harms, deny these harms, and resist mitigation efforts. MDEs are a specific within the broader landscape of commercial determinants of health. We selected three illustrative MDE products reflecting different consumer experiences: cigarettes (nicotine delivery product), sugar (food product), and prescription opioids (medical product). Each met the MDE case definition with proven adverse health impacts, well-documented histories, longitudinal product consumption and health impact data, and sustained reduction in product consumption. Based on these epidemics, we describe five MDE phases: market expansion, evidence of harm, corporate resistance, mitigation, and market adaptation. From the peak of consumption to the most recent data, U.S. cigarette sales fell by 82%, sugar consumption by 15%, and prescription opioid prescriptions by 62%. For each, the consumption tipping point occurred when compelling evidence of harm, professional alarm, and an authoritative public health voice and/or public mobilization overcame corporate marketing and resistance efforts. The gap between suspicion of harm and the consumption tipping point ranged from one to five decades-much of which was attributable to the time required to generate sufficient evidence of harm. Market adaptation to the reduced consumption of target products had both negative and positive impacts. To our knowledge, this is the first comparative analysis of three successful efforts to change the product consumption patterns and the associated adverse health impacts of these products. The MDE epidemiological approach of shortening the latent time to effective mitigation provides a new method to reduce the impacts of harmful products.

Towards Multitargeted Ligands as Pain Therapeutics: Dual Ligands of the Cavα2δ-1 Subunit of Voltage-Gated Calcium Channel and the μ-Opioid Receptor

The synthesis and pharmacological activity of a new series of dual ligands combining activities towards the α2δ-1 subunit of voltage-gated calcium channels (Cavα2δ-1) and the μ-opioid receptor (MOR) as novel pain therapeutics are reported. A careful exploration of the pharmacophores related to both targets, which in principle had few common characteristics, led to the design of novel compounds exhibiting both activities. The construction of the dual ligands started from published Cavα2δ-1 ligands, onto which MOR ligand pharmacophoric elements were added. This exercise led to new amino-acidic substances with good affinities on both targets as well as good metabolic and physicochemical profiles and low potential for drug-drug interactions. A representative compound, (2S,4S)-4-(4-chloro-3-(((cis)-4-(dimethylamino)-4-phenylcyclohexyl)methyl)-5-fluorophenoxy)pyrrolidine-2-carboxylic acid, displayed promising analgesic activities in several in vivo pain models as well as a reduced side-effect profile in relation to morphine.

Satellite glial cells in sensory ganglia play a wider role in chronic pain via multiple mechanisms

Satellite glial cells are unique glial cells that surround the cell body of primary sensory neurons. An increasing body of evidence suggests that in the presence of inflammation and nerve damage, a significant number of satellite glial cells become activated, thus triggering a series of functional changes. This suggests that satellite glial cells are closely related to the occurrence of chronic pain. In this review, we first summarize the morphological structure, molecular markers, and physiological functions of satellite glial cells. Then, we clarify the multiple key roles of satellite glial cells in chronic pain, including gap junction hemichannel Cx43, membrane channel Pannexin1, K channel subunit 4.1, ATP, purinergic P2 receptors, and a series of additional factors and their receptors, including tumor necrosis factor, glutamate, endothelin, and bradykinin. Finally, we propose that future research should focus on the specific sorting of satellite glial cells, and identify genomic differences between physiological and pathological conditions. This review provides an important perspective for clarifying mechanisms underlying the peripheral regulation of chronic pain and will facilitate the formulation of new treatment plans for chronic pain.

Xylazine: A Drug Adulterant of Clinical Concern

PURPOSE OF REVIEW

The opioid epidemic has been responsible for significant morbidity and mortality in the USA and worldwide. As a result, it is essential to recognize the threat these potent drugs can cause when illicitly used. Specifically, introducing fentanyl as a drug adulterant has been shown to impact overdose rates drastically. In this regard, the Drug Enforcement Agency recently released a public safety alert announcing the new threat of a new adulterant called xylazine. Xylazine is a powerful animal sedative with a different mechanism of action when compared to illicit opioids such as heroin and fentanyl. Xylazine is typically injected intravenously via a syringe, often in combination with multiple other drugs. One of the most common drugs, xylazine, is taken in combination with fentanyl, with users of this drug combination describing xylazine as prolonging the euphoric sensation produced by fentanyl.

RECENT FINDINGS

Xylazine may cause adverse effects such as bradycardia, brief hypertension followed by hypotension, premature ventricular contractions, ataxia, slurred speech, sedation, and respiratory depression. Much of the recent literature on xylazine use in humans comes from case reports and review articles. Related to widespread use in veterinary medicine and increasing circulation in illicit drug markets, there is a critical need for public awareness and additional clinical-based studies to further increase understanding of mediated or modulated pharmacological effects of xylazine in humans. Further research is urgently needed to more clearly understand the implications of unregulated xylazine in the illicit drug market, to formulate public health interventions, and to implement harm reduction strategies.

Unraveling the Tapestry of Pain: A Comprehensive Review of Ethnic Variations, Cultural Influences, and Physiological Mechanisms in Pain Management and Perception

The medical management of pain is a nuanced challenge influenced by sociocultural, demographic, and ethical factors. This review explores the intricate interplay of these dimensions in shaping pain perception and treatment outcomes. Sociocultural elements, encompassing cultural beliefs, language, societal norms, and healing practices, significantly impact individuals' pain experiences across societies. Gender expectations further shape these experiences, influencing reporting and responses. Patient implications highlight age-related and socioeconomic disparities in pain experiences, particularly among the elderly, with challenges in managing chronic pain and socioeconomic factors affecting access to care. Healthcare provider attitudes and biases contribute to disparities in pain management across racial and ethnic groups. Ethical considerations, especially in opioid use, raise concerns about subjective judgments and potential misuse. The evolving landscape of placebo trials adds complexity, emphasizing the importance of understanding psychological and cultural factors. In conclusion, evidence-based guidelines, multidisciplinary approaches, and tailored interventions are crucial for effective pain management. By acknowledging diverse influences on pain experiences, clinicians can provide personalized care, dismantle systemic barriers, and contribute to closing knowledge gaps, impacting individual and public health, well-being, and overall quality of life.

Qualitative findings from a randomized trial of mindfulness-based and cognitive-behavioral group therapy for opioid-treated chronic low back pain

This article reports qualitative outcomes from a randomized controlled trial comparing eight weeks of cognitive-behavioral group therapy for chronic pain (CBT-CP) and mindfulness-based group therapy (MBT) in individuals with chronic low back pain (CLBP). Approximately 10 months post-treatment, 108 participants completed structured qualitative interviews to express how the study treatment affected their life or health. Responses were qualitatively analyzed to generate a set of themes and subthemes, with between-groups comparisons to evaluate differences (if any) in treatment-response between MBT and CBT-CP. A majority of participants (n = 88, 81.5%) across both groups reflected positively on the study intervention and outcomes, identifying benefits in pain management (31.5%), meditation and mindfulness skills (25.9%), and relaxation skills (22.2%). Perceived benefits varied widely, suggesting no one intervention may be ideal for CLBP. Future research should examine tailoring interventions to target diverse clinical presentations to achieve optimal outcomes.

The relationship between felt stigma and non-fatal overdose among rural people who use drugs

BACKGROUND

Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs.

METHODS

Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose.

RESULTS

6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14).

CONCLUSIONS

Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

Estimated Number of Injection-Involved Overdose Deaths in US States From 2000 to 2020: Secondary Analysis of Surveillance Data

BACKGROUND

In the United States, both drug overdose mortality and injection-involved drug overdose mortality have increased nationally over the past 25 years. Despite documented geographic differences in overdose mortality and substances implicated in overdose mortality trends, injection-involved overdose mortality has not been summarized at a subnational level.

OBJECTIVE

We aimed to estimate the annual number of injection-involved overdose deaths in each US state from 2000 to 2020.

METHODS

We conducted a stratified analysis that used data from drug treatment admissions (Treatment Episodes Data Set-Admissions; TEDS-A) and the National Vital Statistics System (NVSS) to estimate state-specific percentages of reported drug overdose deaths that were injection-involved from 2000 to 2020. TEDS-A collects data on the route of administration and the type of substance used upon treatment admission. We used these data to calculate the percentage of reported injections for each drug type by demographic group (race or ethnicity, sex, and age group), year, and state. Additionally, using NVSS mortality data, the annual number of overdose deaths involving selected drug types was identified by the following specific multiple-cause-of-death codes: heroin or synthetic opioids other than methadone (T40.1, T40.4), natural or semisynthetic opioids and methadone (T40.2, T40.3), cocaine (T40.5), psychostimulants with abuse potential (T43.6), sedatives (T42.3, T42.4), and others (T36-T59.0). We used the probabilities of injection with the annual number of overdose deaths, by year, primary substance, and demographic groups to estimate the number of overdose deaths that were injection-involved.

RESULTS

In 2020, there were 91,071 overdose deaths among adults recorded in the United States, and 93.1% (84,753/91,071) occurred in the 46 jurisdictions that reported data to TEDS-A. Slightly less than half (38,253/84,753, 45.1%; 95% CI 41.1%-49.8%) of those overdose deaths were estimated to be injection-involved, translating to 38,253 (95% CI 34,839-42,181) injection-involved overdose deaths in 2020. There was large variation among states in the estimated injection-involved overdose death rate (median 14.72, range 5.45-31.77 per 100,000 people). The national injection-involved overdose death rate increased by 323% (95% CI 255%-391%) from 2010 (3.78, 95% CI 3.33-4.31) to 2020 (15.97, 95% CI 14.55-17.61). States in which the estimated injection-involved overdose death rate increased faster than the national average were disproportionately concentrated in the Northeast region.

CONCLUSIONS

Although overdose mortality and injection-involved overdose mortality have increased dramatically across the country, these trends have been more pronounced in some regions. A better understanding of state-level trends in injection-involved mortality can inform the prioritization of public health strategies that aim to reduce overdose mortality and prevent downstream consequences of injection drug use.

Use of Perioperative Intravenous Lidocaine as Part of an Abdominal Surgery Enhanced Recovery Pathway Does Not Significantly Impact Postoperative Pain

BACKGROUND

The utility of perioperative intravenous lidocaine in improving postoperative pain control remains unclear. We aimed to compare postoperative pain outcomes in ERP abdominal surgery patients who did vs did not receive intravenous lidocaine. We hypothesized that patients receiving lidocaine would have lower postoperative pain scores and consume fewer opioids.

METHODS

We performed a retrospective cohort study of patients undergoing elective abdominal surgery at a single institution via an ERP from 2017 to 2018. Patients who received lidocaine in the 6 months prior to a lidocaine shortage were compared to those who did not receive lidocaine for 6 months following the shortage. The primary outcome measures were pain scores as measured on the visual analogue scale and opioid consumption as measured by oral morphine equivalents (OME).

RESULTS

We identified 1227 consecutive ERP abdominal surgery patients for inclusion (519 patients receiving lidocaine and 708 patients not receiving lidocaine). Demographics between the two cohorts were similar, with the following exceptions: more females, and more patients with a history of psychiatric diagnoses in the group that did not receive lidocaine. Adjusted, mixed linear models for both OME (P = .23) and pain scores (P = .51) found no difference between the lidocaine and no lidocaine groups.

DISCUSSION

In our study of ERP abdominal surgery patients, perioperative intravenous lidocaine did not offer improvement in postoperative pain scores or OME consumed. We therefore do not recommend the use of intravenous lidocaine as part of an ERP multimodal pain management strategy in abdominal surgery patients.

A "just in time" educational intervention for opioid overprescribing in dialysis access surgery

BACKGROUND

Despite widespread efforts to combat the opioid epidemic, an ongoing contributor to opioid misuse remains post-operative opioid overprescribing by residents. The goal of this study was to evaluate the impact of a low-cost, reproducible "just in time" intervention on opioid prescribing in dialysis access operations.

METHODS

Standardized opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. Wilcoxon rank-sum test and tests of proportions were used to compare groups.

RESULTS

Overall, 299 patients underwent dialysis access procedures. There was a decrease in patients discharged with opioids following the intervention from 58% to 36% (p ​= ​0.003). For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents (p ​= ​0.03).

CONCLUSIONS

This low-cost and timely learning intervention may be a useful adjunct to reduce post-operative opioid prescriptions.

Analysis of physical activity and prescription opioid use among US adults: a cross-sectional study

BACKGROUND

Opioid crisis has become a global concern, but whether physical activity (PA) can effectively reduce prescription opioid use remains unclear. The study aimed to examine the relationship of different domains of PA (e.g., occupation-related PA [OPA], transportation-related PA [TPA], leisure-time PA [LTPA]) with prescription opioid use and duration of prescription opioid use.

METHODS

This cross-sectional study was conducted on 27,943 participants aged ≥ 18 years from National Health and Nutrition Examination Survey (NHANES, 2007- March 2020). We examined the relationship of different domains of PA with prescription opioid use and duration of prescription opioid use using multivariable logistic regression. Stratified analysis and a series of sensitivity analysis were used to elevate robustness. All analyses were conducted using appropriate sampling weights.

RESULTS

Of the 27,943 participants, the mean age was 45.10 years, with 14,018 [weighted, 50.0%] females and 11,045 [weighted, 66.0%] non-Hispanic White. After multivariable adjustment, inverse associations between PA and prescription opioid use were observed for sufficient (≥ 150 min/week) total PA (OR,0.68 95%CI [0.56-0.81]), TPA (OR,0.73 95%CI [0.58-0.92]), and LTPA (OR,0.60 95%CI [0.48-0.75]) compared with insufficient PA(< 150 min/week), but not for sufficient OPA (OR,0.93 95%CI [0.79-1.10]). In addition, the associations were dose-responsive, participants had 22-40%, 27-36%, and 26-47% lower odds of using prescription opioids depending on the duration of total PA, TPA, and LTPA, respectively. Nevertheless, the impact of PA on prescription opioid use varied by duration of opioid use. Sufficient total PA was associated with elevated odds of short-term use of prescription opioids (< 90 days). Comparatively, sufficient total PA, TPA, and LTPA had different beneficial effects on reducing long-term use of prescription opioids (≥ 90 days) depending on the strength of opioids.

CONCLUSIONS

This study demonstrated sufficient total PA, TPA, and LTPA were inversely associated with prescription opioid use and varied depending on the duration and strength of prescription opioid use. These findings highlight PA can provide policy guidance to address opioid crisis.

Effects of comprehensive medication review on opioid overuse among medicare beneficiaries

Objectives

This study examined the effects of the comprehensive medication review of Medicare medication therapy management programs on opioid overuse among Medicare beneficiaries.

Methods

This retrospective study analyzed Medicare data from 2016 to 2017. The intervention group included Medicare beneficiaries who newly received comprehensive medication review in 2017; the control group referred to patients who met the general eligible criteria for the medication therapy management program but did not enroll in 2016 or 2017. Propensity score matching was performed to increase characteristic compatibility between the intervention and control groups. Three measures of opioid overuse were analyzed: use of opioids at a high dosage, use of opioids from multiple providers, and concurrent use of opioids and benzodiazepines. The effects of comprehensive medication review on opioid overuse were analyzed with a multivariate logistic regression with an interaction term between the receipt of comprehensive medication review and the year 2017.

Key Findings

The proportion of concurrent use of opioids and benzodiazepines declined at a greater rate among the recipients (2.21%) than non-recipients (1.55%) of the comprehensive medication review. In the adjusted analysis, the odds ratio of no concurrent use of opioids and benzodiazepines was 5% higher (1.05; 95% confidence interval = 1.02-1.09) among recipients than non-recipients. These significant findings were not found for the other two measures of opioid overuse.

Conclusions

Comprehensive medication review is associated with reduced concurrent use of opioids and benzodiazepines among Medicare beneficiaries. Such service should be incorporated into the current approaches for addressing the opioid epidemic.

Interventions to increase naloxone access for undergraduate students: A systematic review of the literature

OBJECTIVE

To identify and describe interventions that increase access to naloxone for undergraduate students.

METHODS

A systematic review across 4 databases identified interventions that expand access to naloxone at colleges in the United States from 2015-2023. Three reviewers extracted the following data to create a narrative synthesis and summary of program elements: setting, rationale for intervention, timeline, intervention components, study size, collaboration, sustainability, outcomes and results.

RESULTS

Seven articles met inclusion criteria. Institutions' implemented naloxone interventions due to concerns for student safety and/or student overdose fatalities. Three universities collaborated with their School of Pharmacy for program design and/or dissemination, while two partnered with state-based naloxone distribution programs. Most programs combined opioid-overdose/naloxone training; four distributed naloxone kits. Three studies included pre/post-outcomes, and all reported increases in participant knowledge, attitudes, and/or ability to respond to an overdose.

CONCLUSIONS

Our results indicates an opportunity for wide-scale implementation of undergraduate naloxone programs within US colleges. However, more rigorous implementation research is needed to identify barriers and facilitators to program feasibility, acceptability, and participation.

Digital Therapeutics for Improving Effectiveness of Pharmaceutical Drugs and Biological Products: Preclinical and Clinical Studies Supporting Development of Drug + Digital Combination Therapies for Chronic Diseases

Limitations of pharmaceutical drugs and biologics for chronic diseases (e.g., medication non-adherence, adverse effects, toxicity, or inadequate efficacy) can be mitigated by mobile medical apps, known as digital therapeutics (DTx). Authorization of adjunct DTx by the US Food and Drug Administration and draft guidelines on "prescription drug use-related software" illustrate opportunities to create drug + digital combination therapies, ultimately leading towards drug-device combination products (DTx has a status of medical devices). Digital interventions (mobile, web-based, virtual reality, and video game applications) demonstrate clinically meaningful benefits for people living with Alzheimer's disease, dementia, rheumatoid arthritis, cancer, chronic pain, epilepsy, depression, and anxiety. In the respective animal disease models, preclinical studies on environmental enrichment and other non-pharmacological modalities (physical activity, social interactions, learning, and music) as surrogates for DTx "active ingredients" also show improved outcomes. In this narrative review, we discuss how drug + digital combination therapies can impact translational research, drug discovery and development, generic drug repurposing, and gene therapies. Market-driven incentives to create drug-device combination products are illustrated by Humira® (adalimumab) facing a "patent-cliff" competition with cheaper and more effective biosimilars seamlessly integrated with DTx. In conclusion, pharma and biotech companies, patients, and healthcare professionals will benefit from accelerating integration of digital interventions with pharmacotherapies.

At a Crossroads: Opioid Use Disorder, the X-Waiver, and the Road Ahead

Background: Buprenorphine/naloxone (Suboxone) is widely considered the first-line treatment for opioid use disorder (OUD), which causes significant morbidity and mortality in the United States, but prior to 2023, practitioners interested in prescribing buprenorphine/naloxone for OUD needed a special Drug Enforcement Administration certification (the X-Waiver) that imposed a patient cap and other limitations. The Consolidated Appropriations Act of 2023 considerably decreased the restrictions on prescribing practitioners. Buprenorphine/naloxone can now be prescribed like any other prescription opioid, excluding methadone. The historic context for the opioid crisis, OUD, the X-Waiver, and additional initiatives that may be needed beyond legislative change to effectively address OUD are the subjects of this review. Methods: To develop this review of the opioid crisis, OUD, and OUD treatment, we conducted a literature search of the PubMed database and constructed a timeline of the opioid crisis and changes in OUD treatment, specifically the X-Waiver, to characterize the historic context of OUD and the X-Waiver against the background of the opioid crisis. Results: The opioid crisis has had pervasive public health and economic impacts in the United States. Major changes to the treatment of OUD have occurred as a result of the Drug Addiction Treatment Act of 2000 that imposed the X-Waiver and the Consolidated Appropriations Act of 2023 that repealed the X-Waiver. Conclusion: The repeal of the X-Waiver is predicted to increase the accessibility of buprenorphine/naloxone in the United States. However, additional work beyond legislative change, including institutional support and reduction of stigma and disparities, is needed to substantially improve outcomes for OUD patients.

Gabapentin and postoperative pain and opioid consumption: A double-blind randomized controlled trial of perioperative pain management for sinus surgery

BACKGROUND

The link between post-operative narcotic prescription and opioid misuse has spurred a nationwide effort to reduce perioperative opioid use. Previous work has suggested that perioperative gabapentin may reduce post-operative pain and opioid consumption across different procedures, although the optimal regimen remains to be defined.

METHODS

Chronic rhinosinusitis (CRS) patients undergoing functional endoscopic sinus surgery (FESS) with or without septoplasty were randomized to receive a 7-day pre- and post-operative course of placebo or gabapentin, starting at 300 mg daily and titrated to 300 mg three times daily, in a double-blind fashion. Primary endpoint was pain level using a validated visual analog scale (VAS). Secondary endpoints included post-operative opioid consumption and side effects, as well as modified Lund-Kennedy endoscopy, Lund-Mackay, and SNOT-22 scores.

RESULTS

Analysis of 35 patients (20 gabapentin, 15 control) showed no significant difference in mean postoperative VAS (p = 0.18) or postoperative opioid consumption between the placebo and gabapentin groups (2.3 and 4.8 oxycodone tablets respectively, p = 0.18). 15 of 35 patients did not require any post-operative oxycodone tablets, and only two patients required more than six tablets.

CONCLUSION

Preliminary results show no significant change in pain after FESS with or without septoplasty in patients taking 7-day pre- and post-operative gabapentin versus placebo. Results also showed no significant difference in opioid consumption between the treatment and placebo groups. Post-operative pain scores and opioid requirements are both quite low following FESS. Many patients do not need opioids at all, suggesting that routine initial post-operative opioid prescriptions can be limited accordingly.

Trends in oxycodone and oxycodone-containing analgesics administration for back pain in emergency departments in the USA (2007-2018)

BACKGROUND

To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments (EDs) in the USA from 2007 to 2018.

METHODS

Data were gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007 to 2018. The study population included individuals of all ages presenting to USA EDs. The NHAMCS reasons for visit and oxycodone drug ID codes were used to isolate patients with back pain. The main outcome was the proportion of oxycodone and oxycodone-containing analgesics prescribed for back pain in the EDs over the specified time period.

RESULTS

There was a relative decrease in the overall administration of oxycodone for back pain in the EDs by 62.3% from 2007 (244,000 visits) to 2018 (92,000 visits). The proportion of ED patients prescribed with oxycodone-containing analgesics for back pain increased among patients aged 45 years and older (from 43.8% to 57.6%), female patients (from 54.5% to 62.0%), black patients (from 22.5% to 30.4%), and Hispanic/Latino patients (from 9.4% to 19.6%). Oxycodone/acetaminophen was most prescribed and accounted for 90.2% of all oxycodone-containing analgesics in 2007, with a decrease to 68.5% in 2018. Pure oxycodone was the second most prescribed medication, accounting for 6.1% in 2007 and 31.5% in 2018.

CONCLUSION

The overall number of oxycodone-containing analgesics decreased significantly from 2007 to 2018. However, that number trended upward in 45-year-old and older, female, black, or Hispanic/Latino patients from 2007 to 2018. The total amount of pure oxycodone increased significantly from 2007 to 2008.

REMAP Periop: a randomised, embedded, multifactorial adaptive platform trial protocol for perioperative medicine to determine the optimal enhanced recovery pathway components in complex abdominal surgery patients within a US healthcare system

INTRODUCTION

Implementation of enhanced recovery pathways (ERPs) has resulted in improved patient-centred outcomes and decreased costs. However, there is a lack of high-level evidence for many ERP elements. We have designed a randomised, embedded, multifactorial, adaptive platform perioperative medicine (REMAP Periop) trial to evaluate the effectiveness of several perioperative therapies for patients undergoing complex abdominal surgery as part of an ERP. This trial will begin with two domains: postoperative nausea/vomiting (PONV) prophylaxis and regional/neuraxial analgesia. Patients enrolled in the trial will be randomised to arms within both domains, with the possibility of adding additional domains in the future.

METHODS AND ANALYSIS

In the PONV domain, patients are randomised to optimal versus supraoptimal prophylactic regimens. In the regional/neuraxial domain, patients are randomised to one of five different single-injection techniques/combination of techniques. The primary study endpoint is hospital-free days at 30 days, with additional domain-specific secondary endpoints of PONV incidence and postoperative opioid consumption. The efficacy of an intervention arm within a given domain will be evaluated at regular interim analyses using Bayesian statistical analysis. At the beginning of the trial, participants will have an equal probability of being allocated to any given intervention within a domain (ie, simple 1:1 randomisation), with response adaptive randomisation guiding changes to allocation ratios after interim analyses when applicable based on prespecified statistical triggers. Triggers met at interim analysis may also result in intervention dropping.

ETHICS AND DISSEMINATION

The core protocol and domain-specific appendices were approved by the University of Pittsburgh Institutional Review Board. A waiver of informed consent was obtained for this trial. Trial results will be announced to the public and healthcare providers once prespecified statistical triggers of interest are reached as described in the core protocol, and the most favourable interventions will then be implemented as a standardised institutional protocol.

TRIAL REGISTRATION NUMBER

NCT04606264.

Intraoperative ultrasound-guided pectoral nerve blocks for cardiac implantable device procedures

BACKGROUND

Pectoral nerve (PECs) blocks are established regional anesthesia techniques that can provide analgesia to the anterior chest wall. Although commonly performed preoperatively by anesthesiologists, the feasibility of electrophysiologist-performed PECs blocks from within cardiac implantable electronic device (CIED) pockets at the time of implantation has not been established. The objective of this study is to assess the feasibility of routine PECs blocks performed by the electrophysiologist from within the exposed device pocket at the time of CIED procedures.

METHODS

Patients undergoing CIED procedures underwent a PECs I block (15 cc of 1% lidocaine/0.25% bupivacaine) injected between the pectoralis major and minor muscles guided by ultrasound placed in the device pocket, or PECs II block, which included a second injection (15 cc) between pectoralis minor and serratus anterior muscles. Postoperatively, pain was assessed on a numeric scale (0-10) at 1, 2, 4, and 24 h, and 2 weeks after the procedure.

RESULTS

Among 20 patients (age 65 ± 16 years, 70% male, 55% with history of chronic pain), PECs I (75%) and PECs II (25%) blocks were performed. The procedures were de novo implantation (n = 17) or device revision (n = 3). The average pain score in the first 4 h was 0.4 ± 0.8 and 0.3 ± 0.6 at 24 h after the procedure. During the 24-h postoperative period, 4 patients received opioids. Two patients were discharged with opioids for pain unrelated to the procedure.

CONCLUSIONS

Intraoperative PECs blocks can be feasibly performed from within an exposed pocket at the time of CIED procedures with minimal postoperative pain.

Increasing Provider Self-Efficacy to Manage Chronic Cancer Pain

BACKGROUND

Aims: Pain is a significant problem for those with a cancer diagnosis. Oncology providers often use opioid therapy to manage cancer-related pain. Accessing opioid therapy has grown increasingly difficult because of the opioid epidemic. The American Society of Clinical Oncology (ASCO) released guidelines to optimize pain management for patients with oncologic diagnoses. The goal of this quality improvement project was to create an educational session and evaluate self-efficacy in providers who manage chronic cancer pain.

DESIGN

The Plan-Do-Study-Act was used as the framework for this quasi-experimental study with a pre/post education survey design.

SETTINGS

Level 1 Trauma Center in Upstate, NY.

PARTICIPANTS/SUBJECTS

Family Nurse Practitioners and Physicians Assistants in a local cancer institute.

METHODS

There was a voice over PowerPoint educational intervention used to discuss key points of the guidelines, which included addressing aberrant behaviors, safe opioid prescribing, and interdisciplinary pain management. A convenience sample size of 18 advanced practice providers (APP) were recruited from a level 1-trauma center in Upstate, New York. Participants reviewed the educational intervention and completed a series of surveys to assess tool satisfaction and self-efficacy scores.

RESULTS

Data analysis revealed a significant increase in the mean self-efficacy scores on the post-education Jackson Opioid Therapy Self-Efficacy tool. The educational intervention was associated with improved perceptions of self-efficacy when managing chronic cancer pain.

CONCLUSIONS

Based on the study's results, the guidelines released by ASCO should be reviewed and used to optimize pain management and self-efficacy in providers who work with oncologic patients. Furthermore, future research is recommended to evaluate the effect of evidence-based guidelines on patient outcomes and morbidity.

Opioid prescription and opioid disorders in burns: A large database analysis from 1990 to 2019

BACKGROUND

Opioids remain crucial in the management of burn pain. A comprehensive analysis of opioid use in burns and their complications has not been investigated.

METHODS

Data were collected from TriNetX, a large multicenter database with de-identified patient information. The population included patients prescribed opioids on or following burn injury from January 1st, 1990, to December 31st, 2019. Opioid prescription use was analyzed after cohort stratification by decades: 1990-1999, 2000-2009, and 2010-2019. Outcomes for opioid-related disorders, opioid dependence, opioid abuse, intentional self-harm, and mental and behavioral disorders from psychoactive substance use were investigated.

RESULTS

Hydrocodone was the most frequently prescribed opioid in 1990-1999 and 2000-2009, with oxycodone taking the lead in 2010-2019 (p < 0.0001). During 1990-1999, patients had a decreased risk of recorded opioid-related disorders (RR=0.52), opioid dependence (RR=0.46), opioid abuse (RR=0.55), mental and behavioral disorders (RR=0.88), and intentional self-harm (RR=0.37) when compared to 2000-2009. A comparison of the 2000-2009-2010-2019 cohorts showed an increased risk of recorded opioid-related disorders (RR= 1.91), opioid dependence (RR=1.56), opioid abuse (RR=1.67), mental and behavioral disorders (RR =1.73), and intentional self-harm (RR=2.02).

CONCLUSIONS

The risk of opioid-related disorders has nearly doubled since the year 2000 warranting precautions when prescribing pain medications to burn patients.

Loperamide cases reported to United States poison centers, 2010-2022

BACKGROUND

Intentional use of high doses of loperamide has been linked to serious cardiac toxicity. The objective of this study is to investigate the characteristics and trends of loperamide cases reported to United States (US) poison centers and to evaluate the changes in reported loperamide cases following US Food and Drug Administration (FDA) warnings, labeling requirements, and packaging restrictions for loperamide starting in 2016, with an emphasis on intentional exposures.

METHODS

Data from the National Poison Data System were analyzed.

RESULTS

There were 12,987 cases reported to US poison centers from 2010 to 2022, for which, loperamide was the most likely substance responsible for observed clinical effects. Although 46.1% of these cases were associated with minor or no effect, 13.4% resulted in a serious medical outcome, including 59 deaths (0.5%). Eight percent (8.1%) of cases were admitted to a critical care unit and 5.0% were admitted to a non-critical care unit. Among cases with a serious medical outcome, most were associated with loperamide abuse (38.0%), intentional-misuse (15.7%), or suspected suicide (27.5%). The majority (60.0%; n = 33) of fatalities were related to abuse, followed by suspected suicide (20.0%; n = 11) and intentional-misuse (5.5%, n = 3). The rate of loperamide cases per 100,000 US population reported to US PCs decreased from 0.44 in 2010 to 0.36 in 2015 (p = 0.0290), followed by an increase to 0.46 in 2017 (p = 0.0013), and then a trend reversal with a decrease to 0.28 in 2022 (p < 0.0001). The rate of serious medical outcomes related to loperamide increased from 0.03 in 2010 to 0.05 in 2015 (p = 0.0109), which subsequently increased rapidly to 0.11 in 2017 (p < 0.0001), and then demonstrated a trend reversal and decreased to 0.04 in 2022 (p < 0.0001).

CONCLUSIONS

FDA warnings, labeling requirements, and packaging restrictions may have contributed to the observed trend reversal and decrease in reports to US poison centers of loperamide cases related to intentional misuse, abuse, and suspected suicide. This demonstrates the potential positive effect that regulatory actions may have on public health. These findings contribute to the evidence supporting the application of similar prevention efforts to reduce poisoning from other medications associated with intentional misuse, abuse, and suicide.

Impact of State Laws on Dispensing Opioid Prescriptions Following Posterior Lumbar Interbody Fusion Procedures: A Retrospective Large National Database Study

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

This study aimed to examine the effect of state legislation on prescribing behavior after a commonly performed spinal procedure, posterior lumbar interbody fusion (PLIF).

METHODS

Two cohorts of patients from the Pearl Diver Database were created based on patients who underwent PLIF surgery in 2014-15 and 2018-19. We compared opioid prescription rates and morphine-milli-equivalent (MME) between states with and without prescription legislation.

RESULTS

We analyzed 50 958 PLIF patients from 2014-15 and 46 751 patients from 2018-19. Among them, 38 states passed opioid prescription laws in 2016-2017, while 12 states did not. The percentage of patients receiving opioid prescriptions within 365 days post-surgery remained similar in both time periods (49% in 2014-15 and 48% in 2018-2019). This trend was consistent across states with and without prescription legislation (50% vs 48% in 2014-2015, and similar in 2018-19). Opioid prescription quantity significantly decreased in all states between 2014-15 and 2018-19. In states with legislation, average MME dropped from 9198 ± 21 002 to 4932 ± 13 213 (46.4% decrease), and in states without legislation, it decreased from 9175 ± 21 032 to 4994 ± 11 687 (45.6% decrease). However, these differences were not statistically significant (P = .7985).

CONCLUSION

From 2014 to 2018, there was a significant decrease in the number of opioids prescribed after PLIF. However, this decrease occurred irrespective of state legislation on prescribing practices being passed. We believe the reduction in opioids prescribed was due to increased awareness surrounding the dangers of opioids among physicians.

Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain

STUDY OBJECTIVES

Ketorolac is a commonly used nonopioid parenteral analgesic for treating emergency department (ED) patients with acute pain. Our systematic review aims to summarize the available evidence by comparing the efficacy and safety of differing ketorolac dosing strategies for acute pain relief in the ED.

METHODS

The review was registered on PROSPERO (CRD42022310062). We searched MEDLINE, PubMed, EMBASE, and unpublished sources from inception through December 9, 2022. We included randomized control trials of patients presenting with acute pain to the ED, comparing ketorolac doses less than 30 mg (low dose) to ketorolac doses more than or equal to 30 mg (high dose) for the outcomes of pain scores after treatment need for rescue analgesia, and incidence of adverse events. We excluded patients in non-ED settings, including postoperative settings. We extracted data independently and in duplicate and pooled them using a random-effects model. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool and the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach.

RESULTS

This review included 5 randomized controlled trials (n=627 patients). Low-dose parenteral ketorolac (15 to 20 mg), as compared to high-dose ketorolac (≥30 mg), probably has no effect on pain scores (mean difference 0.05 mm lower on 100 mm visual analog scale, 95% confidence interval [CI] -4.91 mm to +5.01 mm; moderate certainty). Further, low-dose ketorolac at 10 mg may have no effect on pain scores compared to high-dose ketorolac (mean difference 1.58 mm lower on 100 mm visual analog scale, 95% CI -8.86 mm to +5.71 mm; low certainty). Low-dose ketorolac may increase the need for rescue analgesia (risk ratio 1.27, 95% CI 0.86 to 1.87; low certainty) and may have no difference on rates of adverse events (risk ratio 0.84, 95% CI 0.54 to 1.33; low certainty).

CONCLUSION

In adult ED patients with acute pain, parenteral ketorolac given at doses of 10 mg to 20 mg is probably as effective in relieving pain as doses of 30 mg or higher. Low-dose ketorolac may have no effect on adverse events, but these patients may require more rescue analgesia. This evidence is limited by imprecision and is not generalizable to children or those at higher risk of adverse events.

The Effects of Brief Guided Imagery on Patients Suffering From Chronic Back Pain: An A-B Design Study

BACKGROUND

Guided imagery (GI) is a non-pharmacological method used to reduce pain, stress, and anxiety.

AIMS

This study aimed to evaluate the impact of brief GI on symptoms of chronic back pain in adults treated in the Rheumatology clinic.

DESIGN

A-B design study.

SETTINGS & PARTICIPANTS

A sample of 35 women with chronic back pain were recruited at the Rheumatology Outpatient Clinic of Barzilai Medical Center in Ashkelon, Israel.

METHODS

All subjects completed questionnaires at recruitment (T1), and after 8-10 weeks, they completed questionnaires again before the first intervention (T2). The intervention included five brief GI group meetings every 2-3 weeks, one hour each (3-5 subjects per group). Participants learned 6 GI exercises and were asked to practice brief guided imagery exercises at least once daily. Then, questionnaires were completed the third time (T3).

OUTCOME MEASURES

MOQ - Modified Oswestry Low Back Pain Disability Questionnaire, STAI - State-Trait Anxiety Inventory, FABQ - Fear-Avoidance Beliefs Questionnaire, NPRS - Numerical Pain Rating Scale (average pain over the last week).

RESULTS

Compared with the period without intervention, NPRS (Δ = 2.53, standard error [SE] = 0.43, p < .001), STAI (Δ = 8.41, SE = 1.95, p < .001), and MOQ (Δ = 0.06, SE = 0.02, p = .019) reported significantly lower levels after brief guided imagery training. However, no statistically significant change was found in FABQ.

CONCLUSIONS

The brief guided imagery intervention may help alleviate chronic back pain, help decrease anxiety, and improve daily activity in women who suffer from chronic low back pain.

Feasibility and Efficacy of a Non-Opioid Based Pain Management After Medical Thoracoscopy

BACKGROUND

Prescription opioids are a major cause of the opioid epidemic. Despite the minimally invasive nature of medical thoracoscopy (MT), data on the efficacy of non-opioid-based pain control after MT is lacking. The purpose of this study is to assess the feasibility and efficacy of a non-opioid-based pain management strategy in patients who underwent MT.

METHODS

We performed a retrospective analysis of all patients who underwent MT in the Mayo Clinic (Minnesota and Arizona) outpatient setting. We assessed their pain level and the need for analgesia post-MT from August 1, 2019, to May 24, 2021.

RESULTS

Forty patients were included. In the first 24 hours, 5/40 (12.5%) reported no pain. Twenty-eight patients out of 40 (70%) reported minor pain (pain scale 1-3), and 7/40 (17.5%) reported moderate pain (pain scale 4-6). No patients reported severe pain. Twenty-two out of 35 patients who experienced discomfort (63%) required acetaminophen, 6/35 patients (17%) required nonsteroidal anti-inflammatory drug, and 7/35 patients (20%) did not require analgesia. Of the 7 patients who had moderate pain, 5 (71%) reported that the moderate pain improved to mild at 72 hours post-MT. Zero patients required opioids, and none reported contacting any provider to manage the pain post-MT. Fourteen patients (78%) who had both parietal pleural biopsies and tunneled pleural catheter placed reported minor pain, 3 patients (17%) reported moderate pain, and 1 patient (6%) experienced no discomfort.

CONCLUSION

MT is well-tolerated by patients with non-opioid-based pain management strategy as needed if there is no absolute contraindication.

Transcriptome-wide analysis of trigeminal ganglion and subnucleus caudalis in a mouse model of chronic constriction injury-induced trigeminal neuralgia

Trigeminal neuropathic pain (TNP) induces mechanical allodynia and hyperalgesia, which are known to alter gene expression in injured dorsal root ganglia primary sensory neurons. Non-coding RNAs (ncRNAs) have been linked to TNP. However, the functional mechanism underlying TNP and the expression profile of ncRNAs in the trigeminal ganglion (TG) and trigeminal subnucleus caudalis (Sp5C) are still unknown. We used RNA sequencing and bioinformatics analysis to examine the TG and Sp5C transcriptomes after infraorbital nerve chronic constrictive injury (IoN-CCI). The robust changes in the gene expression of lncRNAs, circRNAs, and mRNAs were observed within the TG and Sp5C from mice that underwent IoN-CCI and the sham-operated mice (day 7). In total, 111,003 lncRNAs were found in TG and 107,157 in Sp5C; 369 lncRNAs were differentially expressed in TG, and 279 lncRNAs were differentially expressed in Sp5C. In addition, 13,216 circRNAs in TG and 21,658 circRNAs in Sp5C were identified, with 1,155 circRNAs and 2,097 circRNAs differentially expressed in TG and Sp5C, respectively. Furthermore, 5,205 DE mRNAs in TG and 3,934 DE mRNAs in Sp5C were differentially expressed between IoN-CCI and sham groups. The study revealed a high correlation of pain-related differentially expressed genes in the TG and Sp5C to anxiety, depression, inflammation, neuroinflammation, and apoptosis. Gene Ontology analysis revealed that binding-related molecular functions and membrane-related cell components were significantly enriched. Kyoto Encyclopedia of Genes and Genomes analysis shows the most significant enrichments in neurogenesis, nervous system development, neuron differentiation, adrenergic signaling, cAMP signaling, MAPK signaling, and PI3K-Akt signaling pathways. Furthermore, protein-protein interaction analysis showed that hub genes were implicated in neuropeptide signaling pathways. Functional analysis of DE ncRNA-targeting genes was mostly enriched with nociception-related signaling pathways underpinning TNP. Our findings suggest that ncRNAs are involved in TNP development and open new avenues for research and treatment.

Peripheral mechanisms of peripheral neuropathic pain

Peripheral neuropathic pain (PNP), neuropathic pain that arises from a damage or disease affecting the peripheral nervous system, is associated with an extremely large disease burden, and there is an increasing and urgent need for new therapies for treating this disorder. In this review we have highlighted therapeutic targets that may be translated into disease modifying therapies for PNP associated with peripheral neuropathy. We have also discussed how genetic studies and novel technologies, such as optogenetics, chemogenetics and single-cell RNA-sequencing, have been increasingly successful in revealing novel mechanisms underlying PNP. Additionally, consideration of the role of non-neuronal cells and communication between the skin and sensory afferents is presented to highlight the potential use of drug treatment that could be applied topically, bypassing drug side effects. We conclude by discussing the current difficulties to the development of effective new therapies and, most importantly, how we might improve the translation of targets for peripheral neuropathic pain identified from studies in animal models to the clinic.

Human IPSC-Derived PreBötC-Like Neurons and Development of an Opiate Overdose and Recovery Model

Opioid overdose is the leading cause of drug overdose lethality, posing an urgent need for investigation. The key brain region for inspiratory rhythm regulation and opioid-induced respiratory depression (OIRD) is the preBötzinger Complex (preBötC) and current knowledge has mainly been obtained from animal systems. This study aims to establish a protocol to generate human preBötC neurons from induced pluripotent cells (iPSCs) and develop an opioid overdose and recovery model utilizing these iPSC-preBötC neurons. A de novo protocol to differentiate preBötC-like neurons from human iPSCs is established. These neurons express essential preBötC markers analyzed by immunocytochemistry and demonstrate expected electrophysiological responses to preBötC modulators analyzed by patch clamp electrophysiology. The correlation of the specific biomarkers and function analysis strongly suggests a preBötC-like phenotype. Moreover, the dose-dependent inhibition of these neurons' activity is demonstrated for four different opioids with identified IC50's comparable to the literature. Inhibition is rescued by naloxone in a concentration-dependent manner. This iPSC-preBötC mimic is crucial for investigating OIRD and combating the overdose crisis and a first step for the integration of a functional overdose model into microphysiological systems.

Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience

BACKGROUND

Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA.

METHODS

In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA.

RESULTS

Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year.

CONCLUSIONS

These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Opioid prescriptions and patients' health services utilization and cost before and during the COVID-19 pandemic: an exploratory population-based administrative data analysis

The objective was to explore percentages of the population treated with prescribed opioids and costs of opioid-related hospitalizations and emergency department (ED) visits among individuals treated with prescription opioids and costs of all opioid-related hospitalizations and ED visits in the province (i.e., provincial costs) before and during the coronavirus disease 2019 (COVID-19) pandemic in Alberta, Canada. In administrative data, we identified individuals treated with prescription opioids and opioid-related hospitalizations and ED visits among those individuals and among all individuals in the province between 2015/16 and 2021/22 fiscal years. Services used were counted on an item-by-item basis and costed using case-mix approaches. Annually, from 9.98% (2020/21-2021/22) to 14.52% (2017/18) of the provincial population was treated with prescription opioids. Between 2015/16 and 2021/22, annual costs of opioid-related hospitalizations and ED visits among individuals treated with prescription opioids were ∼$5 and ∼$2 million, respectively. In 2020/21-2021/22, the provincial costs of opioid-related hospitalizations (∼$14 million) and ED visits (∼$7.0 million) were almost twice the costs observed in 2015/16 and immediately before the pandemic (2019/20). Our findings suggest that increases in the opioid-related utilization of inpatient and ED services between 2015/16 and 2021/22, including the drastic increases observed during the COVID-19 pandemic, were likely driven by unregulated substances.

Chronic non-cancer pain management - insights from Australian general practitioners: a qualitative descriptive study

BACKGROUND

The study explored the experiences and perceptions of GPs regarding the management of chronic non-cancer pain (CNCP). Specifically, participants were asked to identify perceived enablers and barriers to CNCP care and how the care of patients with CNCP may be improved.

METHODS

The study utilised a qualitative descriptive methodology. General practice in Western Australia. The sample was purposive with 12 Australian GPs from predominantly metropolitan locations and with experience in managing CNCP. Semi structured interviews were conducted. Each interview was of 45-60min duration. All interviews were audio recorded and transcribed using a secure transcription service. Thematic analysis developed themes inductively and deductively.

RESULTS

Themes emerged regarding: the importance of a holistic and personalised approach; the important role of a coordinating GP; the need for an evidence-based approach to opioid management; concerns relating to access to multidisciplinary services; the importance of clinician and patient education regarding CNCP; and an acknowledgement of the challenges for doctors and patients in managing CNCP.

CONCLUSIONS

Currently, the management of CNCP in Australia is challenging. Notable challenges include: difficulties with continuity of patient care; challenges with patient expectations of treatment, in particular opioid medications; difficulty with access to the health services required to enable holistic care; and the need for improved pain education in the community. The breadth of these challenges suggests there is a need for supportive organisational and structural considerations in the healthcare system to enable optimal care of CNCP in the community.

Regional Anesthesia With Paravertebral Blockade Is Associated With Improved Outcomes in Patients Undergoing Minithoracotomy Cardiac Surgery

OBJECTIVE

Severe postoperative pain has been shown to affect many patients following minimally invasive cardiac surgeries (MICS). Multimodal pain management with regional anesthesia, particularly by delivery of local anesthetics using a paravertebral catheter (PVC), has been shown to reduce pain in operations involving thoracotomy incisions. However, few studies have reported high-quality safety and efficacy outcomes of PVCs following MICS.

METHODS

Patients who underwent MICS at Vancouver General Hospital between 2016 and 2019 (N = 123) were reviewed for perioperative opioid-narcotic use. Primary outcomes were postoperative opioid use and hospital length of stay (LOS). Statistical analyses were performed using univariate and multivariable regression models to determine independent risk factors.

RESULTS

A total of 54 patients received routine systemic analgesia (control), 53 patients received a paravertebral catheter (PVC), and 16 patients received another mode of regional analgesia (non-PVC). The mean hospital LOS was significantly different in patients in the PVC group at 5.8 ± 2.0 days versus 8.3 ± 7.1 days in the control and 6.6 ± 2.3 days in the non-PVC group (P = 0.033). The percentage of patients who did not require postoperative oxycodone was significantly higher in the PVC group (48.1%), compared with the control (24.5%) and non-PVC (37.5%; P = 0.043) groups.

CONCLUSIONS

The administration of regional anesthesia using PVCs was associated with reduced need for opioids and a shorter LOS. The reduction in postoperative opioids may reduce the risk of potential opioid dependency in this population. Future studies should involve randomized controlled trials with systematic evaluation of pain scores to verify current study results.

Contextualizing drug use and pharmacological harm in the United States: a socio-historical overview

The purpose of this conceptual paper is to navigate through the socio-historical modulations in American tolerance for different psychoactive substances, and propose a theoretical synthesis formed by two vanguard philosophical doctrines, objectivism, and constructivism. Our approach is grounded on the analysis of social historical context and objective harms that have influenced drug use tolerance in the United States based on key historical events such as: heavy drinking at the dawn of nineteenth century, the establishment and repeal of prohibition, late nineteenth century opiate and cocaine tolerance followed by early twentieth century prohibition, post-prohibition drug concerns such as marijuana prohibition in the 1930s, heroin concerns and medical depressant use in the 1950s, poly-drug use in the 1960s, crack cocaine use in the 1980s, and finally modulations in tolerance for peyote use. Evidence supports the notion of drug harms reduction for the privileged, and criminalization of drug use by marginalized groups. Over long spans of history, however, more objectively harmful drugs are rejected, while drugs that can be used regularly without serous dysfunction are tolerated and normalized. We argue that a framework of social status and pharmacological harm can account for the vacillating policy responses that have emerged to different drugs at different times. Our approach informs the role of socio-cultural conflict in drug policy development and infuse the need for empirical research on the effect of socioeconomic positioning on attitudes of medicalization and legalization of marijuana and opioid policy in contemporary America.

Transitional Pain Medicine; New Era, New Opportunities, and New Journey

Chronic postsurgical pain (CPSP), also known as persistent postsurgical pain (PPSP), is pain that develops or increases in intensity after a surgical procedure and lasts more than 3 months. Transitional pain medicine is the medical field that focuses on understanding the mechanisms of CPSP and defining risk factors and developing preventive treatments. Unfortunately, one significant challenge is the risk of developing opioid use dependence. Multiple risk factors have been discovered, with the most common, and modifiable, being uncontrolled acute postoperative pain; preoperative anxiety and depression; and preoperative site pain, chronic pain, and opioid use.

Long-term Outcomes Following a Comprehensive Quality Assurance and Process Improvement Endeavor to Minimize Opioid Use After Kidney Transplant

Importance

Opioid use following kidney transplant is associated with an increased risk of graft loss and mortality. Opioid minimization strategies and protocols have shown reductions in short-term opioid use after kidney transplant.

Objective

To evaluate the long-term outcomes associated with an opioid minimization protocol following kidney transplant.

Design, Setting, and Participants

This single-center quality improvement study evaluated postoperative and long-term opioid use before and after the implementation of a multidisciplinary, multimodal pain regimen and education process in adult kidney graft recipients from August 1, 2017, through June 30, 2020. Patient data were collected from a retrospective chart review.

Exposures

Preprotocol and postprotocol implementation use of opioids.

Main Outcomes and Measures

Between November 7 and 23, 2022, opioid use before and after protocol implementation was evaluated up to 1 year after transplant using multivariable linear and logistic regression.

Results

A total of 743 patients were included, with 245 patients in the preprotocol group (39.2% female and 60.8% male; mean [SD] age, 52.8 [13.1 years]) vs 498 in the postprotocol group (45.4% female and 54.6% male; mean [SD] age, 52.4 [12.9 years]). The total morphine milligram equivalents (MME) in the 1-year follow-up in the preprotocol group was 1203.7 vs 581.9 in the postprotocol group. In the postprotocol group, 313 patients (62.9%) had 0 MME in the 1-year follow-up vs 7 (2.9%) in the preprotocol group (odds ratio [OR], 57.52; 95% CI, 26.55-124.65). Patients in the postprotocol group had 99% lower odds of filling more than 100 MME in the 1-year follow-up (adjusted OR, 0.01; 95% CI, 0.01-0.02; P < .001). Opioid-naive patients postprotocol were one-half as likely to become long-term opioid users vs preprotocol (OR, 0.44; 95% CI, 0.20-0.98; P = .04).

Conclusions and Relevance

The study's findings show a significant reduction in opioid use in kidney graft recipients associated with the implementation of a multimodal opioid-sparing pain protocol.

Reducing Opioid Use for Chronic Pain With a Group-Based Intervention: A Randomized Clinical Trial

Importance

Opioid use for chronic nonmalignant pain can be harmful.

Objective

To test whether a multicomponent, group-based, self-management intervention reduced opioid use and improved pain-related disability compared with usual care.

Design, Setting, and Participants

Multicentered, randomized clinical trial of 608 adults taking strong opioids (buprenorphine, dipipanone, morphine, diamorphine, fentanyl, hydromorphone, methadone, oxycodone, papaveretum, pentazocine, pethidine, tapentadol, and tramadol) to treat chronic nonmalignant pain. The study was conducted in 191 primary care centers in England between May 17, 2017, and January 30, 2019. Final follow-up occurred March 18, 2020.

Intervention

Participants were randomized 1:1 to either usual care or 3-day-long group sessions that emphasized skill-based learning and education, supplemented by 1-on-1 support delivered by a nurse and lay person for 12 months.

Main Outcomes and Measures

The 2 primary outcomes were Patient-Reported Outcomes Measurement Information System Pain Interference Short Form 8a (PROMIS-PI-SF-8a) score (T-score range, 40.7-77; 77 indicates worst pain interference; minimal clinically important difference, 3.5) and the proportion of participants who discontinued opioids at 12 months, measured by self-report.

Results

Of 608 participants randomized (mean age, 61 years; 362 female [60%]; median daily morphine equivalent dose, 46 mg [IQR, 25 to 79]), 440 (72%) completed 12-month follow-up. There was no statistically significant difference in PROMIS-PI-SF-8a scores between the 2 groups at 12-month follow-up (-4.1 in the intervention and -3.17 in the usual care groups; between-group difference: mean difference, -0.52 [95% CI, -1.94 to 0.89]; P = .15). At 12 months, opioid discontinuation occurred in 65 of 225 participants (29%) in the intervention group and 15 of 208 participants (7%) in the usual care group (odds ratio, 5.55 [95% CI, 2.80 to 10.99]; absolute difference, 21.7% [95% CI, 14.8% to 28.6%]; P < .001). Serious adverse events occurred in 8% (25/305) of the participants in the intervention group and 5% (16/303) of the participants in the usual care group. The most common serious adverse events were gastrointestinal (2% in the intervention group and 0% in the usual care group) and locomotor/musculoskeletal (2% in the intervention group and 1% in the usual care group). Four people (1%) in the intervention group received additional medical care for possible or probable symptoms of opioid withdrawal (shortness of breath, hot flushes, fever and pain, small intestinal bleed, and an overdose suicide attempt).

Conclusions and Relevance

In people with chronic pain due to nonmalignant causes, compared with usual care, a group-based educational intervention that included group and individual support and skill-based learning significantly reduced patient-reported use of opioids, but had no effect on perceived pain interference with daily life activities.

Trial Registration

isrctn.org Identifier: ISRCTN49470934.

Drug use patterns and factors related to the use and discontinuation of medications for opioid use disorder in the age of fentanyl: findings from a mixed-methods study of people who use drugs

BACKGROUND

Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal overdoses. However, continued illegal drug use can increase the risk of treatment discontinuation. Given the widespread presence of fentanyl in the drug supply, research is needed to understand who is at greatest risk for concurrent MOUD and drug use and the contexts shaping use and treatment discontinuation.

METHODS

From 2017 to 2020, Massachusetts residents with past-30-day illegal drug use completed surveys (N = 284) and interviews (N = 99) about MOUD and drug use. An age-adjusted multinomial logistic regression model tested associations between past-30-day drug use and MOUD use (current/past/never). Among those on methadone or buprenorphine (N = 108), multivariable logistic regression models examined the association between socio-demographics, MOUD type; and past-30-day use of heroin/fentanyl; crack; benzodiazepines; and pain medications. Qualitative interviews explored drivers of concurrent drug and MOUD use.

RESULTS

Most (79.9%) participants had used MOUD (38.7% currently; 41.2% past), and past 30-day drug use was high: 74.4% heroin/fentanyl; 51.4% crack cocaine; 31.3% benzodiazepines, and 18% pain medications. In exploring drug use by MOUD history, multinomial regression analyses found that crack use was positively associated with past and current MOUD use (outcome referent: never used MOUD); whereas benzodiazepine use was not associated with past MOUD use but was positively associated with current use. Conversely, pain medication use was associated with reduced odds of past and current MOUD use. Among those on methadone or buprenorphine, separate multivariable logistic regression models found that benzodiazepine and methadone use were positively associated with heroin/fentanyl use; living in a medium-sized city and sex work were positively associated with crack use; heroin/fentanyl use was positively associated with benzodiazepine use; and witnessing an overdose was inversely associated with pain medication use. Many participants qualitatively reported reducing illegal opioid use while on MOUD, yet inadequate dosage, trauma, psychological cravings, and environmental triggers drove their continued drug use, which increased their risk of treatment discontinuation and overdose.

CONCLUSIONS

Findings highlight variations in continued drug use by MOUD use history, reasons for concurrent use, and implications for MOUD treatment delivery and continuity.

The association between prescription drug monitoring programs and controlled substance prescribing: a cross-sectional study using data from 2019 National Electronic Health Records Survey

OBJECTIVE

The use of controlled medications such as opioids, stimulants, anabolic steroids, depressants, and hallucinogens has led to an increase in addiction, overdose, and death. Given the high attributes of abuse and dependency, prescription drug monitoring programs (PDMPs) were introduced in the United States as a state-level intervention.

MATERIALS AND METHODS

Using cross-sectional data from the 2019 National Electronic Health Records Survey, we assessed the association between PDMP usage and reduced or eliminated controlled substance prescribing as well as the association between PDMP usage and changing a controlled substance prescription to a nonopioid pharmacologic therapy or nonpharmacologic therapy. We applied survey weights to produce physician-level estimates from the survey sample.

RESULTS

Adjusting for physician age, sex, type of medical degree, specialty, and ease of PDMP, we found that physicians who reported "often" PDMP usage had 2.34 times the odds of reducing or eliminating controlled substance prescriptions compared to physicians who reported never using the PDMP (95% confidence interval [CI] 1.12-4.90). Adjusting for physician age, sex, type of doctor, and specialty, we found that physicians who reported "often" use of the PDMP had 3.65 times the odd of changing controlled substance prescriptions to a nonopioid pharmacologic therapy or nonpharmacologic therapy (95% CI: 1.61-8.26).

DISCUSSION

These results support the continued use, investment, and expansion of PDMPs as an effective intervention for reducing controlled substance prescription and changing to nonopioid/pharmacologic therapy.

CONCLUSION

Overall, frequent usage of PDMPs was significantly associated with reducing, eliminating, or changing controlled substance prescription patterns.

Cannabidiol attenuates the expression of conditioned place aversion induced by naloxone-precipitated morphine withdrawal through the activation of 5-HT1A receptors

The misuse of and addiction to opioids are serious public health problems in some countries, such as the USA. Drug addiction is a chronic and relapsing medical condition that involves motivational and memory-related processes due to the strong associations between drugs and consuming-related stimuli. These stimuli usually trigger continuous and compulsive use and are associated with relapses after periods of withdrawal. Several factors contribute to relapse, including withdrawal-induced mood changes. Therefore, drugs attenuating withdrawal-induced affective alterations could be useful alternative treatments for relapse prevention. Cannabidiol (CBD), a non-psychotomimetic component from the Cannabis sativa plant, has anti-anxiety and anti-stress properties and has been investigated as an alternative for the treatment of several mental disorders, including drug addiction. Here, we evaluated if CBD administered 30min prior to test for a conditioned place aversion (CPA) would attenuate the aversion induced by morphine withdrawal precipitated by the opioid receptor antagonist naloxone in male C57BL/6 mice. We also investigated if this effect involves the activation of 5-HT1A receptors, a mechanism previously associated with CBD anti-aversive effects. As expected, morphine-treated mice spent less time exploring the compartment paired with the naloxone-induced withdrawal, indicating a CPA induced by naloxone-precipitated morphine withdrawal. This effect was not observed in animals treated with CBD, at 30 and 60mg/kg, prior to the CPA test, indicating that CBD attenuated the expression of CPA induced by naloxone-precipitated morphine withdrawal. Pretreatment with the 5-HT1A receptor antagonist WAY100635 (0.3mg/kg) blocked CBD effects. Our findings suggest that CBD may reduce the expression of a previously established conditioned aversion induced by morphine withdrawal by a mechanism involving the activation of 5-HT1A receptors. Thus, CBD may be a therapeutic alternative for preventing relapse to opioid addiction by decreasing withdrawal-induced negative affective changes.

Digital Therapeutics (DTx) Expand Multimodal Treatment Options for Chronic Low Back Pain: The Nexus of Precision Medicine, Patient Education, and Public Health

Digital therapeutics (DTx, software as a medical device) provide personalized treatments for chronic diseases and expand precision medicine beyond pharmacogenomics-based pharmacotherapies. In this perspective article, we describe how DTx for chronic low back pain (CLBP) can be integrated with pharmaceutical drugs (e.g., NSAIDs, opioids), physical therapy (PT), cognitive behavioral therapy (CBT), and patient empowerment. An example of an FDA-authorized DTx for CLBP is RelieVRx, a prescription virtual reality (VR) app that reduces pain severity as an adjunct treatment for moderate to severe low back pain. RelieVRx is an immersive VR system that delivers at-home pain management modalities, including relaxation, self-awareness, pain distraction, guided breathing, and patient education. The mechanism of action of DTx is aligned with recommendations from the American College of Physicians to use non-pharmacological modalities as the first-line therapy for CLBP. Herein, we discuss how DTx can provide multimodal therapy options integrating conventional treatments with exposome-responsive, just-in-time adaptive interventions (JITAI). Given the flexibility of software-based therapies to accommodate diverse digital content, we also suggest that music-induced analgesia can increase the clinical effectiveness of digital interventions for chronic pain. DTx offers opportunities to simultaneously address the chronic pain crisis and opioid epidemic while supporting patients and healthcare providers to improve therapy outcomes.

Association between Initial Opioid Prescription and Patient Pain with Continued Opioid Use among Opioid-Naïve Patients Undergoing Elective Surgery in a Large American Health System

There is growing concern about the over-prescription of opioids and the risks of long-term use. This study examined the relationship between initial need (pre-operative, post-operative, and discharge pain) and dosage of opioids in the first prescription after surgery with continued opioid use through opioid refills over 12 months, while considering patient-level characteristics. A total of 9262 opioid-naïve patients underwent elective surgery, 7219 of whom were prescribed opioids following surgery. The results showed that 17% of patients received at least one opioid refill within one year post-surgery. Higher initial opioid doses, measured in morphine milligram equivalent (MME), were associated with a greater likelihood of continued use. Patients receiving a dose greater than 90 MME were 1.57 times more likely to receive a refill compared to those receiving less than 90 MME (95% confidence interval: 1.30-1.90, p < 0.001). Additionally, patients who experienced pain before or after surgery were more likely to receive opioid refills. Those experiencing moderate or severe pain were 1.66 times more likely to receive a refill (95% confidence interval: 1.45-1.91, p < 0.001). The findings highlight the need to consider surgery-related factors when prescribing opioids and the importance of developing strategies to balance the optimization of pain management with the risk of opioid-related harms.

Europium Nanoparticles-Based Fluorescence Immunochromatographic Detection of Three Abused Drugs in Hair

Drug abuse is becoming increasingly dangerous nowadays. Morphine (MOP), methamphetamine (MET) and ketamine (KET) are the most commonly abused drugs. The abuse of these drugs without supervision can cause serious harm to the human body and also endanger public safety. Developing a rapid and accurate method to screen drug suspects and thus control these drugs is essential to public safety. This paper presents a method for the simultaneous quantitative detection of these three drugs in hair by a europium nanoparticles-based fluorescence immunochromatographic assay (EuNPs-FIA). In our study, the test area of the nitrocellulose membrane was composed of three equally spaced detection lines and a quality control line. The test strip realized the quantitative analysis of the samples by detecting the fluorescence brightness of the europium nanoparticles captured on the test line within 15 min. For the triple test strip, the limits of detection of MOP, KET and MET were 0.219, 0.079 and 0.329 ng/mL, respectively. At the same time, it also showed strong specificity. The strip was stable and could be stored at room temperature for up to one year, and the average recovery rate was 85.98-115.92%. In addition, the EuNPs-FIA was validated by high-performance liquid chromatography (HPLC) analysis, and a satisfactory consistency was obtained. Compared to the current immunochromatographic methods used for detecting abused drugs in hair, this method not only increased the number of detection targets, but also ensured sensitivity, improving detection efficiency to a certain extent. The approach can also be used as an alternative to chromatography. It provides a rapid and accurate screening method for the detection of abused drugs in hair and has great application prospects in regard to public safety.

Opioids, sleep, analgesia and respiratory depression: Their convergence on Mu (μ)-opioid receptors in the parabrachial area

Opioids provide analgesia, as well as modulate sleep and respiration, all by possibly acting on the μ-opioid receptors (MOR). MOR's are ubiquitously present throughout the brain, posing a challenge for understanding the precise anatomical substrates that mediate opioid induced respiratory depression (OIRD) that ultimately kills most users. Sleep is a major modulator not only of pain perception, but also for changing the efficacy of opioids as analgesics. Therefore, sleep disturbances are major risk factors for developing opioid overuse, withdrawal, poor treatment response for pain, and addiction relapse. Despite challenges to resolve the neural substrates of respiratory malfunctions during opioid overdose, two main areas, the pre-Bötzinger complex (preBötC) in the medulla and the parabrachial (PB) complex have been implicated in regulating respiratory depression. More recent studies suggest that it is mediation by the PB that causes OIRD. The PB also act as a major node in the upper brain stem that not only receives input from the chemosensory areas in medulla, but also receives nociceptive information from spinal cord. We have previously shown that the PB neurons play an important role in mediating arousal from sleep in response to hypercapnia by its projections to the forebrain arousal centers, and it may also act as a major relay for the pain stimuli. However, due to heterogeneity of cells in the PB, their precise roles in regulating, sleep, analgesia, and respiratory depression, needs addressing. This review sheds light on interactions between sleep and pain, along with dissecting the elements that adversely affects respiration.

Learning that cannot come from a book: An evaluation of an undergraduate alcohol and other drugs subject co-produced with experts by experience

Alcohol and other drugs (AOD) use is a significant public health issue and is associated with high mortality and morbidity rates. Despite this, people who use drugs are often reluctant to seek care due to the lack of trauma-informed treatment and harm reduction treatment options, as well as experiences of stigma and discrimination in health services. Arguably, AOD education that is co-produced with people who use alcohol and drugs can enhance future health professionals' ability to practice in ways that support the needs of this population. This paper reports on a qualitative co-evaluation of a co-produced undergraduate nursing AOD subject. The AOD subject was co-planned, co-designed, co-delivered, and co-evaluated with experts by experience, who have a lived experience of substance dependence and work as advocates and peer workers. Following the delivery of the subject in 2021 and 2022, focus groups were undertaken with 12 nursing students. Focus group data indicate that the co-produced subject supported participants to understand and appreciate how stigma impacts on nursing care and how to recognize and undertake 'good' nursing care that was oriented to the needs of service users. Student participants noted that being co-taught by people who use drugs was particularly powerful for shifting their nursing perspectives on AOD use and nursing care and took learning beyond what could be understood from a book. Findings indicate that co-produced AOD education can shift nursing students' perceptions of AOD use by providing access to tacit knowledge and embodied equitable and collaborative relationships with people who use drugs.

Metabolic interactions of benzodiazepines with oxycodone ex vivo and toxicity depending on usage patterns in an animal model

BACKGROUND AND PURPOSE

Opioids and benzodiazepines are frequently combined in medical as well as in non-medical contexts. At high doses, such combinations often result in serious health complications attributed to pharmacodynamics interactions. Here, we investigate the contribution of the metabolic interactions between oxycodone, diazepam and diclazepam (a designer benzodiazepine) in abuse/overdose conditions through ex vivo, in vivo and in silico approaches.

EXPERIMENTAL APPROACH

A preparation of pooled human liver microsomes was used to study oxycodone metabolism in the presence or absence of diazepam or diclazepam. In mice, diazepam or diclazepam was concomitantly administered with oxycodone to mimic acute intoxication. Diclazepam was introduced on Day 10 in mice continuously infused with oxycodone for 15 days to mimic chronic intoxication. In silico modelling was used to study the molecular interactions of the three drugs with CYP3A4 and 2D6.

KEY RESULTS

In mice, in acute conditions, both diazepam and diclazepam inhibited the metabolism of oxycodone. In chronic conditions and at pharmacologically equivalent doses, diclazepam drastically enhanced the production of oxymorphone. In silico, the affinity of benzodiazepines was higher than oxycodone for CYP3A4, inhibiting oxycodone metabolism through CYP3A4. Oxycodone metabolism is likely to be diverted towards CYP2D6.

CONCLUSION AND IMPLICATIONS

Acute doses of diazepam or diclazepam result in the accumulation of oxycodone, whereas chronic administration induces the accumulation of oxymorphone, the toxic metabolite. This suggests that overdoses of opioids in the presence of benzodiazepines are partly due to metabolic interactions, which in turn explain the patterns of toxicity dependent on usage.

LINKED ARTICLES

This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.

Investigating the potential of GalR2 as a drug target for neuropathic pain

Neuropathic pain is a chronic and debilitating condition characterised by episodes of hyperalgesia and allodynia. It occurs following nerve damage from disease, inflammation or injury and currently impacts up to 17% of the UK population. Existing therapies lack efficacy and have deleterious side effects that can be severely limiting. Galanin receptor 2 (GalR2) is a G-protein coupled receptor (GPCR) implicated in the control and processing of painful stimuli. Within the nervous system it is expressed in key tissues involved in these actions such as dorsal root ganglia (DRG) and the dorsal horn of the spinal cord. Stimulation of GalR2 is widely reported to have a role in the attenuation of inflammatory and neuropathic pain. Several studies have indicated GalR2 as a possible drug target, highlighting the potential of specific GalR2 agonists to both provide efficacy and to address the side-effect profiles of current pain therapies in clinical use. A strong biological target for drug discovery will be well validated with regards to its role in the relevant disease pathology. Ideally there will be good translational models, sensitive probes, selective and appropriate molecular tools, translational biomarkers, a clearly defined patient population and strong opportunities for commercialisation. Before GalR2 can be considered as a drug target suitable for investment, key questions need to be asked regarding its expression profile, receptor signalling and ligand interactions. This article aims to critically review the available literature and determine the current strength of hypothesis of GalR2 as a target for the treatment of neuropathic pain.

Ketamine decreased opiate use in US military combat operations from 2010 to 2019

BACKGROUND

Ketamine is a dissociative anaesthetic currently used in a variety of healthcare applications. Effects are dose dependent and cause escalating levels of euphoria, analgesia, dissociation and amnesia. Ketamine can be given via intravenous, intramuscular, nasal, oral and aerosolised routes. A 2012 memorandum and the 2014 Tactical Combat Casualty Care (TCCC) guidelines included ketamine as part of the 'Triple Option' for analgesia. This study investigated the effect of ketamine adoption by the US military TCCC guidelines on opioid use between 2010 and 2019.

METHODS

This was a retrospective review of deidentified Department of Defense Trauma Registry data. The study was approved by the Institutional Review Board of Naval Medical Center San Diego (NMCSD) and facilitated by a data sharing agreement between NMCSD and the Defense Health Agency. Patient encounters from all US military operations from January 2010 to December 2019 were queried. All administrations of any pain medications via any route were included.

RESULTS

5965 patients with a total of 8607 pain medication administrations were included. Between 2010 and 2019, the yearly percentage of ketamine administrations rose from 14.2% to 52.6% (p<0.001). The percentage of opioid administrations decreased from 85.8% to 47.4% (p<0.001). Among the 4104 patients who received a single dose of pain medication, the mean Injury Severity Score for those who received ketamine was higher than for those who received an opioid (mean=13.1 vs 9.8, p<0.001).

CONCLUSION

Military opioid use declined as ketamine use increased over 10 years of combat. Ketamine is generally used first for more severely injured patients and has increasingly been employed by the US military as the primary analgesic for combat casualties.

Opioid: Plenitude versus pittance

The opioid crisis in the USA and in other developed countries can potentially affect low- and middle-income countries (LMICs). The licit medical use of opioids has two sides. The USA and high-income countries maintain abundant supply for medical prescription. Between 1990 and 2010, the use of opioids for cancer pain relief was overtaken by a dramatic rise in the opioid prescriptions for non-cancer acute or chronic pain. The surge led to the opioid epidemic, recognized as social catastrophe in the USA, Canada and in some countries in Europe. From 2016, the medical community, health policy regulators and law-makers have taken actions to tackle this opioid crisis. On the other side, formulary deficiency and low opioid availability exists for three-fourths of the global population living in LMICs. Physicians and nurses in Asia and Africa engaged in cancer pain relief and palliative care face a constant paucity of opioids. Millions of patients in LMICs, suffering from life-modifying cancer pain, do not have access to morphine and other essential opioids, due to restrictive opioid policies. Attention will be needed to improve opioid availability in large parts of the world, even though the opioid crisis has led to control the licit medical use in the USA.