1
|
Foglia R, Yan J, Dizdarevic A. Methadone and Buprenorphine in the Perioperative Setting: A Review of the Literature. Curr Pain Headache Rep 2024:10.1007/s11916-024-01286-8. [PMID: 38907792 DOI: 10.1007/s11916-024-01286-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 06/24/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the most recent literature and guidelines regarding perioperative methadone and buprenorphine use. RECENT FINDINGS Surgical patients taking methadone and buprenorphine are being encountered more frequently in the perioperative period, and providers are becoming more familiar with their pharmacologic properties, benefits as well as precautions. Recommendations pertaining to buprenorphine therapy in the perioperative settings have changed in recent years, owing to more clinical and basic science research. In addition to their use in chronic pain and opioid use disorders, they can also be initiated for acute postoperative pain indications, in select patients and situations. Methadone and buprenorphine are being more commonly prescribed for pain management and opioid use disorder, and their continuation during the perioperative period is generally recommended, to reduce the risk of opioid withdrawal, relapse, or inadequately controlled pain. Additionally, both may be initiated safely and effectively for acute pain management during and after the operating room period.
Collapse
Affiliation(s)
- Ralph Foglia
- Columbia University Medical Center, New York, NY, USA
| | - Jasper Yan
- Columbia University Medical Center, New York, NY, USA
| | | |
Collapse
|
2
|
Pfander V. Substance Use Disorder and the Surgical Patient. J Perianesth Nurs 2023; 38:371-372. [PMID: 36965925 DOI: 10.1016/j.jopan.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/06/2023] [Indexed: 03/27/2023]
Affiliation(s)
- Valerie Pfander
- Munson Medical Center, Surgical Services Clinical Nurse Specialist, Traverse City, MI.
| |
Collapse
|
3
|
Opioid Use Disorder is Associated With Complications and Increased Length of Stay After Major Abdominal Surgery. Ann Surg 2021; 274:992-1000. [PMID: 31800489 DOI: 10.1097/sla.0000000000003697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine the impact of opioid use disorder (OUD) on perioperative outcomes after major upper abdominal surgeries. SUMMARY OF BACKGROUND DATA OUD, defined as dependence/abuse, is a national health epidemic. Its impact on outcomes after major abdominal surgery has not been well characterized. METHODS Patients who underwent elective esophagectomy, total/partial gastrectomy, major hepatectomy, and pancreatectomy were identified using the National Inpatient Sample (2003-2015). Propensity score matching by baseline characteristics was performed for patients with and without OUD. Outcomes measured were in-hospital complications, mortality, length of stay (LOS), and discharge disposition. RESULTS Of 376,467 patients, 1096 (0.3%) had OUD. Patients with OUD were younger (mean 53 vs 61 years, P < 0.001) and more often male (55.1% vs 53.2%, P < 0.001), black (15.0% vs 7.6%, P < 0.001), Medicaid beneficiaries (22.0% vs 6.4%, P < 0.001), and in the lowest income quartile (32.6% vs 21.3%, P < 0.001). They also had a higher rate of alcohol (17.2% vs 2.8%, P < 0.001) and nonopioid drug (2.2% vs 0.2%, P = 0.023) dependence/abuse. After matching (N = 1077 OUD, N = 2164 no OUD), OUD was associated with a higher complication rate (52.9% vs 37.3%, P < 0.001), including increased pain [odds ratio (OR) 3.5, P < 0.001], delirium (OR 3.0, P = 0.004), and pulmonary complications (OR 2.0, P = 0.006). Additionally, OUD was associated with increased LOS (mean 12.4 vs 10.6 days, P = 0.015) and nonroutine discharge (OR 1.6, P < 0.001). In-hospital mortality did not differ (OR 2.4, P = 0.10). CONCLUSION Patients with OUD more frequently experienced complications and increased LOS. Close postoperative monitoring may mitigate adverse outcomes.
Collapse
|
4
|
De Aquino JP, Parida S, Avila-Quintero VJ, Flores J, Compton P, Hickey T, Gómez O, Sofuoglu M. Opioid-induced analgesia among persons with opioid use disorder receiving methadone or buprenorphine: A systematic review of experimental pain studies. Drug Alcohol Depend 2021; 228:109097. [PMID: 34601272 PMCID: PMC8595687 DOI: 10.1016/j.drugalcdep.2021.109097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Treating acute pain among persons with opioid use disorder (OUD) on opioid agonist therapy (OAT) is complex, and the therapeutic benefits of opioids remain unclear when weighted against their abuse potential and respiratory depressant effects. METHODS We conducted a systematic review of experimental pain studies examining opioid-induced analgesia among persons with OUD on OAT. We searched multiple databases from inception to July 30, 2021. Study quality was assessed by previously established validity measures. RESULTS Nine studies were identified, with a total of 225 participants, of whom 63% were male, and 37% were female. Six studies included methadone-maintained persons with OUD; four studies included buprenorphine-maintained persons with OUD; and three studies included healthy persons as comparison groups. Either additional doses of OAT or other opioids - morphine, oxycodone, hydromorphone, or remifentanil - were administered. In seven studies, persons with OUD on OAT did not experience analgesia, despite receiving opioid doses up to 20 times greater than those clinically used to treat severe pain among the opioid naïve. Conversely, in two studies, high-potency opioids did produce analgesia, albeit with greater abuse potential. Notably, persons with OUD on OAT remained vulnerable to respiratory depression. CONCLUSIONS Although persons with OUD on OAT can derive analgesic effects from opioids, high-potency compounds may be required to achieve clinically significant pain relief. Further, persons with OUD on OAT may remain vulnerable to opioid-induced abuse potential and respiratory depression. Together, these finding have clinical, methodological, and mechanistic implications for the treatment of acute pain in the context of OAT.
Collapse
Affiliation(s)
- Joao P De Aquino
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA.
| | - Suprit Parida
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Victor J Avila-Quintero
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Jose Flores
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Peggy Compton
- Department of Family and Community Health, University of Pennsylvania, 418 Curie Boulevard, Room 402, Philadelphia, PA 19104, USA
| | - Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Anesthesiology, 333 Cedar Street, New Haven, CT 06520, USA
| | - Oscar Gómez
- Department of Physiological Sciences, Faculty of Medicine, Pontificia Universidad Javeriana, 7th Street, 46-62, Bogota, Colombia
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| |
Collapse
|
5
|
Management of Sedation and Analgesia in Critically Ill Patients Receiving Long-Acting Naltrexone Therapy for Opioid Use Disorder. Ann Am Thorac Soc 2021; 17:1352-1357. [PMID: 32866026 DOI: 10.1513/annalsats.202005-554cme] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The explosion of the opioid epidemic in the United States and across the world has been met with advances in pharmacologic therapy for the treatment of opioid use disorder. Long-acting naltrexone is a promising strategy, but its use has important implications for critical care, as it may interfere with or complicate sedation and analgesia. Currently, there are two available formulations of long-acting naltrexone, which are distinguished by different administration routes and distinct pharmacokinetics. The use of long-acting naltrexone may be identified through a variety of strategies (such as physical examination, laboratory testing, and medical record review), and is key to the safe provision of sedation and analgesia during critical illness. Perioperative experience caring for patients receiving long-acting naltrexone informs management in the intensive care unit. Important lessons include the use of multimodal analgesia strategies and anticipating patients' demonstrating variable sensitivity to opioids. For the critically ill patient, however, there are important distinctions to emphasize, including changes in drug metabolism and medication interactions. By compiling and incorporating the currently available literature, we provide critical care physicians with recommendations for the sedation and analgesia for critically ill patients receiving long-acting naltrexone therapy.
Collapse
|
6
|
Kohan L, Potru S, Barreveld A, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay S, Viscusi E. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med 2021; 46:840-859. [PMID: 34385292 DOI: 10.1136/rapm-2021-103007] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The past two decades have witnessed an epidemic of opioid use disorder (OUD) in the USA, resulting in catastrophic loss of life secondary to opioid overdoses. Medication treatment of opioid use disorder (MOUD) is effective, yet barriers to care continue to result in a large proportion of untreated individuals. Optimal analgesia can be obtained in patients with MOUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected OUD at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives. METHODS The Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, American Academy of Pain Medicine, American Society of Addiction Medicine and American Society of Health System Pharmacists approved the creation of a Multisociety Working Group on Opioid Use Disorder, representing the fields of pain medicine, addiction, and pharmacy health sciences. An extensive literature search was performed by members of the working group. Multiple study types were included and reviewed for quality. A modified Delphi process was used to assess the literature and expert opinion for each topic, with 100% consensus being achieved on the statements and each recommendation. The consensus statements were then graded by the committee members using the United States Preventive Services Task Force grading of evidence guidelines. In addition to the consensus recommendations, a narrative overview of buprenorphine, including pharmacology and legal statutes, was performed. RESULTS Two core topics were identified for the development of recommendations with >75% consensus as the goal for consensus; however, the working group achieved 100% consensus on both topics. Specific topics included (1) providing recommendations to aid physicians in the management of patients receiving buprenorphine for MOUD in the perioperative setting and (2) providing recommendations to aid physicians in the initiation of buprenorphine in patients with suspected OUD in the perioperative setting. CONCLUSIONS To decrease the risk of OUD recurrence, buprenorphine should not be routinely discontinued in the perioperative setting. Buprenorphine can be initiated in untreated patients with OUD and acute pain in the perioperative setting to decrease the risk of opioid recurrence and death from overdose.
Collapse
Affiliation(s)
- Lynn Kohan
- Division of Pain Medicine/Department of Anesthesia, University of Virginia, Charlottesville, Virginia, USA
| | - Sudheer Potru
- Atlanta VA Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Antje Barreveld
- Tufts University School of Medicine-and Newton Wesley Hospital, Boston and Newton, Massachusetts, USA
| | - Michael Sprintz
- Division of Geriatrics and Palliative Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Olabisi Lane
- Division of Pain Medicine, Department of Anestheisology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anuj Aryal
- Cedar Recovery and Deparment of Anesthesiolgy and Pain Medicine, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Trent Emerick
- Department of Anesthesiolgoy and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anna Dopp
- American Society Health System Pharmacists, Bethesda, Maryland, USA
| | - Sophia Chhay
- American Society Health System Pharmacists, Bethesda, Maryland, USA
| | - Eugene Viscusi
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| |
Collapse
|
7
|
Sedney CL, Khodaverdi M, Pollini R, Dekeseredy P, Wood N, Haggerty T. Assessing the impact of a restrictive opioid prescribing law in West Virginia. Subst Abuse Treat Prev Policy 2021; 16:14. [PMID: 33526045 PMCID: PMC7852151 DOI: 10.1186/s13011-021-00349-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 12/13/2022] Open
Abstract
Background The Opioid Reduction Act (SB 273) took effect in West Virginia in June 2018. This legislation limited ongoing chronic opioid prescriptions to 30 days’ supply, and first-time opioid prescriptions to 7 days’ supply for surgeons and 3 days’ for emergency rooms and dentists. The purpose of this study was to determine the effect of this legislation on reducing opioid prescriptions in West Virginia, with the goal of informing future similar policy efforts. Methods Data were requested from the state Prescription Drug Monitoring Program (PDMP) including overall number of opioid prescriptions, number of first-time opioid prescriptions, average daily morphine milligram equivalents (MME) and prescription duration (expressed as “days’ supply”) given to adults during the 64 week time periods before and after legislation enactment. Statistical analysis was done utilizing an autoregressive integrated moving average (ARIMA) interrupted time series analysis to assess impact of both legislation announcement and enactment while controlling secular trends and considering autocorrelation trends. Benzodiazepine prescriptions were utilized as a control. Results Our analysis demonstrates a significant decrease in overall state opioid prescribing as well as a small change in average daily MME associated with the date of the legislation’s enactment when considering serial correlation in the time series and accounting for pre-intervention trends. There was no such association found with benzodiazepine prescriptions. Conclusion Results of the current study suggest that SB 273 was associated with an average 22.1% decrease of overall opioid prescriptions and a small change in average daily MME relative to the date of legislative implementation in West Virginia. There was, however, no association of the legislation on first-time opioid prescriptions or days’ supply of opioid medication, and all variables were trending downward prior to implementation of SB 273. The control demonstrated no relationship to the law. Supplementary Information The online version contains supplementary material available at 10.1186/s13011-021-00349-y.
Collapse
Affiliation(s)
- Cara L Sedney
- School of Medicine, West Virginia University, Morgantown, WV, 26505, USA.
| | - Maryam Khodaverdi
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA
| | - Robin Pollini
- Department of Behavioral Medicine & Psychiatry, West Virginia University, Morgantown, WV, USA.,Department of Epidemiology, West Virginia University, Morgantown, WV, USA
| | | | - Nathan Wood
- West Virginia Board of Pharmacy, Charleston, WV, USA
| | - Treah Haggerty
- School of Medicine, West Virginia University, Morgantown, WV, 26505, USA
| |
Collapse
|
8
|
Chen Y, Ou M, Hao X, Liang P, Liang Y, Wang Y, Li Y, Zhou C. Sub-chronic exposure to morphine alters general anesthetic potency by differentially regulating the expression of neurotransmitter receptor subunits in mice. Brain Res Bull 2021; 169:136-144. [PMID: 33484757 DOI: 10.1016/j.brainresbull.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sub-chronic exposure to morphine can increase the potency of propofol but decrease the potency of ketamine by unknown mechanisms. The present study was designed to investigate the effects of sub-chronic exposure to morphine on the expression of neurotransmitter receptor subunits, which might contribute to the potency changes of ketamine and propofol in vivo. METHODS Sub-chronic exposure to morphine was established by administering subcutaneous injections of morphine for 5 consecutive days. The median effective dose (ED50) of ketamine and/or propofol was measured on day 1, day 3, day 7 and day 15, after the last morphine dosage. Mice in the sham group received an equal volume of normal saline. The expressions of N-methyl D-aspartate (NMDA) receptor and γ-aminobutyric acid A (GABAA) receptor subunits in the forebrain were measured. Knockdown or overexpression of a subunit was used to determine the causality between the change in anesthetic potency and the expression of an identified receptor subunit. RESULTS After sub-chronic exposure of mice to morphine, the expression of NMDA receptor 1 (NR1) was most elevated in the forebrain on day 1 (P < 0.0001 vs. sham). In contrast, the expression of GABAA receptor β3 (GABAARβ3) gradually decreased to its lowest level on day 7 (P = 0.005 vs. sham) in the forebrain. Regression analysis revealed that the expression of NR1 in the forebrain was relevant to the increased ED50 of ketamine (P = 0.0002), while the expression of GABAARβ3 in the forebrain was relevant to the decreased ED50 of propofol (P = 0.0051) after morphine exposure. Knockdown expression of NR1 in the forebrain reversed the elevated ED50 of ketamine after morphine treatment. Overexpression of GABAARβ3 in the forebrain increased the ED50 of propofol to the sham-level after morphine treatment. CONCLUSIONS Sub-chronic exposure to morphine can differentially modulate the expressions of NR1 and GABAARβ3 in mice, which may contribute to the changes in ED50 of ketamine and propofol in vivo.
Collapse
Affiliation(s)
- Yali Chen
- Departments of Anesthesiology, West China Hospital of Sichuan University, Chengdu, 610041, China; Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Mengchan Ou
- Departments of Anesthesiology, West China Hospital of Sichuan University, Chengdu, 610041, China; Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, Chengdu, 610041, China; The Research Units of West China-Chinese Academy of Medical Sciences (2018RU012), West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xuechao Hao
- Departments of Anesthesiology, West China Hospital of Sichuan University, Chengdu, 610041, China; Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Peng Liang
- Departments of Anesthesiology, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yan Liang
- Research Core Facility, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yangyang Wang
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yu Li
- Departments of Anesthesiology, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Cheng Zhou
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, Chengdu, 610041, China.
| |
Collapse
|
9
|
Krajina Kmoniček I, Kvolik S, Pinotić K, Ištvanić T, Mraovic B, Marjanovic K. Epidural analgesia for acute ischemic pain after intra-arterial zolpidem injection in opioid-addicted patient-A case report. Clin Case Rep 2020; 8:3445-3449. [PMID: 33363949 PMCID: PMC7752646 DOI: 10.1002/ccr3.3445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/13/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023] Open
Abstract
A patient taking opioid maintenance therapy unintentionally injected dissolved zolpidem pills into the femoral artery and suffered acute limb ischemia. High amounts of opioids with supplemental therapies were inefficient for intractable ischemic pain, suggesting the presence of opioid-induced hyperalgesia (OIH). Epidural analgesia efficiently relieved pain and symptoms of OIH.
Collapse
Affiliation(s)
| | - Slavica Kvolik
- Department of AnesthesiologyOsijek University HospitalOsijekCroatia
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
| | - Kresimir Pinotić
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of SurgeryOsijek University HospitalOsijekCroatia
| | - Tomislav Ištvanić
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of SurgeryOsijek University HospitalOsijekCroatia
| | - Boris Mraovic
- Department of Anesthesiology & Perioperative MedicineSchool of MedicineUniversity of MissouriColumbiaMOUSA
| | - Ksenija Marjanovic
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of PathologyOsijek University HospitalOsijekCroatia
| |
Collapse
|
10
|
Mendonça FT, Pellizzaro D, Grossi BJ, Calvano LA, de Carvalho LS, Sposito AC. Synergistic effect of the association between lidocaine and magnesium sulfate on peri-operative pain after mastectomy. Eur J Anaesthesiol 2020; 37:224-234. [DOI: 10.1097/eja.0000000000001153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
11
|
Compton P. Acute Pain Management for Patients Receiving Medication-Assisted Therapy. AACN Adv Crit Care 2019; 30:335-342. [DOI: 10.4037/aacnacc2019328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Evidence-based approaches for the treatment of opioid use disorder include the use of opioid medications (methadone, buprenorphine, or naltrexone), collectively referred to as medication-assisted therapy. Patients receiving medication-assisted therapy may present in the acute care setting with pain, often related to planned surgical procedures to treat health issues that were not addressed before entering treatment. Because these medications act on the same receptors as do analgesic opioids—and, in the cases of methadone and buprenorphine, have analgesic properties — managing acute pain in these patients can be challenging. Principles of effective pain management for these patients include continuing the usual medication-assisted therapy dose; using nonpharmacological and nonopioid pain management strategies as possible and immediate-release opioids, titrating to effect and monitoring for toxicity; anticipating tolerance and hyperalgesia; and establishing a collaborative treatment relationship with the medication-assisted therapy provider. Providing effective pain treatment supports ongoing recovery in patients with opioid use disorder.
Collapse
Affiliation(s)
- Peggy Compton
- Peggy Compton is Associate Professor, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Room 402, Philadelphia, PA 19104
| |
Collapse
|
12
|
Chen X, Ren X, Ma Y, Ge L, Hu Z, Yan W. [Research progress of the role of postoperative pain in the development of postoperative cognitive dysfunction in geriatric patients]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:1122-1126. [PMID: 31640954 DOI: 10.12122/j.issn.1673-4254.2019.09.20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Previous studies have shown that postoperative cognitive dysfunction (POCD) is related to multiple factors including age, postoperative trauma, inflammation, postoperative pain, and anesthesia, among which postoperative pain is thought to play an important role in the development of POCD. This review summarizes the recent findings in the study of the role of postoperative pain in the pathogenesis of POCD in light of nerve injuries, neural remodeling and stress, and the progress in the prevention and treatment of POCD in elderly patients. It is of vital important to assess the postoperative pain and formulate adequate analgesic regimens for effective prevention and management of POCD to protect the brain functions of elderly patients.
Collapse
Affiliation(s)
- Xiaohui Chen
- Department of Anesthesiology, Gansu Provincial People's Hospital, Lanzhou 730000, China
| | - Xiaoqiang Ren
- Department of Orthopedics, Zhangye People's Hospital Affiliated to Hexi University, Zhangye 734000, China
| | - Yabing Ma
- Department of Anesthesiology, Gansu Provincial People's Hospital, Lanzhou 730000, China
| | - Li Ge
- Department of Anesthesiology, Gansu Provincial People's Hospital, Lanzhou 730000, China
| | - Zhongyuan Hu
- Department of Anesthesiology, Gansu Provincial People's Hospital, Lanzhou 730000, China
| | - Wenjun Yan
- Department of Anesthesiology, Gansu Provincial People's Hospital, Lanzhou 730000, China
| |
Collapse
|
13
|
Sayal P, Bateman BT, Menendez M, Eikermann M, Ladha KS. Opioid Use Disorders and the Risk of Postoperative Pulmonary Complications. Anesth Analg 2019; 127:767-774. [PMID: 29570152 DOI: 10.1213/ane.0000000000003307] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND As the rate of opioid use disorders continues to rise, perioperative physicians are increasingly faced with the challenge of providing analgesia to these patients after surgery. Due to the likelihood of opioid dose escalation in the perioperative period, we hypothesized that opioid-dependent patients would be at increased risk for postoperative pulmonary complications. METHODS A retrospective cross-sectional analysis of patients undergoing 6 representative elective surgical procedures was performed using the Nationwide Inpatient Sample from 2002 to 2011. The primary outcome was a composite including prolonged mechanical ventilation, reintubation, and acute respiratory failure. Secondary outcomes were length of stay, in-hospital mortality, and total hospital costs. Both multivariable logistic regression and propensity score matching were used to determine the impact of opioid use disorder on outcomes. RESULTS The total sample-weighted cohort consisted of 7,533,050 patients. Patients with opioid use disorders were more likely to suffer pulmonary complications, with a frequency of 4.2% compared to 1.6% in the nonopioid-dependent group (P < .001), and had a 1.62 times higher odds (95% confidence interval [CI], 1.16-2.27) in multivariable regression analysis. In a secondary subgroup analysis, only patients undergoing a colectomy had a greater odds of suffering pulmonary complications (odds ratio, 2.64; 95% CI, 1.42-4.91; P = .0021). Additionally, patients with an opioid use disorder had a longer length of stay (0.84 days [95% CI, 0.52-1.16; P < .001]) and greater costs ($1816 [95% CI, 935-2698; P < .001]). CONCLUSIONS This study demonstrates that patients with opioid use disorders are at increased risk for postoperative pulmonary complications, and have prolonged length of stay and resource utilization. Further research is needed regarding interventions to reduce the risk of complications in this subset of patients.
Collapse
Affiliation(s)
- Puneet Sayal
- From the Division of Research, International Spine, Pain & Performance Center, Washington, DC
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mariano Menendez
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Karim S Ladha
- Department of Anesthesia and Pain Medicine, Toronto General Hospital and University of Toronto, Toronto, Canada
| |
Collapse
|
14
|
Abstract
Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.
Collapse
Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Patricia Lavand'homme
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| |
Collapse
|
15
|
Building a Bridge Between Primary and Perioperative Care: Addressing the Challenges of Perioperative Buprenorphine Maintenance and Postdischarge Therapy. Ochsner J 2018; 18:305-307. [PMID: 30559613 DOI: 10.31486/toj.18.0146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|
16
|
Davis MP, Pasternak G, Behm B. Treating Chronic Pain: An Overview of Clinical Studies Centered on the Buprenorphine Option. Drugs 2018; 78:1211-1228. [PMID: 30051169 PMCID: PMC6822392 DOI: 10.1007/s40265-018-0953-z] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The buprenorphine receptor binding profile is unique in that it binds to all three major opioid receptors (mu, kappa, delta), and also binds to the orphan-like receptor, the receptor for orphanin FQ/nociceptin, with lower affinity. Within the mu receptor group, buprenorphine analgesia in rodents is dependent on the recently discovered arylepoxamide receptor target in brain, which involves a truncated 6-transmembrane mu receptor gene protein, distinguishing itself from morphine and most other mu opioids. Although originally designed as an analgesic, buprenorphine has mainly been used for opioid maintenance therapy and only now is increasingly recognized as an effective analgesic with an improved therapeutic index relative to certain potent opioids. Albeit a second-, third-, or fourth-line analgesic, buprenorphine is a reasonable choice in certain clinical situations. Transdermal patches and buccal film formulations are now commercially available as analgesics. This review discusses buprenorphine pharmacodynamics and pharmacokinetics, use in certain populations, and provides a synopsis of systematic reviews and randomized analgesic trials. We briefly discuss postoperative management in patients receiving buprenorphine maintenance therapy, opioid equivalence to buprenorphine, rotations to buprenorphine from other opioids, and clinical relevance of buprenorphine-related QTc interval changes.
Collapse
Affiliation(s)
- Mellar P Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, PA, USA.
| | - Gavril Pasternak
- Anne Burnett Tandy Chair in Neurology, Laboratory Head, Molecular Pharmacology and Chemistry Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bertrand Behm
- Department of Palliative Care, Geisinger Medical Center, Danville, PA, USA
| |
Collapse
|
17
|
Abstract
Opioid-related overdose deaths have reached epidemic levels within the last decade. The efforts to prevent, identify, and treat opioid use disorders (OUDs) mostly focus on the outpatient setting. Despite their frequent overrepresentation, less is known about the inpatient management of patients with OUDs. Specifically, the perioperative phase is a very vulnerable time for patients with OUDs, and little has been studied on the optimal management of acute pain in these patients. The preoperative evaluation should aim to identify those with OUDs and assess factors that may interfere with OUD treatment and pain management. Efforts should be made to provide education and assistance to patients and their support systems. For those who are actively struggling with opioid use, the perioperative phase can be an opportunity for engagement and to initiate treatment. Buprenorphine, methadone, and naltrexone medication treatment for OUD and opioid tolerance complicate perioperative pain management. A multidisciplinary team approach is crucial to provide clinically balanced pain relief without jeopardizing the patient's recovery. This article reviews the existing literature on the perioperative management of patients with OUDs and provides clinical suggestions for the optimal care of this patient population.
Collapse
Affiliation(s)
- Emine Nalan Ward
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Aurora Naa-Afoley Quaye
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Timothy E. Wilens
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
18
|
Wiznia DH, Zaki T, Leslie MP, Halaszynski TM. Complexities of Perioperative Pain Management in Orthopedic Trauma. Curr Pain Headache Rep 2018; 22:58. [PMID: 29987515 DOI: 10.1007/s11916-018-0713-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period. RECENT FINDINGS Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling. The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an "underground" prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.
Collapse
Affiliation(s)
- Daniel H Wiznia
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Theodore Zaki
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Michael P Leslie
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Thomas M Halaszynski
- Yale Anesthesiology, Yale-New Haven Hospital, 20 York Street, New Haven, CT, 06510, USA. .,Department of Adult and Perioperative Anesthesiology, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA.
| |
Collapse
|
19
|
Coluzzi F, Bifulco F, Cuomo A, Dauri M, Leonardi C, Melotti RM, Natoli S, Romualdi P, Savoia G, Corcione A. The challenge of perioperative pain management in opioid-tolerant patients. Ther Clin Risk Manag 2017; 13:1163-1173. [PMID: 28919771 PMCID: PMC5592950 DOI: 10.2147/tcrm.s141332] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The increasing number of opioid users among chronic pain patients, and opioid abusers among the general population, makes perioperative pain management challenging for health care professionals. Anesthesiologists, surgeons, and nurses should be familiar with some pharmacological phenomena which are typical of opioid users and abusers, such as tolerance, physical dependence, hyperalgesia, and addiction. Inadequate pain management is very common in these patients, due to common prejudices and fears. The target of preoperative evaluation is to identify comorbidities and risk factors and recognize signs and symptoms of opioid abuse and opioid withdrawal. Clinicians are encouraged to plan perioperative pain medications and to refer these patients to psychiatrists and addiction specialists for their evaluation. The aim of this review was to give practical suggestions for perioperative management of surgical opioid-tolerant patients, together with schemes of opioid conversion for chronic pain patients assuming oral or transdermal opioids, and patients under maintenance programs with methadone, buprenorphine, or naltrexone.
Collapse
Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesia, Intensive Care and Pain Medicine, Sapienza University of Rome, Polo Pontino, Latina
| | - Francesca Bifulco
- National Cancer Institute "G Pascale" Foundation, Unit of Anaesthesia, Intensive Care and Pain Medicine, Naples
| | - Arturo Cuomo
- National Cancer Institute "G Pascale" Foundation, Unit of Anaesthesia, Intensive Care and Pain Medicine, Naples
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, Tor Vergata University of Rome
| | - Claudio Leonardi
- Addiction Disease Department, Local Health Unit (ASL) Rome 2, Rome
| | | | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, Tor Vergata University of Rome
| | - Patrizia Romualdi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum University of Bologna, Bologna
| | - Gennaro Savoia
- Department Anesthesia, Fatebenefratelli Hospital, Naples
| | - Antonio Corcione
- Unit of Anaesthesia and Intensive Care, Dei Colli Hospital, V. Monaldi, Naples, Italy
| |
Collapse
|
20
|
Broglio K, Cooney MF. Medication-Assisted Treatment in the Perianesthesia Setting. J Perianesth Nurs 2017; 32:260-263. [DOI: 10.1016/j.jopan.2017.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 04/02/2017] [Indexed: 11/17/2022]
|
21
|
Fredrickson M. Promoting the use of peripheral nerve catheters: better catheter accuracy or more user-friendliness? Anaesthesia 2017; 72:939-943. [DOI: 10.1111/anae.13886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- M. Fredrickson
- Department of Anaesthesiology; University of Auckland; Auckland New Zealand
| |
Collapse
|
22
|
Prevention of chronic post-surgical pain: the importance of early identification of risk factors. J Anesth 2017; 31:424-431. [PMID: 28349202 DOI: 10.1007/s00540-017-2339-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/17/2017] [Indexed: 01/30/2023]
Abstract
Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored.
Collapse
|
23
|
Management of Postoperative Pain in Opioid-Tolerant Patients. J Perianesth Nurs 2017; 30:436-43. [PMID: 26408520 DOI: 10.1016/j.jopan.2015.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/14/2015] [Indexed: 11/24/2022]
|
24
|
Ghaffaripour S, Mahmoudi H, Eghbal H, Rahimi A. The Effect of Intravenous Magnesium Sulfate on Post-Operative Analgesia During Laminectomy. Cureus 2016; 8:e626. [PMID: 27433405 PMCID: PMC4934929 DOI: 10.7759/cureus.626] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives: Post-operative pain control is an important concern for both patients and physicians. Magnesium is being used as an adjuvant for anesthesia and analgesia during and after various surgeries. We aimed to investigate the effects of intravenous magnesium sulfate on post-operative analgesia after laminectomy. Methods Materials: In this randomized double-blind controlled clinical trial, we enrolled 40 adult patients aged 18-60 with American Society of Anesthesiologists (ASA) Class I-II who were candidates for elective laminectomy. The patients were randomly assigned in two control groups and were similarly anesthetized. In the case group, after the induction of anesthesia, a loading dose of magnesium sulfate (30 mg/kg) was administered within five to 10 minutes followed by a maintenance dose of 10 mg/kg/hr up to the end of the surgery; while, the patients in the control group received the same volume of saline. After the surgery, all patients received a patient-controlled intravenous analgesia (PCA) pump containing morphine. The first time of using PCA, the amount of consumed morphine during the first 24 hours, and pain score were recorded at 6,12,18 and 24 hours in the post-operative period. Results: There was no significant difference between the two groups with respect to the amount of morphine consumed in 24 hours after the surgery (P value =0.23), the first time of using of PCA pump (P value =0.79) and pain intensity (P value=0.52). Conclusion: The infusion of Magnesium Sulfate during laminectomy had no effect on patients’ pain and opioid requirement during the first 24 hours after the surgery.
Collapse
Affiliation(s)
- Sina Ghaffaripour
- Shiraz Anesthesiology and Critical Care research center, Department of anesthesiology, Shiraz University of Medical Sciences
| | | | - Hossein Eghbal
- Shiraz Anesthesiology and Critical Care research center, Department of anesthesiology, Shiraz University of Medical Sciences
| | - Ashkan Rahimi
- Shiraz Anesthesiology and Critical Care research center, Department of anesthesiology, Shiraz University of Medical Sciences
| |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW The management of acute pain in the opioid-tolerant patient is an area in perioperative medicine that is growing, as the use of opioids for chronic noncancer pain has been tolerated in the USA. Adding to this population is an increase in opioid abusers, addicts and those in recovery and maintenance programmes. These patients will continue to present for surgery and with acute pain that anaesthesiologists and other members of the healthcare team must become more adept at managing. RECENT FINDINGS This review covers some of the strategies that may be used by practitioners in the management of acute pain in the opioid-tolerant patient. It is important to collect a detailed history of opioid and drugs of abuse, including the timing of the last dose in order to avoid precipitation of withdrawal. The use of multimodal anaesthetic and analgesic strategies is important for both patient safety and satisfaction and can enhance recovery and discharge home. SUMMARY There is a need for more high-level evidence-based guidelines to help practitioners achieve the best care of this growing high-risk population of patients.
Collapse
|
26
|
De Andres J, Fabregat-Cid G, Asensio-Samper JM, Sanchis-Lopez N, Moliner-Velazquez S. Management of acute pain in patients on treatment with opioids. Pain Manag 2016; 5:167-73. [PMID: 25971640 DOI: 10.2217/pmt.15.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The use of opioids for both benign and cancer-related chronic pain has increased exponentially over the last few years. For this reason, increasing numbers of such patients are presenting for surgery. It is known that continuous use of opioids is associated with an increase in postoperative analgesic requirements. This is believed to be mediated by the development of tolerance and opioid-induced hyperalgesia. Patients treated with opioids have special needs in the perioperative setting and it is the anesthesiologist's responsibility to manage these needs optimally. The aim of the present paper is to briefly orient the reader in the management of postoperative pain in patients chronically treated with licit opioids.
Collapse
Affiliation(s)
- Jose De Andres
- Multidisciplinary Pain Management Department. Department of Anesthesiology Critical Care & Pain Management, General University Hospital, Valencia, Spain
| | | | | | | | | |
Collapse
|
27
|
Blum JM, Biel SS, Hilliard PE, Jutkiewicz EM. Preoperative ultra-rapid opiate detoxification for the treatment of post-operative surgical pain. Med Hypotheses 2015; 84:529-31. [DOI: 10.1016/j.mehy.2015.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 02/16/2015] [Indexed: 02/08/2023]
|
28
|
Schäfer M, Denke C, Krampe H, Spies C. Pharmacotherapy in Pain Patients with Substance Abuse. J Pain Palliat Care Pharmacother 2015; 29:59-60. [DOI: 10.3109/15360288.2014.1003677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
29
|
Abstract
Abstract
Background:
The authors investigated nationwide trends in opioid abuse or dependence during pregnancy and assessed the impact on maternal and obstetrical outcomes in the United States.
Methods:
Hospitalizations for delivery were extracted from the Nationwide Inpatient Sample from 1998 to 2011. Temporal trends were assessed and logistic regression was used to examine the associations between maternal opioid abuse or dependence and obstetrical outcomes adjusting for relevant confounders.
Results:
The prevalence of opioid abuse or dependence during pregnancy increased from 0.17% (1998) to 0.39% (2011) for an increase of 127%. Deliveries associated with maternal opioid abuse or dependence compared with those without opioid abuse or dependence were associated with an increased odds of maternal death during hospitalization (adjusted odds ratio [aOR], 4.6; 95% CI, 1.8 to 12.1, crude incidence 0.03 vs. 0.006%), cardiac arrest (aOR, 3.6; 95% CI, 1.4 to 9.1; 0.04 vs. 0.01%), intrauterine growth restriction (aOR, 2.7; 95% CI, 2.4 to 2.9; 6.8 vs. 2.1%), placental abruption (aOR, 2.4; 95% CI, 2.1 to 2.6; 3.8 vs. 1.1%), length of stay more than 7 days (aOR, 2.2; 95% CI, 2.0 to 2.5; 3.0 vs. 1.2%), preterm labor (aOR, 2.1; 95% CI, 2.0 to 2.3; 17.3 vs. 7.4%), oligohydramnios (aOR, 1.7; 95% CI, 1.6 to 1.9; 4.5 vs. 2.8%), transfusion (aOR, 1.7; 95% CI, 1.5 to 1.9; 2.0 vs. 1.0%), stillbirth (aOR, 1.5; 95% CI, 1.3 to 1.8; 1.2 vs. 0.6%), premature rupture of membranes (aOR, 1.4; 95% CI, 1.3 to 1.6; 5.7 vs. 3.8%), and cesarean delivery (aOR, 1.2; 95% CI, 1.1 to 1.3; 36.3 vs. 33.1%).
Conclusions:
Opioid abuse or dependence during pregnancy is associated with considerable obstetrical morbidity and mortality, and its prevalence is dramatically increasing in the United States. Identifying preventive strategies and therapeutic interventions in pregnant women who abuse drugs are important priorities for clinicians and scientists.
Collapse
|
30
|
O'Neill DF, Webb Thomas C. Less is more: limiting narcotic prescription quantities for common orthopedic procedures. PHYSICIAN SPORTSMED 2014; 42:100-5. [PMID: 25419893 DOI: 10.3810/psm.2014.11.2096] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinicians are now appreciating that the perception of pain is a multifaceted, biopsychosocial construct. Expectation of postsurgical pain is part of this construct and should be considered preoperatively. It is our belief that by establishing reasonable expectations with preoperative teaching, we can minimize narcotic use and lessen untoward issues that can potentially follow. With this goal in mind, we have been using a comprehensive pre- and postoperative program for our outpatient orthopedic surgery patients for the last 5 years, which includes physical, pharmacologic, and simple sport psychological techniques. MATERIALS AND METHODS We reviewed postoperative prescription narcotic purchases in 133 consecutive surgical patients during the last year (2013). All patients were given a prescription postoperatively for 10 hydrocodone 5-mg/acetaminophen 500-mg tablets, with 1 refill. We then contacted the patients' pharmacies to assess the actual amount purchased. RESULTS Data were available for 100 patients. Of these, 62 patients had undergone "simple" arthroscopies and 38 had had "open" procedures, including 25 anterior cruciate ligament reconstructions, 4 tibial tubercle osteotomies, and various other surgeries. Of the 62 arthroscopies, 24 patients (39%) refilled their prescriptions, with 4 patients (6%) needing > 1 refill. Of the 38 open procedures, 16 patients (42%) refilled their medications, 2 (5%), more than once. Thus, 89% of patients required ≤ 20 narcotic tablets after undergoing common orthopedic operations. No patient needed chronic narcotic medication. DISCUSSION Pain is a complex issue and patient expectation of postoperative pain is one aspect that can potentially affect the amount of narcotics used. By preparing the patient both physically and psychologically, we believe the amount of narcotics used postoperatively can be decreased without affecting pain control. As a result, the multiple possible detriments of having more narcotics available than actually necessary would be lessened. By limiting the overall number of narcotic tablets prescribed, decreased use by the patient when such a medication may no longer be appropriate, and minimized use by others in the household who might have access to it would decrease.
Collapse
|
31
|
Reply to: An alternative way of managing acute pain in patients who are in buprenorphine opioid substitution therapy programmes. Eur J Anaesthesiol 2014; 30:718-9. [PMID: 23812624 DOI: 10.1097/eja.0b013e328363479e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Huxtable CA, Macintyre PE. An alternative way of managing acute pain in patients who are in buprenorphine opioid substitution therapy programs. Eur J Anaesthesiol 2014; 30:717-8. [PMID: 23803595 DOI: 10.1097/eja.0b013e32836394fe] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christine A Huxtable
- From the Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | |
Collapse
|
33
|
|
34
|
|