1
|
Sandbrink F, Schuster NM. Opioids and Cannabinoids in Neurology Practice. Continuum (Minneap Minn) 2024; 30:1447-1474. [PMID: 39445929 DOI: 10.1212/con.0000000000001487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2024]
Abstract
OBJECTIVE Opioid and cannabinoid therapies for chronic pain conditions including neuropathic pain are controversial. Understanding patient and prescribing factors contributing to risks and implementing risk mitigation strategies optimizes outcomes. LATEST DEVELOPMENTS The ongoing transformation from a biomedical model of pain care toward a biopsychosocial model has been accompanied by a shift away from opioid therapy for pain, in particular for chronic pain. Opioid overdose deaths and opioid use disorder have greatly increased in the last several decades, initially because of increases in opioid prescribing and more recently associated with illicit drug use, in particular fentanyl derivatives. Opioid risk mitigation strategies may reduce risks related to opioid prescribing and tapering or discontinuation. Opioid therapy guidelines from the Centers for Disease Control and Prevention have become the consensus best practice for opioid therapy. Regulatory agencies and licensing medical boards have implemented restrictions and other mandates regarding opioid therapy. Meanwhile, interest in and use of cannabinoids for chronic pain has grown in the United States. ESSENTIAL POINTS Opioid therapy is generally not recommended for the chronic treatment of neuropathic pain conditions. Opioids may be considered for temporary use in patients with severe pain related to selected neuropathic pain conditions (such as postherpetic neuralgia), and only as part of a multimodal treatment regimen. Opioid risk mitigation strategies include careful patient selection and evaluation, patient education and informed consent, querying the state prescription drug monitoring programs, urine drug testing, and issuance of naloxone as potential rescue medication. Close follow-up when initiating or adjusting opioid therapy and frequent reevaluation during long-term opioid therapy is required. There is evidence for the efficacy of cannabinoids for neuropathic pain, with meaningful response rates in select patient populations.
Collapse
|
2
|
Sandhu S, Calcaterra SL. How Do I Manage Acute Pain for Patients Prescribed Buprenorphine for Opioid Use Disorder? NEJM EVIDENCE 2024; 3:EVIDccon2300275. [PMID: 38815158 PMCID: PMC11282871 DOI: 10.1056/evidccon2300275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
AbstractA growing number of patients are prescribed buprenorphine for opioid use disorder (OUD). Consequently, clinicians are likely to encounter hospitalized patients with acute surgical or nonsurgical pain who are also prescribed buprenorphine for OUD. This scenario evokes the clinical question of how to adequately manage acute pain among hospitalized patients receiving buprenorphine for OUD. This article reviews buprenorphine's pharmacology, describes various buprenorphine products used to treat pain and OUD, and provides pain management recommendations for patients prescribed buprenorphine in the setting of acute surgical and nonsurgical pain.
Collapse
Affiliation(s)
- Sukhmeet Sandhu
- Department of Family Medicine, University of Colorado, Aurora
| | - Susan L Calcaterra
- Department of Medicine, Divisions of General Internal Medicine and Hospital Medicine, University of Colorado, Aurora
| |
Collapse
|
3
|
Arnouk S, Wunderlich JR, Sidelnik SA. Evaluation of Low-dose Buprenorphine Initiation With Buprenorphine Buccal Films in Hospitalized Patients: A Retrospective Cohort Study. J Addict Med 2024; 18:42-47. [PMID: 37847570 DOI: 10.1097/adm.0000000000001236] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Low-dose buprenorphine initiation (LDBI) strategies to transition patients from full opioid agonists to buprenorphine have previously been described using sublingual films, intravenous solution, transdermal patches, and, more recently, buccal films. The objective of this study was to describe the effectiveness of LDBI using novel titration schedules with buccal films. METHODS This is a retrospective cohort study of hospitalized patients with opioid use disorder (OUD) or physiologic dependence to opioids who underwent LDBI with buprenorphine buccal films at NYU Langone Health. Two LDBI protocols were evaluated, including a short titration schedule over 4 days and a long schedule over 7 days. The primary outcomes of interest included LDBI completion rates and incidence of opioid withdrawal. RESULTS Forty-two patients underwent 46 LDBIs at NYU Langone Health between October 2020 and April 2022. The cohort comprised patients with OUD (57%), chronic pain with OUD (33%), and chronic pain without OUD (10%). Indications for LDBI most commonly included co-occurring pain precluding discontinuation of full opioid agonists (72%), prior history of precipitated withdrawal (30%), and methadone use (23%). The overall completion rate of LDBI was 78%. Withdrawal was encountered in 33% of patients; however, only 2 patients required LDBI discontinuation as a result. On multivariate analysis, a diagnosis of OUD was independently associated with withdrawal during LDBI. CONCLUSIONS Buprenorphine buccal films can successfully be used off-label to facilitate LDBI in the hospital setting. We present 4- and 7-day titration protocols, which were well-tolerated, and provide practical considerations for use.
Collapse
Affiliation(s)
- Serena Arnouk
- From the Department of Pharmacy, NYU Langone Health, New York, NY (SA); Department of Psychiatry, University of Iowa Hospitals & Clinics, Iowa City, IA (JRW); Department of Psychiatry, NYU Langone Health, New York, NY (SAS)
| | | | | |
Collapse
|
4
|
Hodgson JA, Cyr KL, Sweitzer B. Patient selection in ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:357-372. [PMID: 37938082 DOI: 10.1016/j.bpa.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 01/07/2023]
Abstract
Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.
Collapse
Affiliation(s)
- John A Hodgson
- Walter Reed National Military Medical Center and Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD, 20889, United States.
| | - Kyle L Cyr
- Walter Reed National Military Medical Center and Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD, 20889, United States.
| | - BobbieJean Sweitzer
- Medical Education, University of Virginia, Systems Director, Preoperative Medicine, Inova Health, 3300 Gallows Road, Falls Church, VA, 22042, United States.
| |
Collapse
|
5
|
Jones KF, Broglio K, Ho JJ, Rosa WE. Compassionate Care for People with Cancer and Opioid Use Disorder. Am J Nurs 2023; 123:56-61. [PMID: 37498041 PMCID: PMC10619200 DOI: 10.1097/01.naj.0000947480.74410.06] [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] [Indexed: 07/28/2023]
Abstract
ABSTRACT Opioid use disorder (OUD) is an important comorbidity to assess and manage in people with cancer. In this article, the authors discuss strategies for safe opioid management in individuals with OUD and cancer-related pain using a composite case example. They highlight core approaches to pain management, including motivational interviewing, harm reduction, and evidence-based treatments, as well as advocacy for person-centered end-of-life care.
Collapse
Affiliation(s)
- Katie Fitzgerald Jones
- Katie Fitzgerald Jones is a palliative and addiction NP and researcher in the VA Boston Healthcare System. Kathleen Broglio is associate professor of medicine in the Geisel School of Medicine at Dartmouth, Hanover, NH. J. Janet Ho is a palliative and addiction medicine physician at the University of California, San Francisco. William E. Rosa is assistant attending behavioral scientist, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York City. Contact author: Katie Fitzgerald Jones, . The authors have disclosed no potential conflicts of interest, financial or otherwise
| | | | | | | |
Collapse
|
6
|
Hathaway DB, Bhat JA, Twark C, Rodriguez C, Suzuki J. Patients' experiences with continuation or discontinuation of buprenorphine before painful procedures: A brief report. Am J Addict 2023; 32:410-414. [PMID: 36850041 DOI: 10.1111/ajad.13396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with opioid use disorder may be asked by their clinicians to discontinue maintenance buprenorphine treatment before surgical operations due to concerns that buprenorphine will interfere with acute pain management. However, discontinuation of buprenorphine may not be well tolerated or safe for all patients. We, therefore, administered a survey to better understand the experiences of patients on buprenorphine treatment who had previously undergone painful procedures and had their buprenorphine maintenance treatment either continued or discontinued before the procedure. METHODS After this study received institutional review board approval, patients were invited to participate if they were being prescribed sublingual buprenorphine for treatment of opioid use disorder and had also previously undergone a painful procedure requiring treatment with full agonist opioids. Patients who were eligible and agreed to participate (n = 32) then completed a survey of basic demographics; medical, psychiatric, and substance use histories; and their experience and satisfaction with the treatment of pain and substance use in the perioperative period, including whether buprenorphine was continued or discontinued before their procedure. RESULTS Compared with patients whose home dose of buprenorphine was continued (n = 15), patients whose buprenorphine was discontinued preoperatively (n = 17) reported less satisfaction with pain management and were more likely to be prescribed full agonist opioids upon discharge. DISCUSSION AND CONCLUSIONS Consistent with prior studies, these survey findings suggest that discontinuation of buprenorphine before painful surgeries may be associated with poorer clinical outcomes. SCIENTIFIC SIGNIFICANCE This survey study adds patients' perspective to a growing body of scientific literature suggesting that discontinuation of maintenance buprenorphine treatment before painful procedures may decrease patient satisfaction and increase clinical risk.
Collapse
Affiliation(s)
- David B Hathaway
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Jasra-Ali Bhat
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Claire Twark
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Claudia Rodriguez
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Joji Suzuki
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Vu PD, Malik A, Cohen AS, Bansal V, Cowan MR, Blazek GM, Champagne-Langabeer T. Shared Decision Making in Acute Pain Management in Patients with Opioid Use Disorder: A Scoping Review. J Clin Med 2023; 12:jcm12103555. [PMID: 37240661 DOI: 10.3390/jcm12103555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/11/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
The treatment of acute pain over the years has changed with increasing alternative therapies and increased scrutiny of opioid prescriptions. Shared Decision Making (SDM) has become a vital tool in increasing patient engagement and satisfaction in treatment decisions. SDM has been successfully implemented in the management of pain in a variety of settings; however, information regarding the use of SDM for treating acute pain in patients with a history of opioid use disorder (OUD) remains scarce. Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR), we conducted a review to understand how SDM is used in acute pain management in patients with OUD. We searched Medline, Embase, CINAHL, and PsychInfo databases for relevant articles. Articles were screened and SDM outcomes of eligible articles were charted. The results were grouped by sub-theme based on a 1997 SDM model. There were three original research studies and one quality improvement study. The remaining articles were split evenly between reviews and reviews of clinical guidelines. Four themes emerged from the review: prior judgment and stigma related to OUD, trust and sharing of information, clinical tools, and interprofessional teams. This scoping review consolidated and expounded the current literature on SDM in the management of acute pain in patients with OUD. More work is needed to address prior judgments by both providers and patients and to build greater dialogue. Clinical tools may aid this process as well as the involvement of a multidisciplinary team.
Collapse
Affiliation(s)
- Peter D Vu
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, UTHealth Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Aila Malik
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, UTHealth Houston, 6431 Fannin, Houston, TX 77030, USA
| | - A Sarah Cohen
- Houston ER Opioid System (HEROES), School of Biomedical Informatics, UTHealth Houston, 7000 Fannin, Houston, TX 77030, USA
| | - Vishal Bansal
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, UTHealth Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Morgan R Cowan
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, UTHealth Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Gregory M Blazek
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, UTHealth Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Tiffany Champagne-Langabeer
- Houston ER Opioid System (HEROES), School of Biomedical Informatics, UTHealth Houston, 7000 Fannin, Houston, TX 77030, USA
- Tiffany Champagne-Langabeer, UTHealth Houston, 7000 Fannin St., Suite 600, Houston, TX 77030, USA
| |
Collapse
|
8
|
Neale KJ, Weimer MB, Davis MP, Jones KF, Kullgren JG, Kale SS, Childers J, Broglio K, Merlin JS, Peck S, Francis SY, Bango J, Jones CA, Sager Z, Ho JJ. Top Ten Tips Palliative Care Clinicians Should Know About Buprenorphine. J Palliat Med 2023; 26:120-130. [PMID: 36067137 DOI: 10.1089/jpm.2022.0399] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pain management in palliative care (PC) is becoming more complex as patients survive longer with life-limiting illnesses and population-wide trends involving opioid misuse become more common in serious illness. Buprenorphine, a generally safe partial mu-opioid receptor agonist, has been shown to be effective for both pain management and opioid use disorder. It is critical that PC clinicians become comfortable with indications for its use, strategies for initiation while understanding risks and benefits. This article, written by a team of PC and addiction-trained specialists, including physicians, nurse practitioners, social workers, and a pharmacist, offers 10 tips to demystify buprenorphine use in serious illness.
Collapse
Affiliation(s)
- Kyle J Neale
- The Lois U and Harry R Horvitz Palliative Medicine Program, Department of Palliative Medicine and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mellar P Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Justin G Kullgren
- Palliative Medicine Clinical Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sachin S Kale
- Division of Palliative Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathleen Broglio
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Collaboratory for Implementation Sciences at Dartmouth, Lebanon, New Hampshire, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sarah Peck
- Division of Palliative Medicine, Emory University Healthcare Midtown, Atlanta, Georgia, USA
| | - Sheria Y Francis
- Collaborative Care Management, University of Pittsburgh Medical Center Presbyterian Shadyside, Pittsburgh, Pennsylvania, USA
| | | | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zachary Sager
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J Janet Ho
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
9
|
Perioperative Management of Extended-release Buprenorphine. J Addict Med 2023; 17:e67-e71. [PMID: 35862898 DOI: 10.1097/adm.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Perioperative management of buprenorphine is increasingly characterized by continuation of buprenorphine throughout the perioperative period while coadministering full agonist opioids for analgesia. Although this "simultaneous strategy" is commonly used for the shorter-acting sublingual buprenorphine formulations, there is little to guide management of the extended-release formulations of buprenorphine. Here we report the perioperative experience of an individual maintained on extended-release buprenorphine who successfully underwent major surgeries utilizing a strategy of performing the surgeries at the time of the next scheduled dose.
Collapse
|
10
|
Quaye A, Silvia K, Richard J, Ibrahim Y, Craig WY, Rosen C. A prospective, randomized trial of the effect of buprenorphine continuation versus dose reduction on pain control and post-operative opioid use. Medicine (Baltimore) 2022; 101:e32309. [PMID: 36595741 PMCID: PMC9794322 DOI: 10.1097/md.0000000000032309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION An increasing number of individuals are taking buprenorphine for management of opioid use disorder (OUD). Pain control can be challenging when these patients develop acute pain requiring supplemental analgesia. Buprenorphine's pharmacokinetic profile can render supplemental opioid-based analgesia ineffective. There is limited guidance on the optimal management of buprenorphine when acute pain is anticipated. Although there is growing acceptance that the risk of OUD relapse with buprenorphine discontinuation overshadows the risks of increased opioid utilization and difficult pain control with buprenorphine continuation, perioperative courses comparing buprenorphine dose reduction and full dose buprenorphine continuation have yet to be investigated. Here, we describe the protocol for our randomized controlled, prospective trial investigating the effect of buprenorphine continuation compared to buprenorphine dose reduction on pain control, post-operative opioid use, and OUD symptom management in patients on buprenorphine scheduled for elective surgery. METHODS AND ANALYSIS This is a single institution, randomized trial that aims to enroll 80 adults using 12 mg buprenorphine or greater for treatment of OUD, scheduled for elective surgery. Participants will be randomly assigned to receive 8mg of buprenorphine on the day of surgery onwards until postsurgical pain subsides or to have their buprenorphine formulation continued at full dose perioperatively. Primary outcome will be a clinically significant difference in pain scores 24 hours following surgery. Secondary outcomes will be opioid consumption at 24, 48, and 72 hours postoperatively, opioid dispensing up to 30 days following surgery, changes in mood and withdrawal symptoms, opioid cravings, relapse of opioid misuse, and continued use of buprenorphine treatment postoperatively.
Collapse
Affiliation(s)
- Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
- Spectrum Healthcare Partners, South Portland, ME
- * Correspondence: Aurora Quaye, Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102 (e-mail: )
| | - Kristen Silvia
- Division of Addiction Medicine, Maine Medical Center, Portland, ME
| | - Janelle Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
| | - Yussr Ibrahim
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
| | | | | |
Collapse
|
11
|
Calcaterra SL, Martin M, Bottner R, Englander H, Weinstein Z, Weimer MB, Lambert E, Herzig SJ. Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine. J Hosp Med 2022; 17:744-756. [PMID: 35880813 PMCID: PMC9474708 DOI: 10.1002/jhm.12893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 01/14/2023]
Abstract
Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.
Collapse
Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Marlene Martin
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, TX, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine and Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Zoe Weinstein
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Eugene Lambert
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
| | - Shoshana J. Herzig
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
12
|
Burns SL, Majdak P, Urman RD. Perioperative and Periprocedural anesthetic management of opioid tolerant patients and patients with active and medically treated opioid use disorder. Curr Opin Anaesthesiol 2022; 35:514-520. [PMID: 35788122 PMCID: PMC9308736 DOI: 10.1097/aco.0000000000001157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The increasing prevalence of opioid tolerant individuals, in combination with the expanding scope and utilization of nonoperating room anesthesia (NORA) necessitates ongoing investigation into best clinical practice for managing surgical/procedural pain in this population. The purpose of this article is to review recent guidelines, identify specific challenges, and offer considerations for managing pain in patients who are opioid tolerant secondary to opioid use disorder (OUD), with or without medications for the treatment of OUD. RECENT FINDINGS A comprehensive preoperative evaluation in conjunction with a multidisciplinary, multimodal pain approach is optimal. NORA adds unique situational and environmental challenges for optimizing acute on chronic pain control in tolerant individuals while maintaining safety. Direct and partial/mixed mu-agonists should typically be continued throughout the perioperative period, while mu-antagonists (naltrexone) should be held 72 h. Postprocedural discharge instructions and follow-up must be carefully arranged and ensured. SUMMARY Clinical recommendations continue to evolve as new consensus guidelines are published, although institution-specific guidelines are most often followed. This review focuses on most recent best practices, within NORA and operating room settings, for managing opioid tolerant patients, patients with OUD and those on medications for the treatment of OUD.
Collapse
Affiliation(s)
- Stacey L. Burns
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Petra Majdak
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|