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Sabharwal B, Lawal NO, Smith MA. Rotating Palliative Care Patients From Full Agonist Opioids to Low Dose Milligram Buprenorphine. J Pain Symptom Manage 2024; 68:e156-e158. [PMID: 38777074 DOI: 10.1016/j.jpainsymman.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/02/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Bhanujit Sabharwal
- University of Michigan College of Pharmacy (B.S., M.A.S.), Ann Arbor, Michigan, USA
| | - Nurah O Lawal
- Department of Pediatrics, University of Michigan Medical Center (N.O.L.), Ann Arbor, Michigan, USA
| | - Michael A Smith
- University of Michigan College of Pharmacy (B.S., M.A.S.), Ann Arbor, Michigan, USA.
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Juviler P, Meyers JM, Levatino E, Axford J, Barker E, Correll L, Decker AS, Faria J, Gloff M, Loria A, McKenna M, Schriefer J, Stevens TP, Verna S, Wegman S, Wolcott K, Wakeman D. Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project. J Pediatr Surg 2024; 59:45-52. [PMID: 37845122 DOI: 10.1016/j.jpedsurg.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/08/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Unplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year. METHODS/INTERVENTION A multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods. RESULTS Unplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019-June 2022, n = 145) compared to the pre-intervention group (January 2016-August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001]. CONCLUSIONS Postoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness. TYPE OF STUDY Prospective Quality Improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Peter Juviler
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jeffrey M Meyers
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Elizabeth Levatino
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica Axford
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Erin Barker
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Lynnie Correll
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Andrew S Decker
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - John Faria
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, NY, USA
| | - Marjorie Gloff
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Margo McKenna
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, NY, USA
| | - Jan Schriefer
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Timothy P Stevens
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Sarah Verna
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Sarah Wegman
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kori Wolcott
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Takemura M, Niki K, Okamoto Y, Matsuda Y, Kohno M, Ueda M. Identification of Factors Contributing to Methadone-Induced Daytime Sleepiness in Cancer Patients and Proposal of the Conversion Ratio from Other Opioids to Oral Methadone: A Retrospective Cohort Study. Palliat Med Rep 2023; 4:194-201. [PMID: 37528989 PMCID: PMC10389252 DOI: 10.1089/pmr.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 08/03/2023] Open
Abstract
Background When methadone is used to treat cancer pain, the Japanese health insurance system recommends to determine the starting dose according to the equivalency conversion table based on the morphine-equivalent daily dose (MEDD) of prior opioids proposed by the National Comprehensive Cancer Network. Owing to the wide range in variability of the conversion table, methadone increases the incidence of daytime sleepiness. Objective To identify the factors associated with daytime sleepiness and propose a conversion ratio from pretreatment MEDD to oral methadone that decreases the risk of daytime sleepiness. Design Retrospective cohort study. Setting/Subjects One hundred patients who started oral methadone to relieve cancer pain at Ashiya Municipal Hospital (Hyogo, Japan) from January 1, 2013, to August 31, 2022, were enrolled. Measurements The primary endpoint, the conversion ratio from pretreatment MEDD to oral methadone without daytime sleepiness, was determined using receiver operator characteristic (ROC) curve analysis. Results The incidence of daytime sleepiness within seven days of methadone initiation was 40.0%. The factors identified as contributing to daytime sleepiness were pretreatment MEDD (odds ratio [OR]: 0.941, 95% confidence interval [CI]: 0.916-0.966, p <0.001) and methadone dose (OR: 1.395, 95% CI: 1.178-1.652, p <0.001). The conversion ratio from pretreatment MEDD to oral methadone was 0.24, with an area under the ROC curve of 0.909 (p <0.001). Conclusions Daytime sleepiness developed when methadone dose is high relative to pretreatment MEDD. To the best of our knowledge, this is the first study to suggest the conversion ratio from pretreatment MEDD to oral methadone without causing daytime sleepiness.
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Affiliation(s)
- Miho Takemura
- Department of Clinical Pharmacy Research and Education, Osaka University Graduate School of Pharmaceutical Sciences, Suita, Japan
- Department of Pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Kazuyuki Niki
- Department of Clinical Pharmacy Research and Education, Osaka University Graduate School of Pharmaceutical Sciences, Suita, Japan
- Department of Pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Yoshiaki Okamoto
- Department of Pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Yoshinobu Matsuda
- Department of Palliative Care, Ashiya Municipal Hospital, Ashiya, Japan
| | - Makie Kohno
- Department of Palliative Care, Ashiya Municipal Hospital, Ashiya, Japan
| | - Mikiko Ueda
- Department of Clinical Pharmacy Research and Education, Osaka University Graduate School of Pharmaceutical Sciences, Suita, Japan
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Reddy A, Haider A, Arthur J, Hui D, Dalal S, Dev R, Tanco K, Amaram-Davila J, Hernandez F, Chavez P, De Moraes AR, Wu J, Nguyen K, Subbiah I, Epner D, Shelal Z, Guay MOD, Mallipeddi T, Bruera E. Levorphanol as a Second Line Opioid in Cancer Patients Presenting to an Outpatient Supportive Care Center: An Open-label Study. J Pain Symptom Manage 2023; 65:e683-e690. [PMID: 36720398 DOI: 10.1016/j.jpainsymman.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/27/2022] [Accepted: 01/13/2023] [Indexed: 01/30/2023]
Abstract
CONTEXT Levorphanol is a potent opioid agonist and NMDA receptor blocker with minimal drug interactions, and there are few reports of its use in cancer patients. OBJECTIVES We aimed to determine the frequency of successful opioid rotation (OR) to levorphanol and the median opioid rotation ratio (ORR) from Morphine Equivalent Daily Dose (MEDD). METHODS This is a prospective, single-group, interventional study. Cancer outpatients requiring an OR and receiving a MEDD of 60-300 mg were rotated to levorphanol using a ratio of 10:1 and assessed daily for 10-day. Successful OR was defined as a 2-point improvement in the Edmonton Symptom Assessment System (ESAS) pain score on day 10 or achieving the personalized pain goal between days 3-10 in patients with uncontrolled pain or resolution of opioid side effects (OSE) in those undergoing OR for OSE alone. The ORR to levorphanol was calculated using net-MEDD (MEDD before OR minus the MEDD of the breakthrough opioid used along with levorphanol after OR). RESULTS Forty patients underwent OR to levorphanol, and uncontrolled pain 35/40 (87.5%) was the most common indication. The median net-MEDD and levorphanol doses were 95 and 10 mg, respectively, and 33/40 (82.5%) had a successful OR with a median (IQR) ORR of 8.56 (7.5-10). Successful OR was associated with significant improvement in ESAS and OSE scale scores. There was a strong association between MEDD and levorphanol dose. CONCLUSION This study provided preliminary data that cancer patients could be successfully rotated to levorphanol using an ORR of 8.5. Levorphanol was associated with improved pain and symptom control and was well- tolerated.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Ali Haider
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kimberson Tanco
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaya Amaram-Davila
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farley Hernandez
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul Chavez
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aline Rozman De Moraes
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jimin Wu
- Department of Biostatistics (J.W.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kristy Nguyen
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ishwaria Subbiah
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Daniel Epner
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marvin Omar Delgado Guay
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tarun Mallipeddi
- University of Tennessee Health Science Center College of Medicine (T.M.), Memphis, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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5
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Preoperative transversus abdominis plane block decreases intraoperative opiate consumption during minimally invasive cholecystectomy. Surg Endosc 2023; 37:2209-2214. [PMID: 35864354 DOI: 10.1007/s00464-022-09445-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The ongoing epidemic of prescription opiate abuse is one of the most pressing health issues in the United States today. Consequently, analgesic adjuncts, such as multimodal drug regimens and regional anesthetic blocks (like transversus abdominis plane (TAP) block), have been introduced to the perioperative period in hopes of decreasing postoperative opiate use. However, the effect of these interventions on intraoperative opiate use has not been examined. We hypothesized that preoperative TAP block would be associated with decreased intraoperative opiate use during minimally invasive cholecystectomy. METHODS This was a retrospective review of patients undergoing minimally invasive cholecystectomy between June 2018 and January 2021. Perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements. RESULTS 261 patients were included in this study, of which 62 (23.8%) received preoperative TAP block and 199 (76.2%) did not. Preoperative TAP block was associated with decreased intraoperative opiate use (0.199 vs 0.312, p < 0.001), while there were no statistically significant differences associated with other analgesic adjuncts including preoperative acetaminophen (p = 0.485), celecoxib (p = 0.112), gabapentin (p = 0.165), or intraoperative ketorolac (p = 0.200). On multivariate analysis, preoperative TAP block was independently associated with decreased intraoperative opiate use (< 0.001), while chronic cholecystitis on final pathology was associated with increased intraoperative opiate use (p = 0.002). CONCLUSION The use of preoperative TAP block was associated with decreased intraoperative opiate use during minimally invasive cholecystectomy and should be considered for routine use. Future research should investigate whether preoperative TAP blocks and a subsequent decrease of intraoperative opiates, also result in a decrease in postoperative opiate use and improvements in postoperative outcomes.
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Yu PC, Hao CY, Fan YZ, Liu D, Qiao YF, Yao JB, Li CZ, Yu Y. Altered Membrane Expression and Function of CD11b Play a Role in the Immunosuppressive Effects of Morphine on Macrophages at the Nanomolar Level. Pharmaceuticals (Basel) 2023; 16:282. [PMID: 37259426 PMCID: PMC9963077 DOI: 10.3390/ph16020282] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/31/2023] [Accepted: 02/08/2023] [Indexed: 11/17/2023] Open
Abstract
Morphine, one of the most efficacious analgesics, is effective in severe pain, especially in patients with concomitant painful cancers. The clinical use of morphine may be accompanied by increased immunosuppression, susceptibility to infection and postoperative tumor metastatic recurrence, and the specific mechanisms and clinical strategies to alleviate this suppression remain to be investigated. Expression of CD11b is closely associated with the macrophage phagocytosis of xenobiotic particles, bacteria or tumor cells. Here, we find that morphine at 0.1-10 nM levels inhibited CD11b expression and function on macrophages via a μ-opioid receptor (MOR)-dependent mechanism, thereby reducing macrophage phagocytosis of tumor cells, a process that can be reversed by thymopentin (TP5), a commonly used immune-enhancing adjuvant in clinical practice. By knocking down or overexpressing MOR on macrophages and using naloxone, an antagonist of the MOR receptor, and LA1, a molecule that promotes macrophage CD11b activation, we suggest that morphine may regulate macrophage phagocytosis by inhibiting the surface expression and function of macrophage CD11b through the membrane expression and activation of MOR. The CD47/SIRPα axis, which is engaged in macrophage-tumor immune escape, was not significantly affected by morphine. Notably, TP5, when combined with morphine, reversed the inhibition of macrophage phagocytosis by morphine through mechanisms that promote membrane expression of CD11b and modulate its downstream signaling (e.g., NOS2, IFNG, IL1B and TNFA, as well as AGR1, PDGFB, IL6, STAT3, and MYC). Thus, altered membrane expression and function of CD11b may mediate the inhibition of macrophage phagocytosis by therapeutic doses of morphine, and the reversal of this process by TP5 may provide an effective palliative option for clinical immunosuppression by morphine.
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Affiliation(s)
- Peng-Cheng Yu
- School of Basic Medicine and Clinical Pharmacy and State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
| | - Cui-Yun Hao
- School of Basic Medicine and Clinical Pharmacy and State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
| | - Ying-Zhe Fan
- Interventional Cancer Institute of Chinese Integrative Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Di Liu
- School of Basic Medicine and Clinical Pharmacy and State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
| | - Yi-Fan Qiao
- School of Basic Medicine and Clinical Pharmacy and State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
| | - Jia-Bao Yao
- School of Basic Medicine and Clinical Pharmacy and State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
| | - Chang-Zhu Li
- State Key Laboratory of Utilization of Woody Oil Resource, Hunan Academy of Forestry, Changsha 410004, China
| | - Ye Yu
- School of Basic Medicine and Clinical Pharmacy and State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
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7
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Paice JA, Bohlke K, Barton D, Craig DS, El-Jawahri A, Hershman DL, Kong LR, Kurita GP, LeBlanc TW, Mercadante S, Novick KLM, Sedhom R, Seigel C, Stimmel J, Bruera E. Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol 2023; 41:914-930. [PMID: 36469839 DOI: 10.1200/jco.22.02198] [Citation(s) in RCA: 59] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To provide guidance on the use of opioids to manage pain from cancer or cancer treatment in adults. METHODS A systematic review of the literature identified systematic reviews and randomized controlled trials of the efficacy and safety of opioid analgesics in people with cancer, approaches to opioid initiation and titration, and the prevention and management of opioid adverse events. PubMed and the Cochrane Library were searched from January 1, 2010, to February 17, 2022. American Society of Clinical Oncology convened an Expert Panel to review the evidence and formulate recommendations. RESULTS The evidence base consisted of 31 systematic reviews and 16 randomized controlled trials. Opioids have primarily been evaluated in patients with moderate-to-severe cancer pain, and they effectively reduce pain in this population, with well-characterized adverse effects. Evidence was limited for several of the questions of interest, and the Expert Panel relied on consensus for these recommendations or noted that no recommendation could be made at this time. RECOMMENDATIONS Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Opioids should be initiated PRN (as needed) at the lowest possible dose to achieve acceptable analgesia and patient goals, with early assessment and frequent titration. For patients with a substance use disorder, clinicians should collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management. Opioid adverse effects should be monitored, and strategies are provided for prevention and management.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
- Judith A Paice
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Debra Barton
- University of Michigan School of Nursing, Ann Arbor, MI
| | - David S Craig
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | | | - Dawn L Hershman
- Mailman School of Public Health and Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Lynn R Kong
- Ventura County Hematology Oncology Specialists, Oxnard, CA
| | - Geana P Kurita
- Rigshospitalet Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Kristina L M Novick
- Penn Radiation Oncology Chester County, Chester County Hospital, West Chester, PA
| | - Ramy Sedhom
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | | | | | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX
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8
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Wen RY, Atayee RS, Edmonds KP. A Comparison of Institutional Opioid Equianalgesia Tools: A National Study. J Palliat Med 2022; 25:1686-1691. [PMID: 35559657 PMCID: PMC9836696 DOI: 10.1089/jpm.2021.0678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 01/22/2023] Open
Abstract
Context: Equianalgesic tools are commonly utilized to guide dose of analgesic therapy, but there is no national consensus on equianalgesic calculations in the United States. Objectives: To propose a summary of current opioid equianalgesic data that include variations and trends among national institutions. Methods: Opioid equianalgesic tools were obtained between May and September 2021. For meperidine, tramadol, codeine, hydrocodone, morphine, oxycodone, oxymorphone, hydromorphone, levorphanol, fentanyl, and tapentadol, details of adjustment for incomplete tolerance, opioid equianalgesic ratios, and formulation types were collected and analyzed. Baseline opioid pharmaco kinetic data were obtained through manufacturer labels on FDA databases, including half-life (T1/2), volume of distribution (Vd), clearance (Cl), area under the curve (AUC), max concentration (Cmax), and time to max concentration (Tmax). Results: Thirty-two institutions' equianalgesic tools were included with each study opioid appearing on an average of 23 institutions' tools. Few tools contained guidance on levorphanol or tapentadol; or included minimum and maximum recommended doses. All tools included guidance on fentanyl, hydromorphone, oxycodone, morphine, and hydrocodone. A minority of tools included guidance on cross-tolerance considerations (n = 12, 37.5%). Oral-tramadol-to-oral-morphine and oral-hydromorphone-to-intravenous (IV)-hydromorphone had the largest variances across equianalgesic tools (6.7 ± 2.8 and 4.06 ± 1.2 mg, respectively). Conclusion: Opioid equianalgesia tools from across the United States demonstrated significant variation in their inclusion of guidance on adjustment for incomplete cross-tolerance, oral-to-IV, and oral-to-oral opioid equianalgesic ratios, and which opioids and formulations were listed. Tramadol and hydromorphone had the most variation in their equianalgesic guidance among the opioids.
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Affiliation(s)
- Raymond Y. Wen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Rabia S. Atayee
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
- Palliative Care Program, Department of Medicine, UC San Diego Health Sciences, and Division of Geriatrics, Gerontology, La Jolla, California, USA
| | - Kyle P. Edmonds
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
- Palliative Care Program, Department of Medicine, UC San Diego Health Sciences, and Division of Geriatrics, Gerontology, La Jolla, California, USA
- Section of Palliative Care, Division of Geriatrics, Gerontology, La Jolla, California, USA
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Reddy A, Sinclair C, Crawford GB, McPherson ML, Mercadante S, Hui D, Haider A, Arthur J, Tanco K, Dalal S, Dev R, Amaram-Davila J, Adile C, Liu D, Schuler U, Jammi S, Shelal Z, Del Fabbro E, Davis M, Bruera E. Opioid Rotation and Conversion Ratios Used by Palliative Care Professionals: An International Survey. J Palliat Med 2022; 25:1557-1562. [PMID: 35930252 PMCID: PMC9836667 DOI: 10.1089/jpm.2022.0266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 01/22/2023] Open
Abstract
Background: The opioid rotation ratios (ORRs) and conversion ratios (CRs) used worldwide among palliative care (PC) professionals to perform opioid rotations (ORs) and route conversions may have a wide variation. Methods: We surveyed PC professionals on opioid ratios used through email to the Multinational Association of Supportive Care in Cancer's PC study group and Twitter and Facebook posts between September and November 2020. Results: We received 370 responses from respondents from 53 countries: 276 (76%) were physicians, 46 (13%) advanced practice providers, 39 (11%) pharmacists, and 9 respondents did not report their profession. There were statistically significant variations in median CR from intravenous (IV) to oral morphine (2-3), IV to oral hydromorphone (2-4.5), ORR from IV hydromorphone to oral morphine (10-20), and ORR from transdermal fentanyl mcg/hour to oral morphine (2-3.5) across various groups. Conclusion: This survey highlights the wide variation in ORRs and CRs among PC clinicians worldwide and the need for further research to standardize practice.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christian Sinclair
- Division of Palliative Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gregory B. Crawford
- Northern Adelaide Local Health Network, Adelaide, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Mary Lynn McPherson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Haider
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kimberson Tanco
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaya Amaram-Davila
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ulrich Schuler
- Universitätsklinikum Carl Gustav Carus, PalliativCentrum & Medizinische Klinik, Dresden, Germany
| | - Sheetal Jammi
- Candidate for Bachelor of Science in Biology and Bachelor of Science in Psychology, University of Houston, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Egidio Del Fabbro
- Department of Internal Medicine, Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
| | - Mellar Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Zárate Rodriguez JG, Leigh N, Edgley C, Cos H, Wolfe R, Sanford D, Hammill CW. Preoperative transversus abdominis plane block decreases intraoperative opiate use during pancreatoduodenectomy. HPB (Oxford) 2022; 24:1162-1167. [PMID: 35012875 DOI: 10.1016/j.hpb.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/07/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multimodal analgesia and regional anesthetic blocks, such as transversus abdominis plane (TAP) block, decrease postoperative opiate consumption but their effect on intraoperative opiates is unknown. METHODS This was a retrospective review of patients undergoing pancreatoduodenectomy between June 2018 and February 2021, in which perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements. RESULTS Of the 169 patients in the study, 51 (30.2%) received pre-surgical TAP blocks and 118 (69.8%) did not. There were no statistically significant differences in intraoperative opiate use with preoperative acetaminophen (p = 0.527), celecoxib (p = 0.553), gabapentin (p = 0.308), intraoperative ketorolac (p = 0.698) or epidural placement (p = 0.086). Minimally invasive surgery had lower intraoperative opiate use compared to open (p = 0.011), as well as pre-surgical TAP block compared to no pre-surgical block (5.24 vs 7.27 MED/hour, p < 0.001). On multivariate linear regression, pre-surgical TAP block (p = 0.001) was independently associated with decreased intraoperative opiate use. CONCLUSION Preoperative TAP blocks were associated with decreased intraoperative opiate use during pancreatoduodenectomy and should be considered for routine use.
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Affiliation(s)
- Jorge G Zárate Rodriguez
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA
| | - Natasha Leigh
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA
| | - Carla Edgley
- University College Dublin School of Medicine, Ireland
| | - Heidy Cos
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA
| | | | - Dominic Sanford
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA
| | - Chet W Hammill
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA; Barnes-Jewish Hospital, St Louis, MO, USA.
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3-T magnetic resonance-guided high-intensity focused ultrasound (3 T-MR-HIFU) for the treatment of pain from bone metastases of solid tumors. Support Care Cancer 2022; 30:5737-5745. [PMID: 35332373 DOI: 10.1007/s00520-022-06990-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Bone metastases (BM) are still the main cause of morbidity and mortality in cancer patients, not only because of their complications, defined as skeletal-related events (SREs), but also because of the negative impact bone pain has on quality of life (QoL) and survival, especially when opioid analgesics and locoregional treatments fail. MATERIALS AND METHODS A single-center prospective study was carried out on 12 patients with symptomatic BM treated with MRI-guided focused ultrasound (MR-HIFU). The primary endpoint was the effectiveness of MR-HIFU in reducing current and breakthrough cancer pain (BTCP) scores. The main secondary aims were the evaluation of circulating markers at different time-points and their relation to pain and procedure efficacy. Other secondary objectives included temporal evolution of pain response, evaluation of QoL, and side effects of the treatment. Descriptive statistics were used to evaluate primary and secondary endpoints. Questionnaires on pain and QoL completed at baseline and at 30 days were compared using appropriate statistical tests with exploratory intent. RESULTS MR-HIFU was successfully completed in all 12 patients enrolled between September 2015 and December 2018. On day 30, 6 (50.0%) patients showed a complete response of current pain and 6 a partial response, while 5 (41.7%) obtained a complete BTCP response. A partial response of BM evaluated by MD Anderson criteria was obtained in 9 (81.8%) patients. Only one patient progressed in the target lesion after MR-HIFU. No treatment-related adverse events were recorded. Bone turnover markers CTX/RANK-L (P) do not demonstrate any significant change with the pain or BM response. CONCLUSION In our patients, targeted therapy of painful BM with MRI-guided focused ultrasound ablation was safe and showed encouraging early-onset and functional results.
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Postoperative Respiratory Events in Surgical Patients Exposed to Opioid Analgesic Shortages Compared to Fully Matched Patients Non-exposed to Shortages. Drug Saf 2022; 45:359-367. [PMID: 35298825 DOI: 10.1007/s40264-022-01171-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Shortages of opioid analgesics critically disrupt clinical practice and are detrimental to patient safety. There is a dearth of studies assessing the safety implications of drug shortages. OBJECTIVE We aimed to assess perioperative opioid analgesic use and related postoperative hypoxemia (oxygen saturation less than 90%) in surgical patients exposed to prescription opioid shortages compared to propensity score-matched patients non-exposed to opioid shortages. METHODS We conducted a retrospective study including adult patients who underwent elective surgery at The University of California San Francisco in the period August 2018-December 2019. We conducted a Gamma log-link generalized linear model to assess the effect of shortages on perioperative use of opioids and a weighted logistic regression to assess the likelihood of experiencing postoperative hypoxemia. RESULTS There were 1119 patients exposed to opioid shortages and 2787 matched non-exposed patients. After full matching, patients exposed to shortages used a greater mean of morphine milligram equivalents/day (146.94; 95% confidence interval 123.96-174.16) than non-exposed patients (117.92; 95% confidence interval 100.48-138.38; p = 0.0001). The estimated effect was a 1.25 (95% confidence interval 1.12-1.40; p = 0.0001) times greater use of opioids in patients exposed to opioid shortages than non-exposed patients. After full matching, a greater proportion of patients exposed to shortages (19.06%) experienced hypoxemia compared with non-exposed patients (16.91%). In addition, a greater proportion of patients exposed to opioid shortages (1.20%) experienced hypoxemia reversed by intravenous naloxone administration compared with non-exposed patients (0.44%). CONCLUSIONS Given the shortage prevalence, reliance on opioid medications, and related risk of respiratory depression, harm prevention measures remain critical to prevent postoperative complications that may compromise patients' safety.
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Ma C, Zhao D, Hu X, Li C, Zhang J, Zhang Y, Yuan L. Perioperative Effects of Hydromorphone in Gynecological Laparoscopic Surgery under General Anesthesia. INT J PHARMACOL 2022. [DOI: 10.3923/ijp.2022.534.542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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14
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Ranganath YS, Ramanujam V, Onodera Y, Keech J, Arshava E, Parekh KR, Sondekoppam RV. Impact of paravertebral blocks on analgesic and non-analgesic outcomes after video-assisted thoracoscopic surgery: A propensity matched cohort study. PLoS One 2021; 16:e0252059. [PMID: 34015047 PMCID: PMC8136840 DOI: 10.1371/journal.pone.0252059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/07/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Regional analgesic techniques such as paravertebral blocks (PVBs) have been popularized for analgesia following video-assisted thoracoscopic surgery (VATS). In this single center retrospective propensity matched cohort of subjects, we investigate the impact of paravertebral blocks on the analgesic and non-analgesic outcomes. METHODS Institutional database was queried to identify all patients undergoing VATS between January 2013 and July 2019 and these patients were divided into those who received paravertebral blocks in combination with general anesthesia (GA) [PVB group] and those who received GA without paravertebral blocks [GA group]. Propensity score matching based on common patient confounders were used to identify patients in each group. Primary outcomes of the study were average pain scores and opioid consumption in the first 24 hours. Secondary analgesic outcomes included pain scores and opioid requirements at other timepoints over the first 48 hours. Non analgesic outcomes were obtained from STS General Thoracic Surgery Database and included length of hospital stay, need for ICU admission, composite outcome of any complication during the hospital course and 30-day mortality. Exploratory analyses were conducted to investigate the impact of PVB on analgesia following different types of surgery and as to whether any other covariates had a greater influence on the included patient centered outcomes. MAIN RESULTS After propensity score matching, a total of 520 patients (260 per group) were selected for the study out of 1095 patients. The opioid consumption in terms of oral morphine milligram equivalent (MME) [Median (IQR)] for the first 24 hours was significantly lower with the use of PVB [PVB group- 78.5 (96.75); GA group-127.0 (111.5); p<0.001] while the average pain scores in the first 24 hours did not differ significantly [PVB group-4.71 (2.28); GA group-4.85 (2.30); p = 0.70]. The length of hospital stay, opioid requirements at other timepoints, need for ICU admission in the immediate post-operative period and the composite outcome-'any complication' (35% vs 48%) were significantly lower with the use of PVB. Subgroup analysis showed a longer duration of benefit following major lung surgeries compared to others. CONCLUSION Paravertebral blocks reduced the length of stay and opioid consumption up to 48 hours after VATS without significantly impacting pain scores.
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Affiliation(s)
- Yatish S. Ranganath
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
| | - Vendhan Ramanujam
- Department of Anesthesiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Yoshiko Onodera
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - John Keech
- Department of Surgery – Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
| | - Evgeny Arshava
- Department of Surgery – Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
| | - Kalpaj R. Parekh
- Department of Surgery – Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
| | - Rakesh V. Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
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Patterns of opioid analgesic use in the U.S., 2009 to 2018. Pain 2021; 162:1060-1067. [PMID: 33021566 DOI: 10.1097/j.pain.0000000000002101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Although overall outpatient dispensing of opioid analgesic prescriptions has declined, there may still be overprescribing. Understanding how many opioid analgesic units, primarily tablets, are dispensed with the intention of shorter-vs longer-term use can inform public health interventions. We used pharmacy prescription data to estimate the number of opioid analgesic tablets dispensed annually in the U.S. We studied patterns of new use of opioid analgesics by evaluating how many opioid analgesic prescriptions and tablets were dispensed to patients with no opioid analgesic prescriptions in the previous year. Estimated opioid analgesic tablets dispensed declined from a peak of 17.8 billion in 2012 to 11.1 billion in 2018. Patients newly starting opioid analgesics declined from 47.4 million patients in 2011 to 37.1 million patients in 2017. Approximately 40% fewer tablets were dispensed within a year to patients starting in 2017 (2.4 billion) compared with 2011 (4.0 billion). In 2011, patients with ≥5 opioid analgesic prescriptions within a year were dispensed 2.2 billion tablets (55% of all tablets in our study). This declined by 52% to 1.1 billion tablets (44% of all tablets) in 2017. Tablets dispensed within a year to patients with <5 opioid analgesic prescriptions declined by 26% from 2011 to 2017. Patients with ≥5 prescriptions comprised a small and decreasing proportion of all patients newly starting therapy. However, these patients received almost half of all tablets dispensed within a year to patients in our study, despite a larger decline than tablets dispensed to patients with <5 prescriptions within a year.
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Adeyemo EA, Aoun SG, Barrie U, Nguyen ML, Johnson ZD, Hall K, Peinado Reyes V, El Ahmadieh TY, Adogwa O, McDonagh DL, Bagley CA. Comparison of the effect of epidural versus intravenous patient controlled analgesia on inpatient and outpatient functional outcomes after adult degenerative scoliosis surgery: a comparative study. Spine J 2021; 21:765-771. [PMID: 33352321 DOI: 10.1016/j.spinee.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/14/2020] [Accepted: 12/14/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Perioperative pain can negatively impact patient recovery after spine surgery and be a contributing factor to increased hospital length of stay and cost. Most data currently available is extrapolated from adolescent idiopathic cases and may not apply to adult and geriatric populations with thoracolumbar spine degeneration. PURPOSE Study the impact of epidural analgesia on pain control and outcomes after adult degenerative scoliosis surgery in a large single-institution series of adult patients undergoing thoraco-lumbar-pelvic fusion. STUDY DESIGN/SETTING Retrospective single-center review of prospectively collected data. PATIENT SAMPLE Patients undergoing thoracolumbar fusion with pelvic fixation. OUTCOME MEASURES Self-reported measures: Visual analog scale for pain. Physiologic Measures: Oral pain control requirements converted into daily morphine equivalents. Functional Measures: Ambulation perimeter after surgery, urinary retention and constipation rates. METHODS We retrospectively reviewed patient data for the years 2016 and 2017 before the use of patient controlled epidural analgesia (PCEA), and then 2018 and 2019 after its implementation, for all thoracolumbar degenerative procedures, and compared their postoperative outcomes measures. RESULTS There were 46 patients in the PCEA group and 37 patients in the intravenous PCA (IVPCA) groups. All patients underwent long segment posterolateral thoracolumbar spinal fusion with pelvic fixation. Patients in the PCEA group had lower pain scores and ambulated greater distances compared with those in the IVPCA group. PCEA patients also had lower urinary retention and constipation rates, but no increased intraoperative or postoperative complications related to catheter placement. CONCLUSIONS PCEA can provide optimal pain control after adult degenerative scoliosis spine surgery, and may promote greater early ambulation, while decreasing postoperative constipation and urinary retention rates.
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Affiliation(s)
- Emmanuel A Adeyemo
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Salah G Aoun
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA.
| | - Umaru Barrie
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Madelina L Nguyen
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Zachary D Johnson
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Kristen Hall
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Valery Peinado Reyes
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Owoicho Adogwa
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - David L McDonagh
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Carlos A Bagley
- Department of Neurological Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA; Department of Orthopedic Surgery, UT Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75235 USA
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Adeyemo EA, Aoun SG, Barrie U, Nguyen ML, Badejo O, Pernik MN, Christian Z, Dosselman LJ, El Ahmadieh TY, Hall K, Reyes VP, McDonagh DL, Bagley CA. Enhanced Recovery After Surgery Reduces Postoperative Opioid Use and 90-Day Readmission Rates After Open Thoracolumbar Fusion for Adult Degenerative Deformity. Neurosurgery 2021; 88:295-300. [PMID: 32893863 DOI: 10.1093/neuros/nyaa399] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/02/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The role of enhanced recovery after surgery (ERAS) pathways implementation has not been previously explored in adult deformity patients. OBJECTIVE To determine the impact of ERAS pathways implementation in adult patients undergoing open thoraco-lumbar-pelvic fusion for degenerative scoliosis on postoperative outcome, opioid consumption, and unplanned readmission rates. METHODS In this retrospective single-center study, we included 124 consecutive patients who underwent open thoraco-lumbar-pelvic fusion from October 2016 to February 2019 for degenerative scoliosis. Primary outcomes consisted of postoperative supplementary opioid consumption in morphine equivalent dose (MED), postoperative complications, and readmission rates within the postoperative 90-d window. RESULTS There were 67 patients in the ERAS group, and 57 patients served as pre-ERAS controls. Average patient age was 69 yr. The groups had comparable demographic and intraoperative variables. ERAS patients had a significantly lower rate of postoperative supplemental opioid consumption (248.05 vs 314.05 MED, P = .04), a lower rate of urinary retention requiring catheterization (5.97% vs 19.3%, P = .024) and of severe constipation (1.49% vs 31.57%, P < .0001), and fewer readmissions after their surgery (2.98% vs 28.07%, P = .0001). CONCLUSION A comprehensive multidisciplinary approach to complex spine surgery can reduce opioid intake, postoperative urinary retention and severe constipation, and unplanned 90-d readmissions in the elderly adult population.
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Affiliation(s)
- Emmanuel A Adeyemo
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Salah G Aoun
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Umaru Barrie
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Madelina L Nguyen
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Olatunde Badejo
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Mark N Pernik
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Zachary Christian
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Luke J Dosselman
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Kristen Hall
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Valery Peinado Reyes
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - David L McDonagh
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, Texas
| | - Carlos A Bagley
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas.,Department of Orthopedic Surgery, UT Southwestern Medical Center, Dallas, Texas
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Carmichael H, Wright FL, McIntyre RC, Vogler T, Urban S, Jolley SE, Burnham EL, Firth W, Velopulos CG, Idrovo JP. Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection. Trauma Surg Acute Care Open 2021; 6:e000591. [PMID: 34192162 PMCID: PMC7817387 DOI: 10.1136/tsaco-2020-000591] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/17/2020] [Accepted: 12/27/2020] [Indexed: 01/10/2023] Open
Abstract
Background Since the outset of the coronavirus disease 2019 (COVID-19) pandemic, published tracheostomy guidelines have generally recommended deferral of the procedure beyond the initial weeks of intubation given high mortality as well as concerns about transmission of the infection to providers. It is unclear whether tracheostomy in patients with COVID-19 infection facilitates ventilator weaning, and long-term outcomes are not yet reported in the literature. Methods This is a retrospective study of tracheostomy outcomes in patients with COVID-19 infection at a single-center academic tertiary referral intensive care unit. Patients underwent percutaneous tracheostomy at the bedside; the procedure was performed with limited staffing to reduce risk of disease transmission. Results Between March 1 and June 30, 2020, a total of 206 patients with COVID-19 infection required mechanical ventilation and 26 underwent tracheostomy at a mean of 25±5 days after initial intubation. Overall, 81% of tracheostomy patients were liberated from the ventilator at a mean of 9±6 days postprocedure, and 54% were decannulated prior to hospital discharge at a mean of 21±10 days postprocedure. Sedation and pain medication requirements decreased significantly in the week after the procedure. In-hospital mortality was 15%. Among tracheostomy survivors, 68% were discharged to a facility. Discussion The management of patients with COVID-19 related respiratory failure can be challenging due to prolonged ventilator dependency. In our initial experience, outcomes post-tracheostomy in this population are encouraging, with short time to liberation from the ventilator, a high rate of decannulation prior to hospital discharge, and similar mortality to tracheostomy performed for other indications. Barriers to weaning ventilation in this cohort may be high sedation needs and ventilator dyssynchrony. Level of evidence Level V-Therapeutic/care management.
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Affiliation(s)
| | - Franklin L Wright
- Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
| | - Robert C McIntyre
- Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
| | - Thomas Vogler
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Shane Urban
- Trauma Program, University of Colorado Health, Aurora, Colorado, USA
| | - Sarah E Jolley
- Division of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
| | - Ellen L Burnham
- Division of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
| | - Whitney Firth
- Surgical/Trauma ICU, University of Colorado Health, Aurora, Colorado, USA
| | - Catherine G Velopulos
- Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
| | - Juan Pablo Idrovo
- Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
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Christian Z, Afuwape O, Johnson ZD, Adeyemo E, Barrie U, Dosselman LJ, Pernik MN, Hall K, Aoun SG, Bagley CA. Evaluating the Impact of Psychiatric Disorders on Preoperative Pain Ratings, Narcotics Use, and the PROMIS-29 Quality Domains in Spine Surgery Candidates. Cureus 2021; 13:e12768. [PMID: 33614357 PMCID: PMC7888361 DOI: 10.7759/cureus.12768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective We aimed to study the relationship between psychiatric Disorders (PD), preoperative pain, and opioid medication intake, as well as the quality of life patient-reported outcome measures using the Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29) questionnaire, during the 30-day interval preceding surgery, in a consecutive series of patients who were scheduled to undergo surgical spine procedures. We hypothesized that PD could affect preoperative narcotic use and pain interference in a fashion that was not linearly associated with preoperative pain in spine surgery candidates. Methods The records of consecutive adult patients who underwent elective spinal surgery between October 2016 and August 2017 at a single institution were reviewed. We included patients who underwent preoperative pain assessment within 30 days prior to their planned surgery using the PROMIS-29 questionnaire. Patients with PD were compared to controls. Results A total of 117 patients matched our criteria. The average rating of pain intensity was notably higher in the PD group as compared to controls (p=0.004). The PD group had more patients complaining of high pain levels (>6) as compared to the control group (p=0.026). Controls with high pain levels had a greater incidence of preoperative narcotic use as compared to the low-pain cohort (p=0.029). However, there was no difference in the actual dose of daily narcotic medication taken between the PD and control groups (P=0.099) or between the low- and high pain score groups in the control (p=0.291) and PD (p=0.441) groups, respectively. Patients with PD and higher pain ratings seemed to have a higher incidence of anxiety (p=0.005) and depression (p<0.001). That was not the case for controls. Conclusions PDs may impact the degree of preoperative pain interference and the intake of narcotic medication independently from pain intensity ratings.
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Affiliation(s)
- Zachary Christian
- Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Olusoji Afuwape
- Neurosurgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Zachary D Johnson
- Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Emmanuel Adeyemo
- Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Umaru Barrie
- Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Luke J Dosselman
- Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Mark N Pernik
- Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Kristen Hall
- Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Salah G Aoun
- Neurosurgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Carlos A Bagley
- Neurosurgery, University of Texas Southwestern Medical Center, Dallas, USA
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Chen Q, Zhang P, Xiao QX, Liu Q, Zhang Y. Protective effect of Shengmai injection on myocardial endothelial cell glycoprotein detachment after myocardial ischemia-reperfusion injury in isolated rat hearts. Perfusion 2020; 36:757-765. [PMID: 33070762 DOI: 10.1177/0267659120965921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate effects of Shengmai injection (SMI) postconditioning on myocardial ischemia-reperfusion injury (MIRI) in isolated rat hearts. MATERIALS AND METHODS A total of thirty isolated hearts were randomly divided into three groups: Sham group, I/R group and SMI group. Sham group was continuously perfused with K-H solution for 120 minutes. I/R group and SMI group were given balanced perfusion for 30 min followed by reperfusion for 60 min, with an interval of 30 min, and those in the SMI group were given postconditioning with 1% SMI during the first 10 min of reperfusion. The left ventricular function, markers of myocardial injury, endothelial cell injury and oxidative stress injury were measured at 30 minutes after equilibration (t0), 30 minutes after ischemia (t2) and 60 minutes after reperfusion (t3). RESULTS The results showed that there was no significant difference for all observation indexes at t0. Compared with the Sham group, real portfolio project and coronary arterial flow rate and the activity of superoxide dismutase were significantly decreased in the I/R group, whereas those in the SMI group were significantly higher. Left ventricular end-diastolic pressure, the concentrate of malondialdehyde, lactate dehydrogenase, cTn-I, hyaluronic acid, heparin sulphate, syndecan-1 in the I/R group were markedly higher than those in the Sham group, whereas those in the SMI group were significantly lower. CONCLUSION In summary, the present study indicated that 1% SMI postconditioning can alleviate the detachment of endothelial cell glycoprotein envelope induced by myocardial ischemia-reperfusion injury, and its mechanism is probably related to the inhibition of the oxidative stress injury.
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Affiliation(s)
- Qi Chen
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Ping Zhang
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Qiu-Xia Xiao
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Qing Liu
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Ying Zhang
- Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
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Heins SE, Frey KP, Alexander GC, Castillo RC. Reducing High-Dose Opioid Prescribing: State-Level Morphine Equivalent Daily Dose Policies, 2007-2017. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:308-316. [PMID: 30865779 PMCID: PMC8607298 DOI: 10.1093/pm/pnz038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe current state-level policies in the United States, January 1, 2007-June 1, 2017, limiting high morphine equivalent daily dose (MEDD) prescribing. METHODS State-level MEDD threshold policies were reviewed using LexisNexis and Westlaw Next for legislative acts and using Google for nonlegislative state-level policies. The websites of each state's Medicaid agency, health department, prescription drug monitoring program, workers' compensation board, medical board, and pharmacy board were reviewed to identify additional policies. The final policy list was checked against existing policy compilations and academic literature and through contact with state health agency representatives. Policies were independently double-coded on the categories: state, agency/organization, policy type, effective date, threshold level, and policy exceptions. RESULTS Currently, 22 states have at least one type of MEDD policy, most commonly guidelines (14 states), followed by prior authorizations (four states), rules/regulations (four states), legislative acts (three states), claim denials (two states), and alert systems/automatic patient reports (two states). Thresholds range widely (30-300 mg MEDD), with higher thresholds generally corresponding to more restrictive policies (e.g., claim denial) and lower thresholds corresponding to less restrictive policies (e.g., guidelines). The majority of policies exclude some groups of opioid users, most commonly patients with terminal illnesses or acute pain. CONCLUSIONS MEDD policies have gained popularity in recent years, but considerable variation in threshold levels and policy structure point to a lack of consensus. This work provides a foundation for future evaluation of MEDD policies and may inform states considering adopting such policies.
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Affiliation(s)
| | | | - G. Caleb Alexander
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins School of Medicine, Baltimore, MD
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22
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Suess TM, Beard JW, Trohimovich B. Impact of Patient-Controlled Analgesia (PCA) Smart Pump-Electronic Health Record (EHR) Interoperability with Auto-Documentation on Chart Completion in a Community Hospital Setting. Pain Ther 2019; 8:261-269. [PMID: 31350711 PMCID: PMC6857105 DOI: 10.1007/s40122-019-0132-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Complete and accurate documentation of opioids administered by patient-controlled analgesia (PCA) pumps is critical for ensuring a high-quality medication record and an accurate conversion of the intravenous (IV) regimen to oral therapy. Incomplete charting of PCA usage through a manual process may be associated with fragmented documentation of delivered therapy affecting the completeness of the medical record and the IV to oral dose conversion. This study is the first to evaluate the association between auto-documentation of opioid administration provided by PCA smart pump-electronic health record (EHR) interoperability and the completion of PCA opioid administration charting tasks. METHODS This retrospective cohort study was conducted at Lancaster General Hospital, Lancaster, Pennsylvania. Patients were assigned to pre-auto-documentation (n = 55) or post-auto-documentation groups (n = 58) based on whether they received PCA therapy prior to or after PCA-EHR interoperability was implemented. Charting of PCA therapy included documentation of the number of patient attempts, number of doses given, and total volume infused for both pre- and post-auto-documentation groups. In addition, total dose delivered was documented for the post-auto-documentation group. The overall chart-field completion rate was evaluated as the primary outcome. Individual chart completion percentages were assessed by stratified groups as secondary outcomes. RESULTS PCA smart pump-EHR interoperability with auto-documentation was associated with an increase in overall chart-field completion rate from 69.9 to 97.0% (p < 0.001). Auto-documentation was also associated with an increase in fully completed charts from 38 to 91% (139.3% increase, p < 0.001) and reductions of incomplete records in each stratified group (p < 0.001). CONCLUSIONS PCA smart pump-EHR interoperability with auto-documentation is associated with significant improvements in the completion of opioid administration chart-fields. Improved documentation of PCA administered opioids may have implications for the safety of opioid administration. Additional studies will be needed to assess the potential clinical impact of these results. FUNDING ICU Medical, Inc.
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Opioid Crisis: Equianalgesia Dosing Considerations for Home Care Cancer Patients. Home Healthc Now 2019; 37:350-352. [PMID: 31688470 DOI: 10.1097/nhh.0000000000000825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As a result of the opioid epidemic, strategies have been implemented to reduce opioid consumption. These include regulatory policies, reduced opioid production, and nonopioid approaches for pain management. Although these policies may reduce opioid prescribing, there has been an unintended consequence for patients with severe cancer pain. Opioids are foundational for cancer pain management and are often required for patients during end-of-life care. Shortages of some opioid medications require knowledge of equianalgesic dosing. Equianalgesia is the conversion of comparable pain-relieving effects from one medication to another. There is a lack of consensus with regard to conversion standardization so researchers have created dosing principles that clinicians can follow. This article will describe some of these dosing principles and provide readers with sources for on-line dosage calculators.
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Giles SL, Brown MRD, Rivens I, Deppe M, Huisman M, Kim YS, Farquhar-Smith P, Williams JE, Ter Haar GR, deSouza NM. Comparison of Imaging Changes and Pain Responses in Patients with Intra- or Extraosseous Bone Metastases Treated Palliatively with Magnetic Resonance-Guided High-Intensity-Focused Ultrasound. J Vasc Interv Radiol 2019; 30:1351-1360.e1. [PMID: 31101417 PMCID: PMC6715806 DOI: 10.1016/j.jvir.2019.02.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/07/2019] [Accepted: 02/21/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE This study compared changes in imaging and in pain relief between patients with intraosseous, as opposed to extraosseous bone metastases. Both groups were treated palliatively with magnetic resonance-guided high-intensity-focused ultrasound (MRgHIFU). MATERIALS AND METHODS A total of 21 patients were treated prospectively with MRgHIFU at 3 centers. Intraprocedural thermal changes measured using proton resonance frequency shift (PRFS) thermometry and gadolinium-enhanced T1-weighted (Gd-T1W) image appearances after treatment were compared for intra- and extraosseous metastases. Pain scores and use of analgesic therapy documented before and up to 90 days after treatment were used to classify responses and were compared between the intra- and extraosseous groups. Gd-T1W changes were compared between responders and nonresponders in each group. RESULTS Thermal dose volumes were significantly larger in the extraosseous group (P = 0.039). Tumor diameter did not change after treatment in either group. At day 30, Gd-T1W images showed focal nonenhancement in 7 of 9 patients with intraosseous tumors; in patients with extraosseous tumors, changes were heterogeneous. Cohort reductions in worst-pain scores were seen for both groups, but differences from baseline at days 14, 30, 60, and 90 were only significant for the intraosseous group (P = 0.027, P = 0.013, P = 0.012, and P = 0.027, respectively). By day 30, 67% of patients (6 of 9) with intraosseous tumors were classified as responders, and the rate was 33% (4 of 12) for patients with extraosseous tumors. In neither group was pain response indicated by nonenhancement on Gd-T1W. CONCLUSIONS Intraosseous tumors showed focal nonenhancement by day 30, and patients had better pain response to MRgHIFU than those with extraosseous tumors. In this small cohort, post-treatment imaging was not informative of treatment efficacy.
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Affiliation(s)
- Sharon L Giles
- Cancer Research UK Cancer Imaging Centre, Magnetic Resonance Imaging Unit, The Royal Marsden Hospital, Sutton, Surrey SM2 5PT, United Kingdom.
| | - Matthew R D Brown
- Pain Medicine Department, The Royal Marsden Hospital, Sutton, Surrey SM2 5PT, United Kingdom; Targeted Approaches to Cancer Pain, The Institute of Cancer Research, London, United Kingdom
| | - Ian Rivens
- Therapeutic Ultrasound, The Institute of Cancer Research, London, United Kingdom
| | | | - Merel Huisman
- Image Sciences Institute/Imaging Division, University Medical Center Utrecht, The Netherlands
| | - Young-Sun Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Seoul, Korea; Department of Radiology, Mint Hospital, Seoul, Korea
| | - Paul Farquhar-Smith
- Pain Medicine Department, The Royal Marsden Hospital, Sutton, Surrey SM2 5PT, United Kingdom
| | - John E Williams
- Pain Medicine Department, The Royal Marsden Hospital, Sutton, Surrey SM2 5PT, United Kingdom
| | - Gail R Ter Haar
- Therapeutic Ultrasound, The Institute of Cancer Research, London, United Kingdom
| | - Nandita M deSouza
- Cancer Research UK Cancer Imaging Centre, Magnetic Resonance Imaging Unit, The Royal Marsden Hospital, Sutton, Surrey SM2 5PT, United Kingdom
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Selznick A, Chhina T, Sennik VB, Tam K, El Beheiry H. The effects of adding local infiltration analgesia of the knee to a multimodal pain protocol for total arthroplasty: A matched pair retrospective study. Can J Pain 2019; 3:98-105. [PMID: 35005398 PMCID: PMC8730671 DOI: 10.1080/24740527.2019.1603077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: We hypothesize that the addition of local infiltration analgesia (LIA) to a multimodal pain protocol will reduce the total amount of opioids consumed for acute pain control post total knee arthrolplasty (TKA). Methods: This study was a retrospective, matched pair study including patients who had primary TKA. All patients included in the analysis had preoperative oral celecoxib and acetaminophen, had single-dose spinal anesthetic with intrathecal morphine, and had intravenous patient-controlled analgesia with an opioid agent in addition to gabapentin and celecoxib in the first 48 h. Patients whose charts were excluded from the study had revision TKA, received opioid therapy prior to the surgery, were classified as American Society of Anesthesiology (ASA) IV, and had general anesthesia. Fifty patients who underwent TKA and had LIA were matched for age, body mass index (BMI), and gender with patients who did not receive LIA. The primary outcome measures were total doses of opioids consumed post TKA. Results: Patients receiving LIA consumed on average significantly less intravenous (IV) morphine equivalents than patients not receiving LIA, with a mean difference (±SD) of 88.9 ± 15.6 mg IV morphine equivalents. Furthermore, pain control was better in the LIA group. The incidences of nausea and vomiting, pruritis, and excessive sedation were higher in the non-LIA group compared to the LIA group. There was no difference in the hospital length of stay between both groups. Conclusions: The addition of LIA to our multimodal pain protocol for TKA was associated with a reduction in total opioid consumption.
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Affiliation(s)
- Asher Selznick
- Department of Anesthesia, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Tejinder Chhina
- Department of Anesthesia, Trillium Health Partners, Mississauga, Ontario, Canada.,Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Vir B Sennik
- Department of Orthopedic Surgery, Trillium Health Partners, Mississauga, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kenny Tam
- Department of Anesthesia, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Hossam El Beheiry
- Department of Anesthesia, Trillium Health Partners, Mississauga, Ontario, Canada.,Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
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Treillet E, Laurent S, Hadjiat Y. Practical management of opioid rotation and equianalgesia. J Pain Res 2018; 11:2587-2601. [PMID: 30464578 PMCID: PMC6211309 DOI: 10.2147/jpr.s170269] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose To review the recent literature on opioid rotation (ie, switching from one opioid drug to another or changing an opioid’s administration route) in cancer patients experiencing severe pain and to develop a novel equianalgesia table for use in routine clinical practice. Methods The MEDLINE database was searched with terms “cancer pain,” “opioid rotation,” “opioid switching,” “opioid ratio,” “opioid conversion ratio,” and “opioid equianalgesia” for the major opioids (morphine, oxycodone, fentanyl, and hydromorphone) and the intravenous, subcutaneous, oral, and transdermal administration routes. Selected articles were assessed for the calculated or cited opioid dose ratio, bidirectionality, and use of the oral morphine equivalent daily dose or a direct drug-to-drug ratio. Results Twenty publications met our selection criteria and were analyzed in detail. We did not find any large-scale, prospective, double-blind randomized controlled trial with robust design, and most of the studies assessed relatively small numbers of patients. Bidirectionality was investigated in seven studies only. Conclusion The updated equianalgesic table presented here incorporates the latest data and provides information on bidirectionality. Despite the daily use of equianalgesic tables, they are not based on high-level scientific evidence. More clinical research is needed on this topic.
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Affiliation(s)
- Erwan Treillet
- AP-HP, Médecine de la Douleur et Médecine Palliative, Hôpital Lariboisière, Paris, France,
| | - Sophie Laurent
- Institut de Cancérologie, Institut Gustave Roussy, Villejuif, France
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Foxwell AM, Uritsky TJ. Hydromorphone Conversion Dilemma: A Millennial Problem. J Pain Symptom Manage 2018; 56:e2-e3. [PMID: 29792977 DOI: 10.1016/j.jpainsymman.2018.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 05/15/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Anessa M Foxwell
- Department of Medicine, Palliative Care Program, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tanya J Uritsky
- Department of Medicine, Palliative Care Program, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Yvonne Heung
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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29
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Harding D, Giles SL, Brown MRD, Ter Haar GR, van den Bosch M, Bartels LW, Kim YS, Deppe M, deSouza NM. Evaluation of Quality of Life Outcomes Following Palliative Treatment of Bone Metastases with Magnetic Resonance-guided High Intensity Focused Ultrasound: An International Multicentre Study. Clin Oncol (R Coll Radiol) 2018; 30:233-242. [PMID: 29317145 PMCID: PMC5842401 DOI: 10.1016/j.clon.2017.12.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 11/26/2022]
Abstract
AIMS To determine quality of life (QoL) outcomes after palliation of pain from bone metastases using magnetic resonance-guided high intensity focused ultrasound (MR-guided HIFU), measured using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C15-PAL and the QLQ-BM22 questionnaires. MATERIALS AND METHODS Twenty patients undergoing MR-guided HIFU in an international multicentre trial self-completed the QLQ-C15-PAL and QLQ-BM22 questionnaires before and on days 7, 14, 30, 60 and 90 post-treatment. Descriptive statistics were used to represent changes in symptom and functional scales over time and to determine their clinical significance. QoL changes were compared in pain responders and non-responders (who were classified according to change in worst pain score and analgesic intake, between baseline and day 30). RESULTS Eighteen patients had analysable QoL data. Clinically significant improvements were seen in the QoL scales of physical functioning, fatigue, appetite loss, nausea and vomiting, constipation and pain in the 53% of patients who were classified as responders at day 30. No significant changes were seen in the 47% of patients who were non-responders at this time point. CONCLUSION Local treatment of pain from bone metastases with MR-guided HIFU, even in the presence of disseminated malignancy, has a substantial positive effect on physical functioning, and improves other symptomatic QoL measures. This indicated a greater response to treatment over and above pain control alone. MR-guided HIFU is non-invasive and should be considered for patients with localised metastatic bone pain and poor QoL.
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Affiliation(s)
- D Harding
- The CRUK Cancer Imaging Centre, The Institute of Cancer Research and Royal Marsden Hospital, MRI Unit, Sutton, Surrey, UK
| | - S L Giles
- The CRUK Cancer Imaging Centre, The Institute of Cancer Research and Royal Marsden Hospital, MRI Unit, Sutton, Surrey, UK.
| | - M R D Brown
- Pain Medicine Department, The Royal Marsden Hospital, Sutton, Surrey, UK
| | - G R Ter Haar
- The CRUK Cancer Imaging Centre, The Institute of Cancer Research and Royal Marsden Hospital, MRI Unit, Sutton, Surrey, UK
| | - M van den Bosch
- Image Sciences Institute/Imaging Division, University Medical Center Utrecht, The Netherlands
| | - L W Bartels
- Image Sciences Institute/Imaging Division, University Medical Center Utrecht, The Netherlands
| | - Y-S Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, South Korea; Department of Radiology, Mint Hospital, Seoul, South Korea
| | - M Deppe
- Philips MR Therapy, Äyritie 4, 01510 Vantaa, Finland
| | - N M deSouza
- The CRUK Cancer Imaging Centre, The Institute of Cancer Research and Royal Marsden Hospital, MRI Unit, Sutton, Surrey, UK
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