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Feeney ME, Law AC, Walkey AJ, Bosch NA. Variation in Use of Medications for Opioid Use Disorder in Critically Ill Patients Across the United States. Crit Care Med 2024; 52:e365-e375. [PMID: 38501933 PMCID: PMC11176030 DOI: 10.1097/ccm.0000000000006257] [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: 03/20/2024]
Abstract
OBJECTIVES To describe practice patterns surrounding the use of medications to treat opioid use disorder (MOUD) in critically ill patients. DESIGN Retrospective, multicenter, observational study using the Premier AI Healthcare Database. SETTING The study was conducted in U.S. ICUs. PATIENTS Adult (≥ 18 yr old) patients with a history of opioid use disorder (OUD) admitted to an ICU between 2016 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 108,189 ICU patients (658 hospitals) with a history of OUD, 20,508 patients (19.0%) received MOUD. Of patients receiving MOUD, 13,745 (67.0%) received methadone, 2,950 (14.4%) received buprenorphine, and 4,227 (20.6%) received buprenorphine/naloxone. MOUD use occurred in 37.9% of patients who received invasive mechanical ventilation. The median day of MOUD initiation was hospital day 2 (interquartile range [IQR] 1-3) and the median duration of MOUD use was 4 days (IQR 2-8). MOUD use per hospital was highly variable (median 16.0%; IQR 10-24; range, 0-70.0%); admitting hospital explained 8.9% of variation in MOUD use. A primary admitting diagnosis of unintentional poisoning (aOR 0.41; 95% CI, 0.38-0.45), presence of an additional substance use disorder (aOR 0.66; 95% CI, 0.64-0.68), and factors indicating greater severity of illness were associated with reduced odds of receiving MOUD in the ICU. CONCLUSIONS In a large multicenter, retrospective study, there was large variation in the use of MOUD among ICU patients with a history of OUD. These results inform future studies seeking to optimize the approach to MOUD use during critical illness.
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Affiliation(s)
| | - Anica C. Law
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
| | - Allan J. Walkey
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
| | - Nicholas A. Bosch
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
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Yun DH, Plymale MA, Oyler DR, Slavova SS, Davenport DL, Roth JS. Predictors of postoperative opioid use in ventral and incisional hernia repair. Surg Endosc 2024; 38:3052-3060. [PMID: 38609586 DOI: 10.1007/s00464-024-10808-9] [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] [Received: 02/15/2023] [Accepted: 03/21/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND One in two ventral and incisional hernia repair (VIHR) patients have preoperative opioid prescription within a year before procedure. The study's aim was to investigate risk factors of increased postoperative prescription filling in patients with or without preoperative opioid prescription. METHODS VIHR cases from 2013 to 2017 were reviewed. State prescription drug monitoring program data were linked to patient records. The primary endpoint was cumulative opioid dose dispensed through post-discharge day 45. Morphine milligram equivalent (MME) was used for uniform comparison. RESULTS 205 patients were included in the study (average age 53.5 years; 50.7% female). Over 35% met criteria for preoperative opioid use. Preoperative opioid tolerance, superficial wound infection, current smoking status, and any dispensed opioids within 45 days of admission were independent predictors for increased postoperative opioid utilization (p < 0.001). CONCLUSION Preoperative opioid use during 45-day pre-admission correlated strongly with postoperative prescription filling in VIHR patients, and several independent risk factors were identified.
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Affiliation(s)
- Do Hyun Yun
- College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Margaret A Plymale
- Division of General, Endocrine and Metabolic Surgery, Department of Surgery, University of Kentucky, 800 Rose Street, C-240, Lexington, KY, 40536, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Svetla S Slavova
- Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Daniel L Davenport
- Department of Surgery, Division of Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, KY, USA
| | - John Scott Roth
- Division of General, Endocrine and Metabolic Surgery, Department of Surgery, University of Kentucky, 800 Rose Street, C-240, Lexington, KY, 40536, USA.
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3
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Koltenyuk V, Mrad I, Choe I, Ayoub MI, Kumaraswami S, Xu JL. Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review. J Pain Res 2024; 17:797-813. [PMID: 38476879 PMCID: PMC10928917 DOI: 10.2147/jpr.s434010] [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] [Received: 09/02/2023] [Accepted: 01/08/2024] [Indexed: 03/14/2024] Open
Abstract
The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.
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Affiliation(s)
| | - Ismat Mrad
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, NY, USA
| | - Ian Choe
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Mohamad Ibrahim Ayoub
- Department of Anesthesiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sangeeta Kumaraswami
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jeff L Xu
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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4
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Delorme J, Kerckhove N, Authier N, Pereira B, Bertin C, Chenaf C. Systematic Review and Meta-Analysis of the Prevalence of Chronic Pain Among Patients With Opioid Use Disorder and Receiving Opioid Substitution Therapy. THE JOURNAL OF PAIN 2023; 24:192-203. [PMID: 36220483 DOI: 10.1016/j.jpain.2022.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/08/2022]
Abstract
To assess studies examining the prevalence of chronic pain (CP) in patients treated with Opioid Substitution Treatment (OST - buprenorphine or methadone) for Opioid Used Disorder (OUD), we conducted a systematic review and meta-analysis of the literature between the years 2000 and 2020. We searched EMBASE, PsycINFO, Cochrane, and MEDLINE databases and included studies assessing the prevalence of CP in OUD adults treated with OST. The studies were assessed for risk of bias and overall quality and the results were pooled using a random-effects model. Subgroup analyses and meta-regressions were used to identify possible factors associated with CP. Twenty-three studies reported data on the prevalence of CP in patients treated with OST were evaluated. The prevalence obtained was 45.3% (CI95% [38.7; 52.1]). Overall, 78.3% of the studies had a low risk of bias. Subgroup analysis estimates did not vary according to gender, OST, and CP duration. However, it appeared that the clinical settings was associated with a lower CP prevalence when assessed in primary care sites. Our study provided an estimate regarding the prevalence of CP among OST patients. These patients deserve specific attention from health professionals and health authorities. Thus, the real challenge in OST patients is the implementation of a multidisciplinary approach to manage CP. PERSPECTIVE: Our meta-analysis provided an estimate of CP prevalence, reaching almost 50% of OUD patients with OST. Thus, the urgent challenge in OST patients is to pay systematic attention to chronic pain diagnosis, along with the implementation of a multidisciplinary patient-focused approach for an appropriate management of CP. REGISTRATION: PROSPERO (CRD42021284790).
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Affiliation(s)
- Jessica Delorme
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Nicolas Kerckhove
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France.
| | - Nicolas Authier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
| | - Bruno Pereira
- CHU Clermont-Ferrand, Secteur Biométrie et Médico-économie, Clermont-Ferrand, France
| | - Célian Bertin
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
| | - Chouki Chenaf
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
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Abstract
Importance The use and misuse of opioids in pregnancy have been increasing and are a major public health issue. Opioid use in pregnancy and during lactation has been associated with increased maternal and neonatal morbidity and mortality. Objective This review aims to summarize the existing literature and current recommendations for opioid use while pregnant or lactating. Evidence Acquisition A PubMed, Cochrane Library, and Google Scholar literature search using the following terms was performed to gather relevant data: "opioids," "opioid maintenance therapy," "opioid use disorder," "suboxone," "buprenorphine," "methadone," "medication for opioid use disorder," "fetal outcomes," "perinatal outcomes," "pregnancy," "lactation," and "neonatal abstinence syndrome." Results Available studies on opioid use in pregnancy and during lactation were reviewed and support association with increased odds of maternal death, placental insufficiency, cardiac arrest, preterm birth, neonatal intensive care unit admission, low birth weight, and small for gestational age infants. Studies were also reviewed on pharmacotherapy options in pregnancy and promising prenatal care models. Conclusion and Relevance There is a critical need for research on the effects of opioid use and related pharmacotherapy options in pregnancy. Once the adverse perinatal effects of opioid exposure are identified and well-characterized, patient education, intervention, and antenatal surveillance can be developed to predict and mitigate its impact on maternal and fetal health.
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Hargett J, Criswell A, Palokas M. Nonpharmacological interventions for acute pain management in patients with opioid abuse or opioid tolerance: a scoping review. JBI Evid Synth 2022; 20:2697-2720. [PMID: 36065876 DOI: 10.11124/jbies-21-00169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The objective of this scoping review was to identify and map the evidence on nonpharmacological interventions for acute pain management in patients with opioid tolerance or opioid abuse. INTRODUCTION Opioid therapy is the mainstay of pain management for adults experiencing moderate-to-severe acute pain. However, considering the known risks of opioid use and the growing number of patients with opioid tolerance or opioid abuse, nonpharmacological pain management interventions are of increasing interest to health care providers. Nonpharmacological techniques have shown potential in reducing postoperative pain, opioid consumption, stress, and anxiety. INCLUSION CRITERIA Eligible studies included participants in either inpatient or outpatient health care settings who were experiencing acute pain and a tolerance to opioid medications or opioid abuse. Studies that examined nonpharmacological interventions for treating acute pain in these patients were considered. Nonpharmacological interventions included, but were not limited to, acupuncture, electroacupuncture, massage, mindfulness, electroanalgesia, low-level light therapy, meditation, biofeedback, hypnosis, and relaxation techniques. METHODS MEDLINE, CINAHL, Scopus, Embase, Europe PubMed Central, PsycINFO, Cochrane Central Register of Controlled Trials, and the US National Library of Medicine ( https://ClinicalTrials.gov/ ) were searched, as were sources of unpublished studies on December 30, 2020. Only studies published in English were included, and there was no limit on date of publication. After screening the titles and abstracts of identified citations, 2 independent reviewers retrieved potentially relevant full-text studies and extracted data. Data are presented in diagrammatic format, and accompany the narrative synthesis. RESULTS Fourteen articles were included in the study, including 10 expert opinion papers or chapters, 3 case reports, and 1 implementation report. The most common setting was the perioperative setting, specifically orthopedic surgery. Nonpharmacological pain interventions identified in the literature included physical interventions such as acupuncture, physical therapy, therapeutic exercise, yoga, bracing, heat, cold, elevation, compression, chiropractic interventions, massage, manual therapy, transcutaneous electrical nerve stimulation, and pulsed electromagnetic field therapy. Behavioral and psychological modalities included positive affirmations, cognitive behavioral therapy, acceptance and commitment therapy, mindfulness, distraction, guided imagery, meditation, biofeedback, relaxation, hypnosis, breathing exercises, and energy healing. Many expert opinions included only brief mentions or recommendations for nonpharmacological interventions without full explanations, evidence from the literature, or discussion of the level of support for the recommendation. CONCLUSIONS The findings of this review indicate that nonpharmacological interventions for patients with opioid tolerance or dependence include physical, psychological, and multimodal approaches. Nonpharmacological interventions in this scoping review were often presented as combined with opioid or non-opioid medications for a pain management regimen that is opioid-sparing, opioid-free, or drug-free. More primary research is needed on the nonpharmacological acute pain management of patients with opioid dependence or opioid tolerance.
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Affiliation(s)
- Jennifer Hargett
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
| | - Amanda Criswell
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
| | - Michelle Palokas
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.,Mississippi Centre for Evidence Based Practice: A JBI Centre of Excellence, Jackson, MS, USA
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7
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Hargett JL, McElwain SD, McNair ME, Palokas MJ, Martin BS, Adcock DL. Virtual Reality Based Guided Meditation for Patients with Opioid Tolerance and Opioid Use Disorders. Pain Manag Nurs 2022; 23:259-264. [PMID: 35331652 DOI: 10.1016/j.pmn.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/13/2021] [Accepted: 02/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The management of acute pain in patients with pre-existing opioid tolerance or opioid use disorders presents unique challenges. In light of the concerns regarding opioid use, safe and effective alternatives to opioid medications are of increasing interest. AIMS This study was conducted to determine if the use of guided meditation delivered through immersive virtual reality can reduce pain in patients with opioid tolerance or opioid use disorders, including opioid abuse or opioid dependence. DESIGN A quasi-experimental pre-test and post-test study design was used. SETTINGS A 31-bed inpatient orthopedic/trauma unit in the southeastern United States. PARTICIPANTS/SUBJECTS Subjects of the pilot study were hospitalized adults over the age of 18 with pre-existing opioid tolerance or opioid use disorder who were experiencing acute pain. METHODS This pilot study examined the effect of a 10-minute guided meditation activity through immersive virtual reality on the reported acute pain of hospitalized adults (n = 11) with pre-existing opioid tolerance or opioid use disorders. The Calm® application on an Oculus Go® virtual reality head-mounted display was used for the meditation activity. RESULTS Before the intervention, the mean patient-reported pain rating was 6.68, and the mean pain score after the virtual reality experience was 3.36. Using the Wilcoxon signed rank test, this was a statistically significant difference (p = .003). Patients were also observed and queried regarding any significant side effects or other incidental findings, none of which were reported. CONCLUSIONS This study demonstrates that the use of guided meditation through virtual reality can result in statistically significant reductions in patient-reported pain scores.
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Affiliation(s)
- Jennifer L Hargett
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Sharon D McElwain
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mary E McNair
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michelle J Palokas
- School of Nursing, University of Mississippi Medical Center, Jackson, MS, USA
| | - Bradford S Martin
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Dorothy L Adcock
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
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Hickey T, Abelleira A, Acampora G, Becker WC, Falker CG, Nazario M, Weimer MB. Perioperative Buprenorphine Management: A Multidisciplinary Approach. Med Clin North Am 2022; 106:169-185. [PMID: 34823729 DOI: 10.1016/j.mcna.2021.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Buprenorphine formulations (including buprenorphine/naloxone) are effective treatments of pain and opioid use disorder (OUD). Historically, perioperative management of patients prescribed buprenorphine involved abstinence from buprenorphine sufficient to allow for unrestricted mu-opioid receptor availability to full agonist opioid (FAO) treatment. Evidence is mounting that a multimodal analgesic strategy, including simultaneous administration of buprenorphine and FAO, nonopioid adjuncts such as acetaminophen and nonsteroidal anti-inflammatory drugs, and regional anesthesia, is a safe and effective perioperative strategy for the patient prescribed long-term buprenorphine treatment of OUD. This strategy will likely simplify management and more seamlessly provide continuous buprenorphine treatment of OUD after hospital discharge.
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MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Aged
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/pharmacology
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Buprenorphine/administration & dosage
- Buprenorphine/pharmacology
- Buprenorphine/therapeutic use
- Combined Modality Therapy/methods
- Drug Compounding/methods
- Female
- Humans
- Interdisciplinary Communication
- Male
- Opiate Substitution Treatment/methods
- Opioid-Related Disorders/drug therapy
- Pain/drug therapy
- Pain Management/methods
- Pain, Postoperative/prevention & control
- Perioperative Care/methods
- Receptors, Opioid, mu/drug effects
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Affiliation(s)
- Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA; Department of Anesthesiology, Yale School of Medicine, 950 Campbell Avenue, West Haven, CT 06516, USA.
| | - Audrey Abelleira
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Gregory Acampora
- MGH/Harvard Center for Addiction Medicine, Pain Management Center at MGH, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System; Program in Addiction Medicine, Yale School of Medicine
| | - Caroline G Falker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Mitchell Nazario
- National PBM Clinical Program Manager, VHA Pharmacy Benefits Management (12PBM), 1st Avenue - 1 Block North of Cermak (Building 37), Hines, IL 60141, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Yale School of Medicine; Yale School of Public Health
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9
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Impact of opioid use disorder on resource utilization and readmissions after operative trauma. Surgery 2021; 171:541-548. [PMID: 34294450 DOI: 10.1016/j.surg.2021.06.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/27/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although patients with opioid use disorder have been shown to be more susceptible to traumatic injury, the impact of opioid use disorder after trauma-related admission remains poorly characterized. The present nationally representative study evaluated the association of opioid use disorder on clinical outcomes after traumatic injury warranting operative intervention. METHODS The 2010 to 2018 Nationwide Readmissions Database was used to identify adult trauma victims who underwent major operative procedures. Injury severity was quantified using International Classification of Diseases Trauma Mortality Prediction Model. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were developed to assess the association of opioid use disorder on in-hospital mortality, perioperative complications, resource utilization, and readmissions. RESULTS Of an estimated 5,089,003 hospitalizations, 54,097 (1.06%) had a diagnosis of opioid use disorder with increasing prevalence during the study period. Compared with others, opioid use disorder had a lower proportion of extremity injuries and falls but greater predicted mortality measured by Trauma Mortality Prediction Model. After adjustment, opioid use disorder was associated with decreased odds of in-hospital mortality (adjusted odds ratio: 0.61; 95% confidence interval, 0.53-0.70) but had greater likelihood of pneumonia, infectious complications, and acute kidney injury. Additionally, opioid use disorder was associated with longer hospitalization duration as well as greater index costs and risk of readmission within 30 days (adjusted odds ratio: 1.36; 95% confidence interval, 1.25-1.49). CONCLUSION Opioid use disorder in operative trauma has significantly increased in prevalence and is associated with decreased in-hospital index mortality but greater resource utilization and readmission.
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10
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Abstract
OBJECTIVES We performed a descriptive analysis of patient and treatment characteristics in premature discharges "against medical advice" (AMA) in a cohort of patients with opioid-related hospitalizations. METHODS We abstracted data from 1152 opioid related hospitalizations of 928 adult patients in a large academic health system. Using electronic health record data, hospitalizations were categorized as AMA or conventional discharge (CD). To determine differences between AMA and CD regarding treatment characteristics, Fisher exact test, t tests, ANOVA, and logistic regression were performed. RESULTS 74 / 1152 (6%) of opioid-related hospitalizations were discharged AMA. Hospitalizations that resulted in AMA discharge had shorter median length of stay (AMA vs CD 3.5 vs 5.5 days, P < 0.001) and received fewer of any type of opioid agonist treatment (AMA vs CD 73% vs 84%, P = 0.03). Although the number of hospitalizations in which methadone was administered did not differ between the AMA and CD groups, hospitalizations that resulted in AMA had more dose reductions and lesser quantities of methadone overall before discharge. Buprenorphine use was low overall in AMA and CD (0% and 2.1%, respectively). CONCLUSION In this sample of opioid related hospitalizations, admissions that resulted in AMA discharge had fewer opioid agonist administrations and lower methadone dosing. These findings support efforts to initiate opioid agonist therapy during hospital admissions, and further studies should determine whether this practice mitigates AMA discharges.
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Buresh M, Ratner J, Zgierska A, Gordin V, Alvanzo A. Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations. J Gen Intern Med 2020; 35:3635-3643. [PMID: 32827109 PMCID: PMC7728902 DOI: 10.1007/s11606-020-06115-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023]
Abstract
Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We recommend that clinicians (1) continue buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles.
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Affiliation(s)
- Megan Buresh
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jessica Ratner
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Aleksandra Zgierska
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA, USA
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Vitaly Gordin
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Anika Alvanzo
- Divisions of General Internal Medicine and Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Pyramid Healthcare, Inc., Duncansville, PA, USA
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Mikhail CM, Warburton A, Girdler SJ, Platt S, Cong GT, Cho SKW. Risk Factors for 30- and 90-Day Readmission due to Intestinal Bowel Obstruction after Posterior Lumbar Fusion. Asian Spine J 2020; 15:618-627. [PMID: 33108851 PMCID: PMC8561157 DOI: 10.31616/asj.2020.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/11/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design A retrospective analysis of data from the Healthcare Cost and Utilization Project Nationwide Readmissions Database (HCUP-NRD). Purpose To identify the perioperative characteristics associated with 30-day and 90-day readmission due to intestinal bowel obstructions (IBOs) following posterior lumbar fusion (PLF) procedure. Overview of Literature PLF procedures are used to repair spinal injuries and curvature deformities. IBO is a common surgical complication and its repair often necessitates surgery that increases the readmission rates and healthcare costs. Previous studies have identified the preoperative risk factors for 30-day readmissions in PLF; however, no study has specifically investigated IBO or identified risk factors for 90-day readmissions. Methods Data on demographic characteristics and medical comorbidities of patients who underwent PLF with subsequent readmission were obtained from the HCUP-NRD. The perioperative characteristics that were significantly different between patients readmitted with and without an active diagnosis of IBO were identified with bivariate analysis for both 30-day and 90-day readmissions. The significant characteristics were then included in a multivariate analysis to identify those that were independently associated with 30-day and 90-day readmissions. Results Drug abuse (odds ratio [OR], 4.00), uncomplicated diabetes (OR, 2.06), having Medicare insurance (OR, 1.65), age 55–64 years (OR, 2.42), age 65–79 years (OR, 2.77), and age >80 years (OR, 3.87) were significant risk factors for 30-day readmission attributable to IBO after a PLF procedure. Conclusions Of the several preoperative risk factors identified for readmission with IBO after PLF surgery, drug abuse had the strongest association and was likely to be the most clinically relevant factor. Physicians and care teams should understand the risks of opioid-based pain management regimens, attempt to manage pain with a multimodal approach, and minimize the opioid use.
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Affiliation(s)
| | - Andrew Warburton
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven Joseph Girdler
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Platt
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Guang-Ting Cong
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel Kang-Wook Cho
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Comparison of Perioperative Systemic Lidocaine or Systemic Ketamine in Acute Pain Management of Patients With Opioid Use Disorder After Orthopedic Surgery. J Addict Med 2020; 13:220-226. [PMID: 30499871 DOI: 10.1097/adm.0000000000000483] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION AND AIMS Patients with opioid use disorder experience great challenges during acute pain management due to opioid tolerance or withdrawal symptoms. Previous studies have recommended the use of adjuvant drugs in these patients. In this study, we compared the effect of intraoperative lidocaine with ketamine in postoperative pain management of these patients. DESIGN AND METHODS In this randomized clinical trial, 180 patients with opioid use disorder who underwent orthopedic surgery under general anesthesia were randomly allocated into 3 groups. Patients in groups A, B, and C received intravenous lidocaine, ketamine, or normal saline, respectively, during the operation. Then, postoperative pain scores, analgesic requirements, patient satisfaction, and patient sleepiness were recorded and compared among the 3 groups. RESULTS Numerical rating scales during the first hour postoperation were significantly lower in the lidocaine group than in the ketamine or control group (P < 0.001). The mean total amount of morphine consumption during the first 24-hour postoperation was 14.49 ± 26.89, 16.59 ± 30.65, and 21.72 ± 43.29 mg in the lidocaine, ketamine, and control group, respectively, being significantly lower in the lidocaine group in comparison with the other groups (P < 0.001). Patients in the lidocaine group were less restless, calmer, and less drowsy than patients in the ketamine and control group (P < 0.001). DISCUSSION AND CONCLUSION According to these findings, systemic lidocaine is more effective than systemic ketamine to improve the quality of acute pain management without causing any significant complications in patients with opioid use disorder.
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14
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Pain management in trauma patients affected by the opioid epidemic: A narrative review. J Trauma Acute Care Surg 2020; 87:430-439. [PMID: 30939572 DOI: 10.1097/ta.0000000000002292] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.
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Edmonds KP, Saunders IM, Willeford A, Ajayi TA, Atayee RS. Emerging Challenges to the Safe and Effective Use of Methadone for Cancer-Related Pain in Paediatric and Adult Patient Populations. Drugs 2019; 80:115-130. [PMID: 31820362 DOI: 10.1007/s40265-019-01234-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Methadone continues to be an important medication for the treatment of paediatric and adult cancer-related pain. Appropriate patient selection to ensure safe and effective treatment by a team of clinicians who appreciate and are familiar with methadone and its unique pharmacology is crucial. Unlike morphine and other more common opioids, methadone is purported to have involvement with delta-opioid receptor and higher affinity as an N-methyl-D-aspartate-receptor antagonist. Clinically this gives it the advantage of being effective for both nociceptive and neuropathic pain, but also may be useful in the setting of tolerance to other opioids. Methadone also comes in multiple available formulations that can be administrated through a variety of routes beyond the oral route. Challenges with methadone in treating cancer-related pain include drug interactions specifically as it relates to new targeted cancer therapies. Recent guidelines recommend electrocardiogram monitoring with methadone and there is potential for additive cardiac toxicity in the oncology setting. Appropriate dosing of methadone for pain management given age, organ dysfunction, and patients who are on methadone maintenance therapy are also key factors. This article aims to provide clinicians with evidence and clinical practice guidelines for safe and appropriate use of methadone including indication, initiation, and monitoring given its complexity for management of pain in the dynamic oncology setting.
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Affiliation(s)
- Kyle P Edmonds
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Andrew Willeford
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Toluwalase A Ajayi
- Digital Medicine, Scripps Research Translational Institute, La Jolla, CA, 92037, USA
| | - Rabia S Atayee
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA.
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA.
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA.
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Abstract
The rapid rise in the opioid epidemic has had a deleterious impact across the United States. This increase has drawn the attention of the critical care community not only because of the surge in acute opioid overdose-related admissions, but also due to the increase in the number of opioid-dependent and opioid-tolerant patients being treated in the intensive care unit (ICU). Opioid-related issues relevant to the critical care physician include direct care of patients with opioid overdoses, the provision of sufficient analgesia to patients with opioid dependence and tolerance, and the task of preventing long-term opioid dependence in patients who survive ICU care. This review identifies the challenges facing the ICU physician working with patients presenting with opioid-related complications, discusses current solutions, and suggests future areas of research and heightened ICU clinician attention.
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Hargett JL, Criswell AC. Non-pharmacological interventions for acute pain management in patients with opioid abuse or opioid tolerance: a scoping review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2019; 17:1283-1289. [PMID: 30864979 DOI: 10.11124/jbisrir-2017-003878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The objective of this scoping review is to identify and map the evidence on non-pharmacological interventions for acute pain management in patients with opioid tolerance and opioid abuse. INTRODUCTION The mainstay of pain management for adults experiencing moderate to severe acute pain is opioid therapy. However, in light of the known risks of opioid use and the growing number of patients with opioid tolerance or opioid abuse, non-pharmacological interventions are of increasing interest to healthcare providers. Non-pharmacological techniques have shown potential in reducing postoperative pain, opioid consumption, stress and anxiety. INCLUSION CRITERIA Eligible studies will include participants in a hospital or healthcare facility who are experiencing acute pain and have a tolerance to or dependence on opioids. Studies that examine non-pharmacological interventions for treating acute pain in these patients will be considered. Non-pharmacological interventions may include, but are not limited to, acupuncture, electroacupuncture, massage, mindfulness, electroanalgesia, laser therapy, low-level light therapy, meditation, biofeedback, hypnosis and relaxation techniques. Only studies published in English will be included, and there will be no limit on dates of publication. METHODS PubMed, CINAHL, Scopus, Embase, Europe PubMed Central, PsycINFO, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov will be searched, as well as sources of unpublished studies. After screening the titles and abstracts of identified citations, two independent reviewers will retrieve potentially relevant full-text studies, assess methodological quality and extract data. Data will be presented in diagrammatic or tabular form, and a qualitative thematic analysis will be undertaken. A narrative summary will accompany the tabulated results.
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Affiliation(s)
- Jennifer L Hargett
- School of Nursing, University of Mississippi Medical Center, Jackson, USA
- Mississippi Centre for Evidence Based Practice: a Joanna Briggs Institute Centre of Excellence
| | - Amanda C Criswell
- School of Nursing, University of Mississippi Medical Center, Jackson, USA
- Mississippi Centre for Evidence Based Practice: a Joanna Briggs Institute Centre of Excellence
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18
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Abstract
In the United States nearly one in four patients presenting for surgery reports current opioid use. Many of these patients suffer from chronic pain disorders and opioid tolerance or dependence. Opioid tolerance and preexisting chronic pain disorders present unique challenges in regard to postoperative pain management. These patients benefit from providers who are not only familiar with multimodal pain management and skilled in the assessment of acute pain, but also empathetic to their specific struggles. Chronic pain patients often face stigmas surrounding their opioid use, and this may lead to underestimation and undertreatment of their pain. This article aims to review the challenges presented by these complex patients and provide strategies for treating acute postoperative pain in opioid-tolerant patients.
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Soens MA, He J, Bateman BT. Anesthesia considerations and post-operative pain management in pregnant women with chronic opioid use. Semin Perinatol 2019; 43:149-161. [PMID: 30791974 DOI: 10.1053/j.semperi.2019.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of opioid use disorder in pregnancy has escalated markedly in recent years. Chronic opioid use during pregnancy poses several challenges for providing adequate analgesia and anesthesia in the peripartum period. These challenges include the potential for withdrawal, opioid tolerance and opioid-induced hyperalgesia. Here we discuss alterations in analgesic pharmacokinetics and pharmacodynamics that are associated with chronic opioid use. In addition, when treating pain in patients with opioid use disorder it is important to distinguish between different subgroups. In this review, we will discuss practical management strategies for parturients with (1) untreated opioid use disorder, (2) parturients on medication-assisted treatment (methadone, buprenorphine) and (3) patients recovering from opioid use disorder that are currently abstinent. Finally, we offer an overview of non-opioid strategies that may be utilized as part of a multimodal approach to providing optimal analgesia in this patient population.
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Affiliation(s)
- Mieke A Soens
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Jingui He
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Stamenkovic DM, Laycock H, Karanikolas M, Ladjevic NG, Neskovic V, Bantel C. Chronic Pain and Chronic Opioid Use After Intensive Care Discharge - Is It Time to Change Practice? Front Pharmacol 2019; 10:23. [PMID: 30853909 PMCID: PMC6395386 DOI: 10.3389/fphar.2019.00023] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/10/2019] [Indexed: 12/12/2022] Open
Abstract
Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33-73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.
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Affiliation(s)
- Dusica M Stamenkovic
- Department of Anesthesiology and Intensive Care, Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defense, Belgrade, Serbia
| | - Helen Laycock
- Imperial College London, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States
| | - Nebojsa Gojko Ladjevic
- Center for Anesthesia, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vojislava Neskovic
- Department of Anesthesiology and Intensive Care, Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defense, Belgrade, Serbia
| | - Carsten Bantel
- Universitätsklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin, und Schmerztherapie, Universität Oldenburg, Klinikum Oldenburg, Oldenburg, Germany.,Imperial College London, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
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21
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The Effect of Preoperative Medications on Length of Stay, Inpatient Pain, and Narcotics Consumption After Minimally Invasive Transforaminal Lumbar Interbody Fusion. Clin Spine Surg 2019; 32:E37-E42. [PMID: 30234567 DOI: 10.1097/bsd.0000000000000713] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE To determine the association between preoperative medications and length of stay, inpatient pain, and narcotics consumption after a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA Previous studies have identified risk factors for increased length of hospital stay, inpatient pain, and narcotics consumption. However, little is known regarding the effects of preoperative medications on outcomes after spine surgery. METHODS A prospectively maintained surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Preoperative medications taken within 30 days before surgery were recorded for each patient and categorized by medication type. Poisson regression with robust error variance was used to determine the association between preoperative medications and length of stay, pain scores, and narcotics consumption. Multivariate analysis was performed using a backwards, stepwise regression to identify independent risk factors. RESULTS In total, 138 patients were included in this analysis. On bivariate analysis, benzodiazepines were associated with longer hospital stays [relative risk (RR)=2.03; P=0.031]. Benzodiazepines (RR=3.71; P<0.001) and preoperative narcotics (RR=2.60; P=0.012) were risk factors for pain ≥7 on postoperative day 0. On multivariate analysis, benzodiazepines were an independent risk factor for prolonged stay. Benzodiazepines, narcotics, and nonsteroidal anti-inflammatories were identified as independent risk factors for increased postoperative pain. CONCLUSIONS These results suggest that benzodiazepines are a risk factor for increased length of stay and postoperative pain after MIS TLIF. Preoperative narcotics and nonsteroidal anti-inflammatories were also identified as risk factors for postoperative pain though this did not lead to increases in narcotics consumption. Patients taking these medications should undergo more vigilant perioperative monitoring for adequate pain management. More work must be done to further elucidate the association between preoperative medications and postoperative outcomes after MIS TLIF.
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Martin YN, Pearson ACS, Tranchida JR, Weingarten TN, Schulte PJ, Sprung J. Implications of uninterrupted preoperative transdermal buprenorphine use on postoperative pain management. Reg Anesth Pain Med 2019; 44:342-347. [PMID: 30635504 DOI: 10.1136/rapm-2018-100018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/24/2018] [Accepted: 10/28/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Buprenorphine is a partial µ-receptor agonist resistant to displacement from receptors by conventional opioids, which can block the effect of conventional opioids and may interfere with postoperative pain management. We aimed to quantify perioperative opioid use in patients receiving transdermal buprenorphine (TdBUP). METHODS We identified patients receiving TdBUP who underwent surgery between 2004 and 2016. To compare opioid requirements (intravenous morphine equivalents (IV-MEq)), we constructed a matched study, matching each TdBUP patient with two opioid-naive patients by sex, age, and type of anesthesia and procedure. RESULTS Nineteen unique patients underwent 22 procedures while receiving TdBUP. Total (IQR) amounts of IV-MEq (intraoperative, recovery room, and 24 hours after recovery-room discharge) were 98 (63, 145) and 46 (30, 65) mg IV-MEq for TdBUP and opioid-naive patients, respectively (p<0.001). Postoperative IV-MEq requirements were 54 (38, 90) and 15 (3, 35) mg for TdBUP and opioid-naive patients, respectively (p<0.001). Among TdBUP patients, higher preoperative doses of TdBUP were associated with greater postoperative opioid requirements (p=0.02). Specifically, patients with a 20 µg/hour TdBUP patch required 133.8 mg IV-MEq more postoperatively than patients with a 5 µg/hour patch (p=0.002). Following discharge from the recovery room, 17 (77%) TdBUP patients and 15 (34%) opioid-naive patients reported severe pain (OR 6.6 (95% CI 2.0 to 21.3); p<0.001; adjusting for baseline pain score, 5.0 (95% CI, 1.4 to 17.8); p=0.01). CONCLUSIONS Analgesic management for patients receiving TdBUP therapy must account for increased opioid needs, and greater preoperative doses of TdBUP were associated with greater postoperative opioid requirements.
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Affiliation(s)
- Yvette N Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy C S Pearson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Anesthesia, University of Iowa Health Care, Iowa City, Iowa, USA
| | - John R Tranchida
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip J Schulte
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Vahedi HSM, Hajebi H, Vahidi E, Nejati A, Saeedi M. Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury. World J Emerg Med 2019; 10:27-32. [PMID: 30598715 DOI: 10.5847/wjem.j.1920-8642.2019.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Rapid and effective pain relief in acute traumatic limb injuries (ATLI) is one of the most important roles of emergency physicians. In these situations, opioid addiction is an important concern because of the dependency on opioids. The study aims to compare the effectiveness of intravenous (IV) fentanyl versus morphine in reducing pain in patients with opioid addiction who suffered from ATLI. METHODS In this double-blind randomized clinical trial, 307 patients with ATLI, who presented to the emergency department (ED) from February 2016 to April 2016, were randomly divided into two groups. One group (152 patients) received 0.1 mg/kg IV morphine. The other group (155 patients) received 1 mcg/kg IV fentanyl. Patients' demographic data, pain score at specific intervals, vital signs, side effects, satisfaction and the need for rescue analgesia were recorded. RESULTS Eight patients in the morphine group and five patients in the fentanyl group were excluded. Pain score in the fentanyl group had a significant decrease at 5-minute follow-up (P value=0.00). However, at 10, 30, and 60-minute follow-ups no significant differences were observed between the two groups in terms of pain score reduction. The rescue analgesia was required in 12 (7.7%) patients in the fentanyl group and in 48 (31.6%) patients in the morphine group (P value=0.00). No significant difference was observed regarding side effects, vital signs and patients' satisfaction between the two groups. CONCLUSION Fentanyl might be an effective and safe drug in opioid addicts suffering from ATLI.
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Affiliation(s)
| | - Hadi Hajebi
- Emergency Medicine Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Elnaz Vahidi
- Emergency Medicine Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Nejati
- Emergency Medicine Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Saeedi
- Emergency Medicine Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Hamdy MM, Elbadr MM, Barakat A. Bupropion attenuates morphine tolerance and dependence: Possible role of glutamate, norepinephrine, inflammation, and oxidative stress. Pharmacol Rep 2018; 70:955-962. [DOI: 10.1016/j.pharep.2018.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/07/2018] [Accepted: 04/09/2018] [Indexed: 01/13/2023]
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26
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Lusk SL, Stipp A. Opioid use disorders as an emerging disability. JOURNAL OF VOCATIONAL REHABILITATION 2018. [DOI: 10.3233/jvr-180943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Perioperative Management of Patients with Addiction to Opioid and Non-opioid Medications. Curr Pain Headache Rep 2018; 22:52. [PMID: 29904819 DOI: 10.1007/s11916-018-0704-6] [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: 01/10/2023]
Abstract
PURPOSE OF REVIEW With the rise of the opioid epidemic, anesthesiologists will find themselves faced with opioid-addicted patients more frequently. Addiction to opioids may also occur concurrently with abuse of other non-opioid medications. Our review article seeks to outline an armamentarium of pain management strategies in the perioperative period for these patients with addiction to opioid and non-opioid medications. RECENT FINDINGS Statistics from the CDC demonstrate a shocking increase in opioid prescription rates and opioid-related deaths. Furthermore, opioid-addicted patients have notoriously undertreated pain in the perioperative period. A multitude of strategies are available in the perioperative period to treat pain in these patients. Formulating treatment plans for opioid and non-opioid-addicted patients undergoing surgery should include considerations in the pre-, intra-, and post-operative period. Our review article outlines several non-opioid modalities which may be employed to treat pain in these patients; however, particularly in the opioid-addicted population, the practitioner must be aware that non-opioids alone may not suffice to treat post-surgical pain. Consultation with pain management may be warranted to optimize opioid and non-opioid treatment for these patients.
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Ordean A, Wong S, Graves L. No. 349-Substance Use in Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 39:922-937.e2. [PMID: 28935057 DOI: 10.1016/j.jogc.2017.04.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers. OPTIONS This guideline reviews the use of screening tools, general approach to care, and recommendations for the clinical management of problematic substance use in pregnancy. OUTCOMES Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. EVIDENCE Updates in the literature were retrieved through searches of Medline, PubMed, and The Cochrane Library published from 1996 to 2016 using the following key words: pregnancy, electronic cigarettes, tobacco use cessation products, buprenorphine, and methadone. Results were initially restricted to systematic reviews and RCTs/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report. BENEFITS, HARMS, AND COSTS This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care lead to reduced health care costs and decreased maternal and neonatal morbidity and mortality. RECOMMENDATIONS
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Nurse Anesthetists' Reflections on Caring for Patients With Previous Substance Dependence: Balancing Between Professionalism and Preconceptions. J Perianesth Nurs 2018; 33:69-77. [DOI: 10.1016/j.jopan.2016.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 12/28/2015] [Accepted: 01/09/2016] [Indexed: 11/18/2022]
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van de Donk T, Ward S, Langford R, Dahan A. Pharmacokinetics and pharmacodynamics of sublingual sufentanil for postoperative pain management. Anaesthesia 2017; 73:231-237. [DOI: 10.1111/anae.14132] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2017] [Indexed: 12/14/2022]
Affiliation(s)
- T. van de Donk
- Department of Anesthesiology; Leiden University Medical Center; Leiden the Netherlands
| | - S. Ward
- Pain and Anaesthesia Research Centre; St Bartholomew's Hospital; London UK
| | - R. Langford
- Pain and Anaesthesia Research Centre; St Bartholomew's Hospital; London UK
| | - A. Dahan
- Department of Anesthesiology; Leiden University Medical Center; Leiden the Netherlands
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N o 349 - Consommation de substances psychoactives pendant la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:938-956.e3. [PMID: 28935058 DOI: 10.1016/j.jogc.2017.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIFS Accroître la sensibilisation à la consommation problématique de substances psychoactives pendant la grossesse et les connaissances à ce sujet, et formuler des recommandations factuelles relatives à la prise en charge de cet épineux problème clinique à l'intention de l'ensemble des fournisseurs de soins. OPTIONS La présente directive clinique analyse l'utilisation d'outils de dépistage, l'approche générale de soins et les recommandations pour la prise en charge clinique de la consommation problématique de substances psychoactives pendant la grossesse. ISSUES Recommandations factuelles pour le dépistage et la prise en charge de la consommation problématique de substances psychoactives pendant la grossesse et l'allaitement. RECHERCHE DOCUMENTAIRE La littérature à jour a été obtenue au moyen de recherches dans Medline, PubMed et la Bibliothèque Cochrane visant les articles publiés entre 1996 et 2016, avec les mots clés suivants : « pregnancy », « electronic cigarettes », « tobacco use cessation products », « buprenorphine » et « methadone ». Les résultats ont d'abord été restreints aux analyses systématiques, aux ECR et aux essais cliniques contrôlés. Ensuite, en raison de la rareté des ECR sur le sujet, des recherches d'études observationnelles ont également été menées. Les articles sélectionnés ont été limités aux études chez l'humain publiées en anglais, puis d'autres articles ont été trouvés manuellement, par l'analyse des listes de références. VALEURS La qualité des données a été évaluée au moyen des critères énoncés dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport. AVANTAGES, DéSAVANTAGES ET COûTS: La présente directive clinique a pour but d'améliorer les connaissances et le degré d'aisance des fournisseurs qui dispensent des soins aux femmes enceintes ayant un trouble de l'usage d'une substance. L'amélioration de l'accès aux soins de santé et de l'aide pour obtenir un traitement adéquat de la dépendance fait diminuer les coûts de santé et les taux de morbidité et de mortalité chez la mère et l'enfant. RECOMMANDATIONS.
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Raub JN, Vettese TE. Acute Pain Management in Hospitalized Adult Patients with Opioid Dependence: A Narrative Review and Guide for Clinicians. J Hosp Med 2017; 12:375-379. [PMID: 28459910 DOI: 10.12788/jhm.2733] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pain management is a core competency of hospital medicine, and effective acute pain management should be a goal for all hospital medicine providers. The prevalence of opioid use in the United States, both therapeutic and non-medical in origin, has dramatically increased over the past decade. Although nonopioid medications and nondrug treatments are essential components of managing all acute pain, opioids continue to be the mainstay of treatment for severe acute pain in both opioid-naïve and opioid-dependent patients. In this review, we provide an evidence-based approach to appropriate and safe use of opioid analgesics in treating acute pain in hospitalized patients who are opioid-dependent. Journal of Hospital Medicine 2017;12:375-379.
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Affiliation(s)
- Joshua N Raub
- Internal Medicine, Detroit Receiving Hospital/Detroit Medical Center, Wayne State University School of Medicine, and Department of Pharmacy Services, Wayne State University, all in Detroit, MI
| | - Theresa E Vettese
- Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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Barth KS, Guille C, McCauley J, Brady KT. Targeting practitioners: A review of guidelines, training, and policy in pain management. Drug Alcohol Depend 2017; 173 Suppl 1:S22-S30. [PMID: 28363316 PMCID: PMC5555357 DOI: 10.1016/j.drugalcdep.2016.08.641] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/31/2016] [Accepted: 08/31/2016] [Indexed: 01/03/2023]
Abstract
This paper reviews the current literature on clinical guidelines, practitioner training, and government/payer policies that have come forth in response to the national rise in prescription opioid overdoses. A review of clinical opioid prescribing guidelines highlights the need for more research on safe and effective treatment options for chronic pain, improved guidance for the best management of post-operative pain, and evaluation of the implementation and impact of guideline recommendations on patient risk and outcomes. Although there is increasing attention to training in pain management in medical schools and medical residency programs, educational opportunities remain highly variable, and the need for additional clinician training in the recognition and treatment of pain as well as opioid use disorder has been recognized. Mandated use of private, federal and state educational and clinical initiatives such as Risk Evaluation and Mitigation Strategies (REMS) and Prescription Drug Monitoring Programs (PDMPs) generally increase utilization of these initiatives, but more research is needed to determine the impact of these initiatives on provider behaviors, treatment access, and patient outcomes. Finally, there is an acute need for more research on safe and effective treatments for chronic pain as well as an increased multi-level focus on improving training and access to evidence-based treatment for opioid use disorder as well as non-pharmacologic and non-interventional chronic pain treatments, so that these guideline-recommended interventions can become mainstream, accessible, first-line interventions for chronic pain and/or opioid use disorders.
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Affiliation(s)
- Kelly S Barth
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Constance Guille
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Jenna McCauley
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Kathleen T Brady
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
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Vadivelu N, Lumermann L, Zhu R, Kodumudi G, Elhassan AO, Kaye AD. Pain Control in the Presence of Drug Addiction. Curr Pain Headache Rep 2016; 20:35. [PMID: 27068665 DOI: 10.1007/s11916-016-0561-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Drug addiction is present in a significant proportion of the population in the USA and worldwide. Drug addiction can occur with the abuse of many types of substances including cocaine, marijuana, stimulants, alcohol, opioids, and tranquilizers. There is a high likelihood that clinicians will encounter patients with substance abuse disorders on a regular basis with the prevalence of the use of illicit substances and the high rate of abuse of prescription drugs. The use of abuse deterrent formulations of prescription opioid agents, pill counts, and urine drug abuse screenings are all useful strategies. Optimum pain management of patients with addiction in the outpatient and inpatient setting is essential to minimize pain states. Careful selection of medications and appropriate oversight, including drug agreements, can reduce drug-induced impairments, including sleep deficits and diminished physical, social, and sexual functioning. This review, therefore, discusses the prevalence of illicit and prescription drug addiction, the challenges of achieving optimum pain control, and the therapeutic approaches to be considered in this challenging population. More research is warranted to develop improved therapies and routes of treatments for optimum pain relief and to prevent the development of central sensitization, chronic pain, and impaired physical and social functioning in patients with drug addiction.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, 06520, USA.
| | | | - Richard Zhu
- Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Gopal Kodumudi
- California North State University College of Medicine, 9700 W Taron, Elk Grove, CA, 95757, USA
| | - Amir O Elhassan
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA
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Donroe JH, Holt SR, Tetrault JM. Caring for patients with opioid use disorder in the hospital. CMAJ 2016; 188:1232-1239. [PMID: 27647616 PMCID: PMC5135493 DOI: 10.1503/cmaj.160290] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Joseph H Donroe
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn.
| | - Stephen R Holt
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Jeanette M Tetrault
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn
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Vaid P, Green T, Shinkaruk K, King-Shier K. Low-Dose Ketamine Infusions for Highly Opioid-Tolerant Adults Following Spinal Surgery: A Retrospective Before-and-after Study. Pain Manag Nurs 2016; 17:150-8. [PMID: 27095389 DOI: 10.1016/j.pmn.2016.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 11/28/2022]
Abstract
Managing acute-on-chronic pain in opioid-tolerant individuals is complex and challenging; exploring new analgesia regimens for this population is essential. Ketamine is an N-methyl D-aspartate antagonist that blocks transmission of painful stimuli and could be a useful medication for this patient population. A new low-dose ketamine protocol as an adjunct to conventional pain therapy was implemented in a major urban Level 1 trauma center in Canada. A retrospective before-and-after chart review was conducted to explore the research question, "What is the effect of low-dose ketamine continuous intravenous infusions on pain of highly opioid-tolerant adults following spinal surgery?". All patients had spine surgery, used a minimum of 100 mg daily oral morphine equivalent preoperatively and were followed postoperatively by the hospital's Acute Pain Service. Data from individuals treated with conventional therapy during the year prior to protocol implementation were compared with data from patients who received conventional therapy plus ketamine post implementation. Outcome measures included pain scores and daily opioid consumption on postoperative days 0 through 5, time to ambulation, time to discharge, and adverse effects. There were no statistically significant differences between conventional therapy and conventional therapy plus ketamine. Ketamine may still be of benefit to patients with acute-on-chronic pain, although this was not evident in this study. Future research using more robust assessment tools to determine effectiveness of ketamine is required.
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Affiliation(s)
- Patrycja Vaid
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada; Acute Pain Service, Alberta Health Services, Foothills Medical Centre, Calgary, Alberta, Canada.
| | - Theresa Green
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada; Queensland University of Technology, Faculty of Health, School of Nursing, Kelvin Grove Campus, Brisbane, Australia
| | - Kelly Shinkaruk
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada; Acute Pain Service, Alberta Health Services, Foothills Medical Centre, Calgary, Alberta, Canada
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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.
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Xavier Scheuermeyer F, Andolfatto G, Lange L, de Jong D, Qian H, Grafstein E. Do injection drug users have more adverse events during procedural sedation and analgesia for incision and drainage of cutaneous abscesses? CAN J EMERG MED 2016; 15:90-100. [PMID: 23458140 DOI: 10.2310/8000.2012.120710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) in the emergency department (ED). We compared adverse events (AEs) for IDUs to those for non-IDUs receiving PSA for incision and drainage of cutaneous abscesses. METHODS This was a retrospective analysis of a PSA safety audit. IDU status was prospectively documented among consecutive patients undergoing PSA at two urban EDs. Structured data describing comorbidities, vital signs, sedation regimens, and adverse events were collected. Primary outcome was the proportion of patients in each group experiencing an AE, whereas the secondary outcomes included recovery times. RESULTS Of 525 consecutive patients receiving PSA for incision and drainage of an abscess, 244 were deemed IDUs and 281 non-IDUs. IDUs received higher doses of sedatives and analgesics, and 14 experienced AEs (5.7%), whereas 10 non-IDUs had AEs (3.6%), for a risk difference of 2.1% (95% CI -1.8, 6.5). Median recovery times were 18 minutes (interquartile range [IQR] 10-36) for IDUs and 12 minutes (IQR 7-19) for non-IDUs, for a difference of 6 minutes (95% CI 2-9 minutes). Median sedation times were also longer in IDUs, for a difference of 6 minutes (95% CI 5-10 minutes). Of 20 IDU patients and 1 non-IDU patient admitted to hospital, none had experienced an AE related to PSA. CONCLUSIONS For ED patients requiring PSA for incision and drainage, IDUs had an AE rate similar to that of non-IDUs but longer sedation and recovery times. In experienced hands, PSA may be as safe in IDUs as in patients who do not use injection drugs.
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Abstract
OBJECTIVES The aim of this article is to expose common myths and misconceptions regarding pain assessment and management in critically ill patients that interfere with effective care. We comprehensively review the literature refuting these myths and misconceptions and describe evidence-based strategies for improving pain management in the ICU. DATA SOURCES Current peer-reviewed academic journals, as well as standards and guidelines from professional societies. STUDY SELECTION The most current evidence was selected for review based on the highest degree of supportive evidence. DATA EXTRACTION Data were obtained via medical search databases, including OvidSP, and the National Library of Medicine's MEDLINE database via PubMed. DATA SYNTHESIS After a comprehensive literature review, conclusions were drawn based on the strength of evidence and the most current understanding of pain management practices in ICU. CONCLUSIONS Myths and misconceptions regarding management of pain in the ICU are prevalent. Review of current evidence refutes these myths and misconceptions and provides insights and recommendations to ensure best practices.
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Abstract
Acute pain management remains a challenge in opioid dependent patients, and it has been recognised that these patients are commonly under-treated.Chronic opioid exposure leads to widespread adaptations both at cellular and synaptic level.Physical dependence is a neuropharmacological phenomenon as a result of neuroadaptation and neuroplasticity, in contrast to addiction that is both neuropharmacological and behavioural.While providing the patient's pre-existing opioid requirement, the acute pain episode should be managed using additional multimodal analgesia: non-opioid medications in combination with local anaesthetic techniques and as required, short-acting opioid titrated to effect.Patients on long term buprenorphine and methadone with acute pain episode should be continued with their maintenance therapy and an additional short-acting opioid analgesic titrated to achieve therapeutic effect.
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Affiliation(s)
- Vivek Mehta
- Consultants in Pain Medicine and Anaesthesia, Pain and Anaesthesia Research Centre, St Bartholomew's Hospital. Barts and The London NHS Trust, London, UK
| | - Richard Langford
- Consultants in Pain Medicine and Anaesthesia, Pain and Anaesthesia Research Centre, St Bartholomew's Hospital. Barts and The London NHS Trust, London, UK
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Wilson JLC, Poulin PA, Sikorski R, Nathan HJ, Taljaard M, Smyth C. Opioid use among same-day surgery patients: Prevalence, management and outcomes. Pain Res Manag 2015; 20:300-4. [PMID: 26357683 PMCID: PMC4676499 DOI: 10.1155/2015/897491] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine whether the prevalence of opioid use among patients requiring elective same-day admission (SDA) surgery is greater than the 2.5% prevalence found in the general population. Secondary objectives were to assess compliance with expert recommendations on acute pain management in opioid-tolerant patients and to examine clinical outcomes. METHODS A retrospective review of 812 systematically sampled adult SDA surgical cases between April 1, 2008 and March 31, 2009 was conducted. RESULTS Among 798 eligible patients, 148 (18.5% [95% CI 15.9% to 21.2%]) were prescribed opioids, with 4.4% prescribed long-acting opioids (95% CI 3.0% to 5.8%). Use of opioids was most prevalent among orthopedic and neurosurgery patients. Among the 35 patients on long-acting opioids who had a high likelihood of being tolerant, anesthesiologists correctly identified 33, but only 13 (37%) took their usual opioid preoperatively while 22 (63%) had opioids continued postoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered preoperatively in 18 (51%), 15 (43%) and 18 (51%) cases, respectively, while ketamine was used in 15 (43%) patients intraoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered postoperatively in 31 (89%), 15 (43%) and 17 (49%) of the cases, respectively. No differences in length of stay, readmissions and emergency room visits were found between opioid-tolerant and opioid-naive patients. CONCLUSION Opioid use is more common in SDA surgical patients than in the general population and is most prevalent within orthopedic and neurosurgery patients. Uptake of expert opinion on the management of acute pain in the opioid tolerant patient population is lacking.
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Affiliation(s)
| | - Patricia A Poulin
- Department of Anesthesiology, University of Ottawa
- Department of Psychology, The Ottawa Hospital, University of Ottawa, Ottawa
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa
- School of Psychology, University of Ottawa, Ottawa
| | - Robert Sikorski
- Department of Anesthesiology, Thunder Bay Regional Health Sciences Centre, Thunder Bay
| | - Howard J Nathan
- Department of Anesthesiology, University of Ottawa
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario
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Malcolm C. Acute pain management in the older person. J Perioper Pract 2015; 25:134-139. [PMID: 26309959 DOI: 10.1177/1750458915025007-804] [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: 06/04/2023]
Abstract
The proportion of older people in society is growing steadily. This particular group is more likely to be admitted to hospital and a number of papers have highlighted the inadequate or inappropriate assessment and management of their pain, particularly in the perioperative period. Pain relief is possible for the majority of people. This paper aims to give an overview of the assessment and management of pain in older people.
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Xavier Scheuermeyer F, Andolfatto G, Qian H, Grafstein E. Does the sedation regimen affect adverse events during procedural sedation and analgesia in injection drug users? CAN J EMERG MED 2015; 15:279-88. [PMID: 23972133 DOI: 10.2310/8000.2013.130933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) as part of emergency department (ED) treatment. We compared adverse events (AEs) using a variety of sedation regimens. METHODS This was a retrospective analysis of a PSA safety audit in two urban EDs. Consecutive self-reported IDUs were identified, and structured data describing comorbidities, vital signs, sedation regimens (propofol [P], propofol-fentanyl [PF], fentanyl-midazolam [FM], ketofol [1:1 ketamine:propofol, KF], and ketamine-propofol [KP]) and AEs were collected. The primary outcome was the proportion of patients in each sedation group having an AE; the secondary outcome was the proportion of patients having a cardiovascular or respiratory AE. RESULTS Data were collected on 276 IDUs (78 P, 82 PF, 65 FM, 25 KF, and 26 KP), and 18 patients had AEs (6.5%, 95% CI 4.0-10.3). The AE rates were 0.0%, 8.5%, 9.2%, 12.0%, and 7.6%, respectively, with propofol having a significantly lower rate (Pearson coefficient 14.9, p = 0.007). The cardiovascular/respiratory AE rates were significantly different as well, with P, KP, and KF having the lowest rates (Pearson coefficient 13.3, p = 0.01). CONCLUSIONS For IDU PSA, the overall AE rate was 6.5%, and propofol appeared to have a significantly lower rate.
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Eyler ECH. Chronic and acute pain and pain management for patients in methadone maintenance treatment. Am J Addict 2014; 22:75-83. [PMID: 23398230 DOI: 10.1111/j.1521-0391.2013.00308.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 03/01/2012] [Accepted: 08/20/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many individuals receiving methadone maintenance treatment (MMT) for opioid addiction also require treatment for acute or chronic pain, and the presence of pain is known to have a negative impact on patient health and function. However, effective pain management in this population is complicated by many factors, including heightened pain sensitivity, high opioid tolerance, illicit substance use, and variable cross-tolerance to opioid pain medications. This article reviews the recent literature on acute and chronic pain among, and pain treatment of, patients receiving MMT for opioid addiction and discusses the implications for effective pain management. Acute pain management among women maintained on methadone during and after labor and delivery is also discussed, as well as common concerns held by patients and providers about appropriate pain management strategies in the context of methadone maintenance and addiction treatment. METHODS One hundred nine articles were identified in a PubMed/MEDLINE electronic database search using the following search terms: methadone, methadone maintenance, methadone addiction, pain, pain management, chronic pain, and acute pain. Abstracts were reviewed for relevance, and additional studies were extracted from the reference lists of articles identified in the original search. RESULTS The pain sensitivity and pain responses of MMT patients differ significantly from those of patients not maintained on opioids, and few data are available to guide patient care. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Rigorous studies are needed to identify and evaluate effective pain management approaches for this unique patient population and to improve patient treatment outcomes.
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Affiliation(s)
- Elizabeth C H Eyler
- JBS International, Inc., 5515 Security Lane, Suite 800, North Bethesda, MD 20852, USA.
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Juan Pablo Acuña B. Tratamiento del dolor agudo en el paciente dependiente de sustancias. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70088-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Wasson M, Beirne OR. Buprenorphine therapy: an increasing challenge in oral and maxillofacial surgery. Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 116:142-6. [PMID: 23849373 DOI: 10.1016/j.oooo.2013.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 03/10/2013] [Accepted: 04/27/2013] [Indexed: 11/30/2022]
Abstract
Suboxone is a 4:1 mixture of buprenorphine and naloxone and Subutex is buprenorphine alone. The high affinity μ-receptor binding of buprenorphine (Suboxone and Subutex) renders other opioids ineffective. Inadequate procedural sedation, inadequate analgesia, and significant drug interactions complicate the treatment of patients taking Suboxone or Subutex. Careful planning and an understanding of buprenorphine pharmacology can minimize potential perioperative complications in patients taking Suboxone or Subutex.
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Affiliation(s)
- Michael Wasson
- Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, WA 98195-7134, USA
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47
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Clark AJ, Spanswick CC. Why anesthesiologists need to care about the way chronic pain is managed. Can J Anaesth 2013; 61:95-100. [DOI: 10.1007/s12630-013-0066-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 10/22/2013] [Indexed: 11/29/2022] Open
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Barreveld AM, Correll DJ, Liu X, Max B, McGowan JA, Shovel L, Wasan AD, Nedeljkovic SS. Ketamine decreases postoperative pain scores in patients taking opioids for chronic pain: results of a prospective, randomized, double-blind study. PAIN MEDICINE 2013; 14:925-34. [PMID: 23786558 DOI: 10.1111/pme.12086] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients prescribed opioids for chronic pain may suffer from inadequate postoperative pain control. Ketamine is an adjuvant demonstrating analgesic and opioid-sparing effects. We hypothesize that an intravenous ketamine infusion in addition to opioid-based patient-controlled analgesia (PCA) improves postoperative pain relief in this patient population. METHODS We evaluated 64 patients with chronic pain taking opioids undergoing nononcologic surgery. Patients were randomized to receive either postoperative hydromorphone PCA and continuous ketamine (0.2 mg/kg/hour), or hydromorphone PCA and saline. Patients provided numeric rating scale (NRS) pain scores for "worst," "average," and "least" pain following surgery. The primary outcome measure was change in patients' postoperative NRS scores compared with baseline NRS. Secondary and tertiary outcomes included postoperative day one 24-hour opioid use and the amount of opioid used 24 hours prior to hospital discharge. RESULTS Fifty-nine patients were included in the analysis. Baseline patient characteristics were similar with the exception of age. Patients using ketamine had decreased "average" pain scores (percent change between postoperative and preoperative NRS) after surgery (13.5% decrease in the ketamine group vs 15.5% increase in NRS in the placebo group, P = 0.0057). There were no differences in "worst" or "least" pain scores or postoperative opioid use. Side effects between groups were similar. CONCLUSIONS Our study demonstrates that a postoperative ketamine infusion at 0.2 mg/kg/hour in addition to opioids results in a statistically significant reduction of "average" pain scores in patients undergoing surgery who take opioids for chronic pain. However, "least" and "worst" pain scores and the amount of opioid used postoperatively did not differ between groups. Thus, the use of a postoperative ketamine infusion at 0.2 mg/kg/hour provides limited benefit in improving pain management for this challenging population.
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Affiliation(s)
- Antje M Barreveld
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Gharaei B, Jafari A, Aghamohammadi H, Kamranmanesh M, Poorzamani M, Elyassi H, Rostamian B, Salimi A. Opioid-Sparing Effect of Preemptive Bolus Low-Dose Ketamine for Moderate Sedation in Opioid Abusers Undergoing Extracorporeal Shock Wave Lithotripsy. Anesth Analg 2013; 116:75-80. [DOI: 10.1213/ane.0b013e31826f0622] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Upp J, Kent M, Tighe PJ. The evolution and practice of acute pain medicine. PAIN MEDICINE (MALDEN, MASS.) 2013; 14:124-44. [PMID: 23241132 PMCID: PMC3547126 DOI: 10.1111/pme.12015] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In recent years, the field of acute pain medicine (APM) has witnessed a surge in its development, and pain has begun to be recognized not merely as a symptom, but as an actual disease process. This development warrants increased education of residents both in the performance of regional anesthesia as well as in the disease course of acute pain and the biopsychosocial mechanisms that define interindividual variability. REVIEW SUMMARY We reviewed the organization and function of the modern APM program. Following a discussion of the nomenclature of acute pain-related practices, we discuss the historical evolution and modern role of APM teams, including the use of traditional, as well as complementary and alternative, therapies for treating acute pain. Staffing and equipment requirements are also evaluated, in addition to the training requirements for achieving expertise in APM. Lastly, we briefly explore future considerations related to the essential role and development of APM. CONCLUSION The scope and practice of APM must be expanded to include pre-pain/pre-intervention risk stratification and extended through the phase of subacute pain.
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Affiliation(s)
- Justin Upp
- Staff Anesthesiologist, Walter Reed National Military Medical Center, Bethesda, MD
| | - Michael Kent
- Staff Anesthesiologist, Walter Reed National Military Medical Center, Bethesda, MD
| | - Patrick J. Tighe
- Assistant Professor of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
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