1
|
Lane O, Ambai V, Bakshi A, Potru S. Alcohol use disorder in the perioperative period: a summary and recommendations for anesthesiologists and pain physicians. Reg Anesth Pain Med 2024; 49:621-627. [PMID: 38050177 DOI: 10.1136/rapm-2023-104354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 09/26/2023] [Indexed: 12/06/2023]
Abstract
Excessive alcohol consumption and alcohol use disorder (AUD) increase the risk of perioperative morbidity and mortality. Aspiration, malnutrition, coagulopathies, seizures, and hemodynamic alterations are only a few of the major concerns related to acute alcohol intoxication and AUD. There are also numerous physiological effects, changes in medication metabolism and pharmacology, and adverse events related to chronic alcohol consumption. These are all important considerations for the anesthesiologist in the perioperative management of a patient with AUD. Pain perception and thresholds are altered in patients with acute and chronic alcohol use. Medications used to manage AUD symptoms, particularly naltrexone, can have significant perioperative implications. Patients on naltrexone who continue or stop this medication in the perioperative period are at an increased risk for undertreated pain or substance use relapse. This review highlights key considerations for the anesthesiologist and pain physician in the perioperative management of patients with active AUD (or those in recovery). It discusses the effects of acute and chronic alcohol use on pain perception and thresholds, provides guidance on the perioperative management of naltrexone and low-dose naltrexone, and reviews a multimodal approach to pain management.
Collapse
Affiliation(s)
- Olabisi Lane
- Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vats Ambai
- Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arjun Bakshi
- Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sudheer Potru
- Atlanta VA Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
2
|
Larach DB, Waljee JF, Bicket MC, Brummett CM, Bruehl S. Perioperative opioid prescribing and iatrogenic opioid use disorder and overdose: a state-of-the-art narrative review. Reg Anesth Pain Med 2024; 49:602-608. [PMID: 37931982 PMCID: PMC11070448 DOI: 10.1136/rapm-2023-104944] [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: 08/15/2023] [Accepted: 10/22/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND/IMPORTANCE Considerable attention has been paid to identifying and mitigating perioperative opioid-related harms. However, rates of postsurgical opioid use disorder (OUD) and overdose, along with associated risk factors, have not been clearly defined. OBJECTIVE Evaluate the evidence connecting perioperative opioid prescribing with postoperative OUD and overdose, compare these data with evidence from the addiction literature, discuss the clinical impact of these conditions, and make recommendations for further study. EVIDENCE REVIEW State-of-the-art narrative review. FINDINGS Nearly all evidence is from large retrospective studies of insurance claims and Veterans Health Administration (VHA) data. Incidence rates of new OUD within the first year after surgery ranged from 0.1% to 0.8%, while rates of overdose events ranged from 0.01% to 0.8%. Higher rates were seen among VHA patients, which may reflect differences in data completeness and/or risk factors. Identified risk factors included those related to substance use (preoperative opioid use; non-opioid substance use disorders; preoperative sedative, anxiolytic, antidepressant, and gabapentinoid use; and postoperative new persistent opioid use (NPOU)); demographic attributes (chiefly male sex, younger age, white race, and Medicaid or no insurance coverage); psychiatric comorbidities such as depression, bipolar disorder, and PTSD; and certain medical and surgical factors. Several challenges related to the use of administrative claims data were identified; there is a need for more granular retrospective studies and, ideally, prospective cohorts to assess postoperative OUD and overdose incidence with greater accuracy. CONCLUSIONS Retrospective data suggest an incidence of new postoperative OUD and overdose of up to 0.8% during the first year after surgery, but prospective studies are lacking.
Collapse
Affiliation(s)
- Daniel B Larach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
3
|
Chen Y, Wang E, Sites BD, Cohen SP. Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians. Reg Anesth Pain Med 2024; 49:581-601. [PMID: 36707224 DOI: 10.1136/rapm-2022-104203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.
Collapse
Affiliation(s)
- Yian Chen
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Wang
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Brian D Sites
- Anesthesiology and Orthopaedics, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
4
|
Goel A, Kapoor B, Wu M, Iyayi M, Englesakis M, Kohan L, Ladha KS, Clarke HA. Perioperative Naltrexone Management: A Scoping Review by the Perioperative Pain and Addiction Interdisciplinary Network. Anesthesiology 2024; 141:388-399. [PMID: 38980158 DOI: 10.1097/aln.0000000000005040] [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: 07/10/2024]
Abstract
Substance use disorders, including alcohol use disorder, are a public health concern that affect more than 150 million people globally. The opioid antagonist naltrexone is being increasingly prescribed to treat opioid use disorder, alcohol use disorder, and chronic pain. Perioperative management of patients on naltrexone is inconsistent and remains a controversial topic, with mismanagement posing a significant risk to the long-term health of these patients. This scoping review was conducted to identify human studies in which the perioperative management of naltrexone was described. This review includes a systematic literature search involving Medline, Medline In-Process, Embase, PsycINFO, and Web of Science. Seventeen articles that describe perioperative naltrexone management strategies were included, including thirteen guidelines, one case report, and three randomized trials. Despite its use in patients with alcohol use disorder and chronic pain, no clinical studies, case reports, or guidelines addressed naltrexone use in these clinical populations. All of the guideline documents recommended the preoperative cessation of naltrexone, irrespective of dose, indication, or route of administration. None of these guideline documents were designed on the basis of a systematic literature search or a Delphi protocol. As described by the primary studies, perioperative pain relief varied depending on naltrexone dose and route of administration, time since last naltrexone administration, and underlying substance use disorder. None of the studies commented on the maintenance of recovery for the patient's substance use disorder in the context of perioperative naltrexone management. The current understanding of the risks and benefits of continuing or stopping naltrexone perioperatively is limited by a lack of high-quality evidence. In patients with risk factors for return to use of opioids or alcohol, the discontinuation of naltrexone should have a strong rationale. Future studies and guidelines should seek to address both acute pain management and maintaining recovery when discussing perioperative naltrexone management strategies.
Collapse
Affiliation(s)
- Akash Goel
- Department of Anesthesiology, St. Michael's Hospital, Toronto, Canada; Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | | | - Mia Wu
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Mudia Iyayi
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Canada
| | - Lynn Kohan
- Department of Anaesthesiology, University of Virginia, Charlottesville, Virginia
| | - Karim S Ladha
- Department of Anesthesiology, St. Michael's Hospital, Toronto, Canada; Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Hance A Clarke
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Anesthesiology and Pain Medicine, Toronto General Hospital, Toronto, Canada
| |
Collapse
|
5
|
Jain L, Meeks TW, Blazes CK. Reconsidering the usefulness of long-term high-dose buprenorphine. Front Psychiatry 2024; 15:1401676. [PMID: 39114740 PMCID: PMC11303732 DOI: 10.3389/fpsyt.2024.1401676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/04/2024] [Indexed: 08/10/2024] Open
Abstract
Buprenorphine has been successfully used for decades in the treatment of opioid use disorder, yet there are complexities to its use that warrant attention to maximize its utility. While the package insert of the combination product buprenorphine\naloxone continues to recommend a maximum dose of 16 mg daily for maintenance, the emergence of fentanyl and synthetic analogs in the current drug supply may be limiting the effectiveness of this standard dose. Many practitioners have embraced and appropriately implemented novel practices to mitigate the sequelae of our current crisis. It has become common clinical practice to stabilize patients with 24 - 32 mg of buprenorphine daily at treatment initiation. Many of these patients, however, are maintained on these high doses (>16 mg/d) indefinitely, even after prolonged stability. Although this may be a necessary strategy in the short term, there is little evidence to support its safety and efficacy, and these high doses may be exposing patients to more complications and side effects than standard doses. Commonly known side effects of buprenorphine that are likely dose-related include hyperhidrosis, sedation, decreased libido, constipation, and hypogonadism. There are also complications related to the active metabolite of buprenorphine (norbuprenorphine) which is a full agonist at the mu opioid receptor and does not have a ceiling on respiratory suppression. Such side effects can lead to medical morbidity as well as decreased medication adherence, and we, therefore, recommend that after a period of stabilization, practitioners consider a trial of decreasing the dose of buprenorphine toward standard dose recommendations. Some patients' path of recovery may never reach this stabilization phase (i.e., several months of adherence to medications, opioid abstinence, and other clinical indicators of stability). Side effects of buprenorphine may not have much salience when patients are struggling for survival and safety, but for those who are fortunate enough to advance in their recovery, the side effects become more problematic and can limit quality of life and adherence.
Collapse
Affiliation(s)
- Lakshit Jain
- Department of Psychiatry, University of Connecticut, Farmington, CT, United States
| | - Thomas W. Meeks
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Christopher K. Blazes
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Foglia R, Yan J, Dizdarevic A. Methadone and Buprenorphine in the Perioperative Setting: A Review of the Literature. Curr Pain Headache Rep 2024:10.1007/s11916-024-01286-8. [PMID: 38907792 DOI: 10.1007/s11916-024-01286-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 06/24/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the most recent literature and guidelines regarding perioperative methadone and buprenorphine use. RECENT FINDINGS Surgical patients taking methadone and buprenorphine are being encountered more frequently in the perioperative period, and providers are becoming more familiar with their pharmacologic properties, benefits as well as precautions. Recommendations pertaining to buprenorphine therapy in the perioperative settings have changed in recent years, owing to more clinical and basic science research. In addition to their use in chronic pain and opioid use disorders, they can also be initiated for acute postoperative pain indications, in select patients and situations. Methadone and buprenorphine are being more commonly prescribed for pain management and opioid use disorder, and their continuation during the perioperative period is generally recommended, to reduce the risk of opioid withdrawal, relapse, or inadequately controlled pain. Additionally, both may be initiated safely and effectively for acute pain management during and after the operating room period.
Collapse
Affiliation(s)
- Ralph Foglia
- Columbia University Medical Center, New York, NY, USA
| | - Jasper Yan
- Columbia University Medical Center, New York, NY, USA
| | | |
Collapse
|
8
|
Morrissey PJ, Quinn M, Mikolasko B, Fadale PD. Optimizing Safe Opioid Prescribing: A Paradigm Shift in Buprenorphine Management for Orthopaedic Surgery. J Arthroplasty 2024:S0883-5403(24)00652-1. [PMID: 38914144 DOI: 10.1016/j.arth.2024.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 06/26/2024] Open
Abstract
The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in perioperative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the perioperative period. The patient's buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a preoperative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Nonsteroidal anti-inflammatory drugs when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate-release opioids for breakthrough pain. Transdermal buprenorphine is emerging as an excellent option for the management of acute perioperative pain in both elective and nonelective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to 1 week during the postoperative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, transdermal buprenorphine patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, etc. As the stigma surrounding buprenorphine decreases, further opportunities for perioperative use may develop.
Collapse
Affiliation(s)
- Patrick J Morrissey
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew Quinn
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Brian Mikolasko
- Department of Palliative Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul D Fadale
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| |
Collapse
|
9
|
Patel J, Snyder K, Brooks AK. Perioperative pain optimization in the age of the opioid epidemic. Curr Opin Anaesthesiol 2024; 37:279-284. [PMID: 38573179 DOI: 10.1097/aco.0000000000001370] [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: 04/05/2024]
Abstract
PURPOSE OF REVIEW The opioid epidemic remains a constant and increasing threat to our society with overdoses and overdose deaths rising significantly during the COVID-19 pandemic. Growing evidence suggests a link between perioperative opioid use, postoperative opioid prescribing, and the development of opioid use disorder (OUD). As a result, strategies to better optimize pain management during the perioperative period are urgently needed. The purpose of this review is to summarize the most recent multimodal analgesia (MMA) recommendations, summarize evidence for efficacy surrounding the increased utilization of Enhanced Recovery After Surgery (ERAS) protocols, and discuss the implications for rising use of buprenorphine for OUD patients who present for surgery. In addition, this review will explore opportunities to expand our treatment of complex patients via transitional pain services. RECENT FINDINGS There is ample evidence to support the benefits of MMA. However, optimal drug combinations remain understudied, presenting a target area for future research. ERAS protocols provide a more systematic and targeted approach for implementing MMA. ERAS protocols also allow for a more comprehensive approach to perioperative pain management by necessitating the involvement of surgical specialists. Increasingly, OUD patients taking buprenorphine are presenting for surgery. Recent guidance from a multisociety OUD working group recommends that buprenorphine not be routinely discontinued or tapered perioperatively. Lastly, there is emerging evidence to justify the use of transitional pain services for more comprehensive treatment of complex patients, like those with chronic pain, preoperative opioid tolerance, or substance use disorder. SUMMARY Perioperative physicians must be aware of the impact of the opioid epidemic and explore methods like MMA techniques, ERAS protocols, and transitional pain services to improve the perioperative pain experience and decrease the risks of opioid-related harm.
Collapse
Affiliation(s)
- Janki Patel
- Department of Anesthesiology, Section on Pain Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | | |
Collapse
|
10
|
Englander H, Thakrar AP, Bagley SM, Rolley T, Dong K, Hyshka E. Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl: A Review. JAMA Intern Med 2024; 184:691-701. [PMID: 38683591 DOI: 10.1001/jamainternmed.2023.7282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Importance The rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions. Observations Clinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl's high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl's unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians' understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing. Conclusions and Relevance The findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.
Collapse
Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in General Internal Medicine and the Division of Hospital Medicine, Department of Medicine, Oregon Health and Science University, Portland
| | - Ashish P Thakrar
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sarah M Bagley
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | | | - Kathryn Dong
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
11
|
Gagnon DJ, Glenn MJ, Quaye AA, Erstad BL. Buprenorphine in the Intensive Care Unit: Commentary on the Unanswered Questions. Ann Pharmacother 2024:10600280241254528. [PMID: 38755998 DOI: 10.1177/10600280241254528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
The removal of the X-waiver in the Mainstreaming Addiction Treatment (MAT) Act of 2023 has substantial implications for buprenorphine prescribing as one of the options to treat opioid use disorder. The purpose of this commentary is to discuss the unanswered questions regarding buprenorphine in the intensive care unit (ICU) including how the passage of the MAT Act will affect ICU providers, which patients should receive buprenorphine, what is the most appropriate route of administration and dose of buprenorphine, what medications interact with buprenorphine, and how can transitions of care be optimized for these patients.
Collapse
Affiliation(s)
- David J Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA
- MaineHealth Institute for Research, Scarborough, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Melody J Glenn
- Banner-University Medical Center Tucson Base Hospital, Tucson, AZ, USA
- Emergency Medicine & Psychiatry, University of Arizona College of Medicine-Tucson, Tucson, AZ, USA
| | - Aurora A Quaye
- Tufts University School of Medicine, Boston, MA, USA
- Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, ME, USA
- Spectrum Healthcare Partners, South Portland, ME, USA
| | - Brian L Erstad
- University of Arizona College of Pharmacy, Tucson, AZ, USA
| |
Collapse
|
12
|
Patel K, Lee P, Witherspoon J, Patel K, Jermyn R. The Efficacy of Buprenorphine in Preoperative and Postoperative Patients: A Literature Review. Cureus 2024; 16:e60341. [PMID: 38883082 PMCID: PMC11177744 DOI: 10.7759/cureus.60341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/18/2024] Open
Abstract
Although research suggests that less than half of individuals who have surgical procedures report effective postoperative pain alleviation, the majority of patients endure acute postoperative discomfort. To lessen and manage postoperative pain, a variety of preoperative, intraoperative, and postoperative treatments and management methods are available. For several years an opioid called buprenorphine has become an effective tool to treat opioid use disorder (OUD) in patients across many different demographics. It has however endured barriers to its usage which can be seen when treating patients with chronic pain or postoperative pain, who also have an OUD. While buprenorphine may be underutilized within the clinical setting, the significantly low rates of chronic abuse when using the drug allow it to be an attractive treatment option for patients. This paper aims to explore a wide range of studies that examine buprenorphine as an analgesic and how it can be used for preoperative pain and postoperative pain. This paper will give an in-depth analysis of buprenorphine and its use in patients with chronic pain as well as OUD. A systematic literature review was performed by identifying studies through the database PubMed. The data from various publications were gathered with preference being given to publications within the last three years. We reviewed studies that examined the pain level of the patients after having buprenorphine. Despite long-available pharmacologic evidence and clinical research, buprenorphine has maintained a mystique as an analgesic. Its usage in the treatment of OUD was further influenced by its well-known safety benefits and relative lack of psychomimetic side effects compared to other opioids. For patients accustomed to long-term, high-dose opioids who may be experiencing hyperalgesia but have not been informed about this phenomenon by their doctors or the potential for buprenorphine to resolve it, buprenorphine's pronounced antihyperalgesic effect is a compelling pharmacologic characteristic that makes it particularly attractive as an option. When used in pre-, peri-, and postoperative circumstances, buprenorphine provides various pain-management benefits and patients can still benefit from effective pain management from mu-opioid agonists while remaining on buprenorphine. Buprenorphine can be continued at a reduced dose as needed to avoid withdrawal symptoms and to improve the analgesic efficiency of mu-opioid agonists used in combination with acute postoperative pain in light of the evidence at hand. Buprenorphine administration needs a patient-centered, multidisciplinary strategy that considers the benefits and drawbacks of the many perioperative therapy options to have the best chance of success.
Collapse
Affiliation(s)
- Keyur Patel
- College of Medicine, NeuroMusculoskeletal Institute, Rowan-Virtua School of Osteopathic Medicine, Stratford, USA
| | - Paul Lee
- College of Medicine, NeuroMusculoskeletal Institute, Rowan-Virtua School of Osteopathic Medicine, Stratford, USA
| | - Jessica Witherspoon
- College of Medicine, NeuroMusculoskeletal Institute, Rowan-Virtua School of Osteopathic Medicine, Stratford, USA
| | - Kunnal Patel
- College of Medicine, NeuroMusculoskeletal Institute, Rowan-Virtua School of Osteopathic Medicine, Stratford, USA
| | - Richard Jermyn
- Physical Medicine and Rehabilitation, NeuroMusculoskeletal Institute, Rowan-Virtua School of Osteopathic Medicine, Stratford, USA
| |
Collapse
|
13
|
Sandhu S, Calcaterra SL. How Do I Manage Acute Pain for Patients Prescribed Buprenorphine for Opioid Use Disorder? NEJM EVIDENCE 2024; 3:EVIDccon2300275. [PMID: 38815158 PMCID: PMC11282871 DOI: 10.1056/evidccon2300275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
AbstractA growing number of patients are prescribed buprenorphine for opioid use disorder (OUD). Consequently, clinicians are likely to encounter hospitalized patients with acute surgical or nonsurgical pain who are also prescribed buprenorphine for OUD. This scenario evokes the clinical question of how to adequately manage acute pain among hospitalized patients receiving buprenorphine for OUD. This article reviews buprenorphine's pharmacology, describes various buprenorphine products used to treat pain and OUD, and provides pain management recommendations for patients prescribed buprenorphine in the setting of acute surgical and nonsurgical pain.
Collapse
Affiliation(s)
- Sukhmeet Sandhu
- Department of Family Medicine, University of Colorado, Aurora
| | - Susan L Calcaterra
- Department of Medicine, Divisions of General Internal Medicine and Hospital Medicine, University of Colorado, Aurora
| |
Collapse
|
14
|
Quaye A, Tsafnat T, Richard JM, Stoddard H, Gagnon DJ. Post-operative pain control in patients on buprenorphine or methadone for opioid use disorder. J Opioid Manag 2024; 20:233-241. [PMID: 39017615 DOI: 10.5055/jom.0823] [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: 07/18/2024]
Abstract
OBJECTIVE This study aimed to determine whether there is a difference in pain scores and opioid consumption after elective surgery in patients maintained on methadone or buprenorphine for opioid use disorder (OUD). Additionally, we investigated the impact of continuing or discontinuing methadone or buprenorphine on post-operative pain outcomes. DESIGN A single-center retrospective cohort study. SETTING Tertiary care medical center. PATIENTS AND PARTICIPANTS Adults aged 18 years or older with OUD maintained on buprenorphine or methadone who underwent elective surgery between January 1, 2017, and January 1, 2021. INTERVENTIONS Patients were identified through electronic medical records, and demographic and clinical data were collected. MAIN OUTCOME MEASURES The primary outcome was opioid consumption at 24 hours post-operatively, measured in milligram morphine equivalents. The secondary outcome was opioid consumption and pain scores up to 72 hours post-operatively, assessed using a numeric rating scale. RESULTS This study included 366 patients (64 percent on buprenorphine and 36 percent on methadone). Opioid utilization significantly increased when buprenorphine was not administered post-operatively. Both groups exhibited comparable total opioid consumption during the post-operative period. In the buprenorphine cohort, pain scores differed significantly based on the receipt of medications for OUD post-operatively. CONCLUSIONS This study reinforces existing evidence supporting the continuation of medications for opioid use disorder, specifically buprenorphine and methadone, during the perioperative period. Dissemination of guideline recommendations is essential to ensure optimal post-operative pain management for this patient population.
Collapse
Affiliation(s)
- Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland; Division of Anesthesiology, Spectrum Healthcare Partners, South Portland, Maine; Tufts University School of Medicine, Boston, Massachusetts. ORCID: https://orcid.org/0000-0002-7573-2164
| | - Tal Tsafnat
- University of New England College of Osteopathic Medicine, Portland, Maine
| | - Janelle M Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine. ORCID: https://orcid.org/0000-0002-2825-6134
| | - Henry Stoddard
- Center for Interdisciplinary Population & Health Research, Maine Health Institute for Research, Scarborough, Maine
| | - David J Gagnon
- Tufts University School of Medicine, Boston, Massachusetts; Department of Pharmacy, Maine Medical Center, Portland; MaineHealth Institute for Research, Scarborough, Maine
| |
Collapse
|
15
|
Shelton T, Nama S, Hall O, Williams M. Case report: Successful induction of buprenorphine in medically complex patients concurrently on opioids: a case series at a tertiary care center. Front Pharmacol 2024; 15:1335345. [PMID: 38523636 PMCID: PMC10960361 DOI: 10.3389/fphar.2024.1335345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/08/2024] [Indexed: 03/26/2024] Open
Abstract
Effective pain management is essential for optimal surgical outcomes; however, it can be challenging in patients with a history of opioid use disorder (OUD). Buprenorphine, a partial opioid agonist, is a valuable treatment option for patients with OUD. Initiating buprenorphine treatment in patients concurrently taking opioids can be complex due to potential adverse outcomes like precipitated withdrawal. Evolving guidelines suggest there are benefits to continuing buprenorphine for surgical patients throughout the perioperative period, however situations do arise when buprenorphine has been discontinued. Typically, in this scenario patients would be restarted on buprenorphine after they have fully recovered from post-surgical pain and no longer require opioids for pain control. Unfortunately, holding MOUD may expose the patient to risks such as opioid induced respiratory depression or addiction relapse. In this case series, we discuss a novel method to restart buprenorphine in small incremental doses, known as micro-dosing, while the patient is still taking opioids for pain. We will present two complex clinical cases when this method was used successfully at a tertiary care hospital system.
Collapse
Affiliation(s)
- Thomas Shelton
- The Ohio State University College of Medicine, Columbus, OH, United States
| | - Sharanya Nama
- Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Orman Hall
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Margaret Williams
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| |
Collapse
|
16
|
Erstad BL, Glenn MJ. Considerations and limitations of buprenorphine prescribing for opioid use disorder in the intensive care unit setting: A narrative review. Am J Health Syst Pharm 2024; 81:171-182. [PMID: 37979138 DOI: 10.1093/ajhp/zxad289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE The purpose of this review is to discuss important considerations when prescribing buprenorphine for opioid use disorder (OUD) in the intensive care unit (ICU) setting, recognizing the challenges of providing detailed recommendations in the setting of limited available evidence. SUMMARY Buprenorphine is a partial mu-opioid receptor agonist that is likely to be increasingly prescribed for OUD in the ICU setting due to the relaxation of prescribing regulations. The pharmacology and pharmacokinetics of buprenorphine are complicated by the availability of several formulations that can be given by different administration routes. There is no single optimal dosing strategy for buprenorphine induction, with regimens ranging from very low-dose to high dose regimens. Faster induction with higher doses of buprenorphine has been studied and is frequently utilized in the emergency department. In patients admitted to the ICU who were receiving opioids either medically or illicitly, analgesia will not occur until their baseline opioid requirements are covered when their preadmission opioid is either reversed or interrupted. For patients in the ICU who are not on buprenorphine at the time of admission but have possible OUD, there are no validated tools to diagnose OUD or the severity of opioid withdrawal in critically ill patients unable to provide the subjective components of instruments validated in outpatient settings. When prescribing buprenorphine in the ICU, important issues to consider include dosing, monitoring, pain management, use of adjunctive medications, and considerations to transition to outpatient therapy. Ideally, addiction and pain management specialists would be available when buprenorphine is prescribed for critically ill patients. CONCLUSION There are unique challenges when prescribing buprenorphine for OUD in critically ill patients, regardless of whether they were receiving buprenorphine when admitted to the ICU setting for OUD or are under consideration for buprenorphine initiation. There is a critical need for more research in this area.
Collapse
Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Melody J Glenn
- Department of Emergency Medicine and Department of Psychiatry, University of Arizona College of Medicine/Banner University Medical Center, Tucson, AZ, USA
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Erstad BL, Glenn MJ. Management of Critically Ill Patients Receiving Medications for Opioid Use Disorder. Chest 2024; 165:356-367. [PMID: 37898187 DOI: 10.1016/j.chest.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 10/30/2023] Open
Abstract
TOPIC IMPORTANCE Critical care clinicians are likely to see an increasing number of patients admitted to the ICU who are receiving US Food and Drug Administration-approved medications for opioid use disorder (MOUDs) given the well-documented benefits of these agents. Oral methadone, multiple formulations of buprenorphine, and extended-release naltrexone are the three types of MOUD most likely to be encountered by ICU clinicians; however, these drugs vary with respect to formulations, pharmacokinetics, and adverse effects. REVIEW FINDINGS No published clinical practice guidelines or consensus statements are available to guide decision-making in patients admitted to the ICU setting who are receiving MOUDs before admission. Additionally, no randomized trials and limited observational studies have evaluated issues related to MOUD use in the ICU. Therefore, ICU clinicians caring for patients admitted who are taking MOUDs must base their decision-making on data extrapolation from pharmacokinetic, pharmacologic, and clinical studies performed in non-ICU settings. SUMMARY Despite the challenges in administering MOUDs in critically ill patients, extrapolation of data from other hospital settings suggests that the benefits of continuing MOUD therapy outweigh the risks in patients able to continue therapy. This article provides guidance for critical care clinicians caring for patients admitted to the ICU already receiving methadone, buprenorphine, or extended-release naltrexone. The guidance includes algorithms to aid clinicians in the clinical decision-making process, recognizing the inherent limitations of the existing evidence on which the algorithms are based and the need to account for patient-specific considerations.
Collapse
Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ.
| | - Melody J Glenn
- Departments of Emergency Medicine and Psychiatry, University of Arizona College of Medicine/Banner University Medical Center, Tucson, AZ
| |
Collapse
|
19
|
Laks J, Alford DP. Treatment of opioid use disorder in patients with liver disease. Clin Liver Dis (Hoboken) 2024; 23:e0207. [PMID: 38831768 PMCID: PMC11146471 DOI: 10.1097/cld.0000000000000207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/15/2024] [Indexed: 06/05/2024] Open
|
20
|
McNaughton MA, Quinlan-Colwell A, Lyons MT, Arkin LC. Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice. Orthop Nurs 2024; 43:10-22. [PMID: 38266259 DOI: 10.1097/nor.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.
Collapse
Affiliation(s)
- Molly A McNaughton
- Molly A. McNaughton, MAN, CNP-BC, PMGT-BC, AP-PMN, Nurse Practitioner, M Health Fairview Pain Management Center, Burnsville, MN
- Ann Quinlan-Colwell, PhD, APRN-CNS, PMGT-BC, AHNBC, Integrative Pain Management Educator and Consultant, AQC Integrative Pain Management Education & Consultation, Wilmington, NC
- Mary T. Lyons, MSN, APRN-CNS, AGCNS-BC, PMGT-BC, AP-PMN, Inpatient Palliative Care, Edward Hospital, Naperville, IL
- Laura C. Arkin, MSN, APRN-CNS, ONC, ONC-A, CCNS, FCNS, Director of Quality Services, Orlando Health Jewett Orthopedic Institute, Orlando, FL
| | - Ann Quinlan-Colwell
- Molly A. McNaughton, MAN, CNP-BC, PMGT-BC, AP-PMN, Nurse Practitioner, M Health Fairview Pain Management Center, Burnsville, MN
- Ann Quinlan-Colwell, PhD, APRN-CNS, PMGT-BC, AHNBC, Integrative Pain Management Educator and Consultant, AQC Integrative Pain Management Education & Consultation, Wilmington, NC
- Mary T. Lyons, MSN, APRN-CNS, AGCNS-BC, PMGT-BC, AP-PMN, Inpatient Palliative Care, Edward Hospital, Naperville, IL
- Laura C. Arkin, MSN, APRN-CNS, ONC, ONC-A, CCNS, FCNS, Director of Quality Services, Orlando Health Jewett Orthopedic Institute, Orlando, FL
| | - Mary T Lyons
- Molly A. McNaughton, MAN, CNP-BC, PMGT-BC, AP-PMN, Nurse Practitioner, M Health Fairview Pain Management Center, Burnsville, MN
- Ann Quinlan-Colwell, PhD, APRN-CNS, PMGT-BC, AHNBC, Integrative Pain Management Educator and Consultant, AQC Integrative Pain Management Education & Consultation, Wilmington, NC
- Mary T. Lyons, MSN, APRN-CNS, AGCNS-BC, PMGT-BC, AP-PMN, Inpatient Palliative Care, Edward Hospital, Naperville, IL
- Laura C. Arkin, MSN, APRN-CNS, ONC, ONC-A, CCNS, FCNS, Director of Quality Services, Orlando Health Jewett Orthopedic Institute, Orlando, FL
| | - Laura C Arkin
- Molly A. McNaughton, MAN, CNP-BC, PMGT-BC, AP-PMN, Nurse Practitioner, M Health Fairview Pain Management Center, Burnsville, MN
- Ann Quinlan-Colwell, PhD, APRN-CNS, PMGT-BC, AHNBC, Integrative Pain Management Educator and Consultant, AQC Integrative Pain Management Education & Consultation, Wilmington, NC
- Mary T. Lyons, MSN, APRN-CNS, AGCNS-BC, PMGT-BC, AP-PMN, Inpatient Palliative Care, Edward Hospital, Naperville, IL
- Laura C. Arkin, MSN, APRN-CNS, ONC, ONC-A, CCNS, FCNS, Director of Quality Services, Orlando Health Jewett Orthopedic Institute, Orlando, FL
| |
Collapse
|
21
|
Vu PD, Bansal V, Chitneni A, Robinson CL, Viswanath O, Urits I, Kaye AD, Nguyen A, Govindaraj R, Chen GH, Hasoon J. Buprenorphine for Chronic Pain Management: a Narrative Review. Curr Pain Headache Rep 2023; 27:811-820. [PMID: 37897592 DOI: 10.1007/s11916-023-01185-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to educate healthcare professionals regarding buprenorphine for the use of opioid use disorder (OUD) as well as for chronic pain management. This review provides physicians and practitioners with updated information regarding the distinct characteristics and intricacies of prescribing buprenorphine. RECENT FINDINGS Buprenorphine is approved by the US Food and Drug Administration (FDA) for acute pain, chronic pain, opioid use disorder (OUD), and opioid dependence. When compared to most other opioids, buprenorphine offers superior patient tolerability, an excellent half-life, and minimal respiratory depression. Buprenorphine does have notable side effects as well as pharmacokinetic properties that require special attention, especially if patients require future surgical interventions. Many physicians are not trained to initiate or manage patients on buprenorphine. However, buprenorphine offers a potentially safer alternative for medication management for patients who require chronic opioid therapy for pain or have OUD. This review provides updated information on buprenorphine for both chronic pain and OUD.
Collapse
Affiliation(s)
- Peter D Vu
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Vishal Bansal
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, NY, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Anvinh Nguyen
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - Ranganathan Govindaraj
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Grant H Chen
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA.
| |
Collapse
|
22
|
Calcaterra SL, Buresh M, Weimer MB. Better care at the bedside for hospitalized patients with opioid use disorder. J Hosp Med 2023; 18:1134-1138. [PMID: 37016586 PMCID: PMC10548352 DOI: 10.1002/jhm.13099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 04/06/2023]
Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Megan Buresh
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Melissa B. Weimer
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| |
Collapse
|
23
|
Macres S, Aldwinckle RJ, Saldahna U, Pritzlaff SG, Jung M, Santos J, Kotova M, Bishop R. Reconceptualizing Acute Pain Management in the 21st Century. Adv Anesth 2023; 41:87-110. [PMID: 38251624 DOI: 10.1016/j.aan.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Acute pain can have many etiologies that include surgical procedures, trauma (motor vehicle accident), musculoskeletal injuries (rib fracture) and, burns among others. Valuable components of a multimodal approach to acute pain management include both opioid and non-opioid medications, procedure specific regional anesthesia techniques (peripheral nerve blocks and neuraxial approaches), and interventional approaches (eg, peripheral nerve stimulation and cryo-neurolysis). Overall, successful acute perioperative pain management requires a multimodal, multidisciplinary approach that involves a coordinated effort between the surgical team, the anesthesia team, nursing, and pharmacy staff using Enhanced Recovery After Surgery (ERAS) protocols.
Collapse
Affiliation(s)
- Stephen Macres
- Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, 4150 V. Street, Sacramento, CA 95817, USA.
| | - Robin J Aldwinckle
- Anesthesiology, Department of Anesthesiology & Pain Medicine, 4150 V. Street, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - Usha Saldahna
- Regional Anesthesia Fellowship, Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, 4150 V. Street, Sacramento, CA 95817, USA
| | - Scott G Pritzlaff
- Division of Pain Medicine, Pain Medicine Fellowship, Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, 4860 Y. Street, Suite 3020, Sacramento CA 95817, USA
| | - Michael Jung
- Pain Fellowship, Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4860 Y. Street, Suite 3020, Sacramento CA 95817, USA
| | - Josh Santos
- Pre-Anesthesia Readiness & Education Program, 4150 V. Street, Sacramento, CA 95817, USA
| | - Mariya Kotova
- Department of Pharmacy, UC Davis Medical Center, 1240 47th Avenue, Sacramento, CA 95831, USA
| | - Robert Bishop
- Department of Anesthesiology and Pain Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| |
Collapse
|
24
|
Quaye A, Mardmomen N, Mogren G, Ibrahim Y, Richard J, Zhang Y. Current State of Perioperative Buprenorphine Management-A National Provider Survey. J Addict Med 2023; 17:640-645. [PMID: 37934521 DOI: 10.1097/adm.0000000000001191] [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: 06/07/2023]
Abstract
OBJECTIVES Buprenorphine maintenance for opioid use disorder (OUD) can present potential challenges for acute postoperative pain management. Provider practice and consistency of buprenorphine management strategies within institutions are unknown. This study aims to identify how providers nationwide manage patients on buprenorphine when they present for elective surgery. METHODS A prospective survey of anesthesiologists was performed nationwide between November 2021 and March 2022. Survey respondents were selected from academic institutions identified using public databases and were also distributed to online social media platforms where members are required to verify medical licensure and hospital affiliation. Survey results were calculated and interpreted as the percentage rate of response. RESULTS Survey invitations were sent to 190 institutions and returned 54 responses (28% response rate). An additional 12 completed surveys were obtained from online social media distribution resulting in 66 responses. Only 36% of respondents reported an established protocol for perioperative management of buprenorphine at their institution. Regarding consistency of buprenorphine management within institutions, the majority of respondents endorsed buprenorphine continuation without dose reduction in procedures where minimal pain was anticipated. However, there was a large discrepancy in buprenorphine management for surgeries with moderate-severe pain. Perioperative dosing frequency of buprenorphine was also inconsistent. CONCLUSIONS The majority of institutions surveyed do not have an established protocol for perioperative buprenorphine management. In addition, there is provider variability in buprenorphine dosing for procedures with moderate-severe pain. This study highlights the need for dissemination of consensus guidelines for buprenorphine management.
Collapse
Affiliation(s)
- Aurora Quaye
- From the Spectrum Healthcare Partners, South Portland, ME (AQ); Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME (AQ, YI, JR); Translational Pain Research Department, Massachusetts General Hospital, Boston, MA (NM, GM); and Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA (YZ)
| | | | | | | | | | | |
Collapse
|
25
|
Haines AJ, Wood KC, Costello JL, Tawil T. Acute Pain Management for Patients Maintained on Sublingual Buprenorphine as Medication for Opioid Use Disorder. J Addict Med 2023; 17:662-669. [PMID: 37934527 DOI: 10.1097/adm.0000000000001205] [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: 07/29/2023]
Abstract
OBJECTIVE The aim of this study was to compare morphine milligram equivalent (MME) requirements for acute pain management between patients admitted for medical or surgical diagnoses with opioid use disorder (OUD) who receive >12 mg of sublingual buprenorphine daily compared with those who receive ≤12 mg/d. DESIGN This study was performed via retrospective chart review. SETTING This study evaluated patient encounters between January 2017 and November 2021 from a single-center community teaching hospital in Lancaster, PA. METHODS Patients were assessed according to daily dose of buprenorphine received while admitted (>12 mg/d vs ≤12 mg/d); patients who had buprenorphine held were included within the ≤12 mg/d study group. The primary outcome evaluated daily average MME requirements over the entirety of hospital length of stay. Key secondary outcomes were total MME requirements and daily average pain scores. SUBJECTS Key inclusion criteria were sublingual buprenorphine therapy for at least 1 month prior to admission, presence of an acute pain diagnosis during hospital stay, and history of OUD. RESULTS Seventy-eight (78) patients were included for analysis. Daily average MME requirements were similar between patients who received buprenorphine >12 mg/d and ≤12 mg/d (median, 7.5 vs 10.6; P = 0.350). Total MME and daily average pain scores were similar between study groups. CONCLUSIONS For OUD patients in need of acute pain management, the continuation of sublingual buprenorphine throughout hospitalization at a daily dose of >12 mg/d compared with ≤12 mg/d did not confer a significant difference in daily average MME requirements.
Collapse
|
26
|
Hodgson JA, Cyr KL, Sweitzer B. Patient selection in ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:357-372. [PMID: 37938082 DOI: 10.1016/j.bpa.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 01/07/2023]
Abstract
Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.
Collapse
Affiliation(s)
- John A Hodgson
- Walter Reed National Military Medical Center and Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD, 20889, United States.
| | - Kyle L Cyr
- Walter Reed National Military Medical Center and Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD, 20889, United States.
| | - BobbieJean Sweitzer
- Medical Education, University of Virginia, Systems Director, Preoperative Medicine, Inova Health, 3300 Gallows Road, Falls Church, VA, 22042, United States.
| |
Collapse
|
27
|
Goel A, Lamba W. Nothing About Us Without Us: A Solution to Iatrogenic Perioperative Morbidity and Mortality in People Who Use Drugs. Anesth Analg 2023; 137:470-473. [PMID: 37590792 DOI: 10.1213/ane.0000000000006571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Affiliation(s)
- Akash Goel
- From the Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wiplove Lamba
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
28
|
Borelli C, Gaub M. Letter: What Neurosurgeons Need to Know About Perioperative Buprenorphine for Opioid Use Disorder. Neurosurgery 2023; 93:e71-e72. [PMID: 37294095 DOI: 10.1227/neu.0000000000002577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Affiliation(s)
- Cara Borelli
- Department of Psychiatry, Addiction Institute of Mount Sinai West and Mount Sinai Morningside, Mount Sinai Morningside/West, New York , New York , USA
| | - Michael Gaub
- Department of Neurosurgery, The University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
| |
Collapse
|
29
|
Jimenez Ruiz F, Warner NS, Acampora G, Coleman JR, Kohan L. Substance Use Disorders: Basic Overview for the Anesthesiologist. Anesth Analg 2023; 137:508-520. [PMID: 37590795 DOI: 10.1213/ane.0000000000006281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Substance use disorders (SUDs) represent a current major public health concern in the United States and around the world. Social and economic stressors secondary to the coronavirus disease 2019 (COVID-19) pandemic have likely led to an increase in SUDs around the world. This chronic, debilitating disease is a prevalent health problem, and yet many clinicians do not have adequate training or clinical experience diagnosing and treating SUDs. Anesthesiologists and other perioperative medical staff frequently encounter patients with co-occurring SUDs. By such, through increased awareness and education, physicians and other health care providers have a unique opportunity to positively impact the lives and improve the perioperative outcomes of patients with SUDs. Understanding commonly used terms, potentially effective perioperative screening tools, diagnostic criteria, basics of treatment, and the perioperative implications of SUDs is essential to providing adequate care to patients experiencing this illness.
Collapse
Affiliation(s)
- Federico Jimenez Ruiz
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory Acampora
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - John R Coleman
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Lynn Kohan
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| |
Collapse
|
30
|
Quaye A, Wampole C, Riker RR, Seder DB, Sauer WJ, Richard JM, Craig WY, Gagnon DJ. Buprenorphine Continuation During Critical Illness Associated With Decreased Inpatient Opioid Use in Individuals Maintained on Buprenorphine for Opioid Use Disorder in a Retrospective Study. J Clin Pharmacol 2023; 63:1067-1073. [PMID: 37204408 PMCID: PMC10524870 DOI: 10.1002/jcph.2286] [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: 03/24/2023] [Accepted: 05/16/2023] [Indexed: 05/20/2023]
Abstract
The number of patients maintained on buprenorphine is steadily increasing. To date, no study has reported buprenorphine management practices for these patients during critical illness, nor its relationship with supplemental full-agonist opioid administration during their hospital stay. In this single-center retrospective study, we have explored the incidence of buprenorphine continuation during critical illness among patients receiving buprenorphine for the treatment of opioid use disorder. Additionally, we investigated the relationship between nonbuprenorphine opioid exposure and buprenorphine administration during the intensive care unit (ICU) and post-ICU phases of care. Our study included adults maintained on buprenorphine for opioid use disorder admitted to the ICU between December 1, 2014, and May 31, 2019. Nonbuprenorphine, full agonist opioid doses were converted to fentanyl equivalents (FEs). Fifty-one (44%) patients received buprenorphine during the ICU phase of care, with an average dose of 8 (8-12) mg/day. During the post-ICU phase of care, 68 (62%) received buprenorphine, with an average dose of 10 (7-14) mg/day. Lack of mechanical ventilation and acetaminophen use were also associated with buprenorphine use. Full agonist opioid use was more frequent on days when buprenorphine was not given (odds ratio [OR], 6.2 [95% CI, 2.3-16.4]; P < .001). Additionally, the average cumulative dose of opioids given on nonbuprenorphine administration days was significantly higher both in the ICU (OR, 1803 [95% CI, 1271-2553] vs OR, 327 [95% CI, 152-708] FEs/day; P < 0.001) and after ICU discharge (OR, 1476 [95% CI, 962-2265] vs OR, 238 [95% CI, 150-377] FEs/day; P < .001). Given these findings, buprenorphine continuation during critical illness should be considered, as it is associated with significantly decreased full agonist opioid use.
Collapse
Affiliation(s)
- Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME, USA
- Spectrum Healthcare Partners, South Portland, ME, USA
| | - Chelsea Wampole
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA
| | - Richard R. Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - David B. Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - William J. Sauer
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME, USA
- Spectrum Healthcare Partners, South Portland, ME, USA
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Janelle M. Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME, USA
| | - Wendy Y. Craig
- MaineHealth Institute for Research, Scarborough, ME, USA
| | - David J. Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
- MaineHealth Institute for Research, Scarborough, ME, USA
| |
Collapse
|
31
|
Seol A, Chan J, Micham B, Ye Y, Mariano ER, Harrison TK, Hunter OO. Acute pain service reduces barriers to buprenorphine/naloxone initiation by using regional anesthesia techniques. Reg Anesth Pain Med 2023; 48:425-427. [PMID: 36792313 DOI: 10.1136/rapm-2022-104317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Medications for opioid use disorder (MOUD) are a life-saving intervention; thus, it is important to address barriers to successful initiation. Spasticity affects many patients with spinal cord injury and can be painful and physically debilitating. Chronic painful conditions can lead to the illicit use of non-prescribed opioids, but fear of pain is a barrier to the initiation of MOUD. In this case report, we describe the novel use of botulinum toxin A injections to treat abdominal spasticity and facilitate Acute Pain Service-led buprenorphine/naloxone initiation in a patient with opioid use disorder and severe abdominal spasticity due to spinal cord injury. CASE PRESENTATION A patient with C4 incomplete tetraplegia and opioid use disorder complicated by abdominal spasticity refractory to oral antispasmodics and self-treating with intravenous heroin was referred to the Acute Pain Service for inpatient buprenorphine/naloxone initiation. The patient began to fail initiation of buprenorphine/naloxone secondary to increased pain from abdominal spasms. The patient was offered ultrasound-guided abdominal muscle chemodenervation with botulinum toxin A, which resulted in the resolution of abdominal spasticity and facilitated successful buprenorphine/naloxone initiation. At 6 months post-initiation, the patient remained abstinent from non-prescribed opioids and compliant with buprenorphine/naloxone 8 mg/2 mg three times a day. CONCLUSIONS This case report demonstrates that inpatient buprenorphine/naloxone initiation by an Acute Pain Service can improve the success of treatment by addressing barriers to initiation. Acute Pain Service clinicians possess unique skills and knowledge, including ultrasound-guided interventions, that enable them to provide innovative and personalized approaches to care in the complex opioid use disorder population.
Collapse
Affiliation(s)
- Alice Seol
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - John Chan
- Department of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA
| | - Brittni Micham
- Department of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA
- Physical Medicine and Rehabilitation Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Ying Ye
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - T Kyle Harrison
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Oluwatobi O Hunter
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| |
Collapse
|
32
|
Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesth Analg 2023:00000539-990000000-00608. [PMID: 37450650 DOI: 10.1213/ane.0000000000006623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Substance use disorders (SUDs) are on the rise in children and young adults in the United States. According to reports, over 40 million people aged 12 and older had a diagnosed SUD in 2020.1 A recent report from the Centers for Disease Control and Prevention (CDC) found that overdose death in children aged 10 to 19 years old increased 109% from 2019 to 2021.2 Given the rapidly increasing prevalence of SUD, anesthesiologists will almost certainly encounter children, adolescents, and young adults with a history of recreational drug use or nonmedical use of prescription opioids in the perioperative period. Since the perioperative period can be a particularly challenging time for patients with SUD, anesthesiologists can tailor their perioperative care to reduce rates of relapse and can serve as both advocates and educators for this vulnerable patient population. This article examines the history of SUD and physiology of substance use in children, adolescents, and young adults, including reasons why young people are more susceptible to the addictive effects of many substances. The coronavirus disease 2019 (COVID-19) pandemic impacted many aspects of life, including increased social isolation and shifted dynamics at home, both thought to impact substance use.3 Substance use patterns in the wake of the COVID-19 pandemic are explored. Although current literature is mostly on adults, the evidence-based medical treatments for patients with SUD are reviewed, and recommendations for perioperative considerations are suggested. The emphasis of this review is on opioid use disorder, cannabis, and vaping particularly because these have disproportionately affected the younger population. The article provides recommendations and resources for recognizing and treating adolescents and young adults at risk for SUD in the perioperative period. It also provides suggestions to reduce new persistent postoperative opioid use.
Collapse
Affiliation(s)
- Jamie M Kitzman
- From the Department of Anesthesiology, Division of Pediatric Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Veronika V Mesheriakova
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California San Francisco, San Francisco, California
| | - Amber N Borucki
- Department of Anesthesiology, University of California San Francisco, San Francisco, California
| | - Rita Agarwal
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
33
|
Hathaway DB, Bhat JA, Twark C, Rodriguez C, Suzuki J. Patients' experiences with continuation or discontinuation of buprenorphine before painful procedures: A brief report. Am J Addict 2023; 32:410-414. [PMID: 36850041 DOI: 10.1111/ajad.13396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with opioid use disorder may be asked by their clinicians to discontinue maintenance buprenorphine treatment before surgical operations due to concerns that buprenorphine will interfere with acute pain management. However, discontinuation of buprenorphine may not be well tolerated or safe for all patients. We, therefore, administered a survey to better understand the experiences of patients on buprenorphine treatment who had previously undergone painful procedures and had their buprenorphine maintenance treatment either continued or discontinued before the procedure. METHODS After this study received institutional review board approval, patients were invited to participate if they were being prescribed sublingual buprenorphine for treatment of opioid use disorder and had also previously undergone a painful procedure requiring treatment with full agonist opioids. Patients who were eligible and agreed to participate (n = 32) then completed a survey of basic demographics; medical, psychiatric, and substance use histories; and their experience and satisfaction with the treatment of pain and substance use in the perioperative period, including whether buprenorphine was continued or discontinued before their procedure. RESULTS Compared with patients whose home dose of buprenorphine was continued (n = 15), patients whose buprenorphine was discontinued preoperatively (n = 17) reported less satisfaction with pain management and were more likely to be prescribed full agonist opioids upon discharge. DISCUSSION AND CONCLUSIONS Consistent with prior studies, these survey findings suggest that discontinuation of buprenorphine before painful surgeries may be associated with poorer clinical outcomes. SCIENTIFIC SIGNIFICANCE This survey study adds patients' perspective to a growing body of scientific literature suggesting that discontinuation of maintenance buprenorphine treatment before painful procedures may decrease patient satisfaction and increase clinical risk.
Collapse
Affiliation(s)
- David B Hathaway
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Jasra-Ali Bhat
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Claire Twark
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Claudia Rodriguez
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Joji Suzuki
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
34
|
Hasoon J, Nguyen A, Urits I, Robinson C, Viswanath O, Kaye AD. A Need for Further Education on Buprenorphine in Pain Medicine. Health Psychol Res 2023; 11:74958. [PMID: 37405316 PMCID: PMC10317507 DOI: 10.52965/001c.74958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
With the ongoing opioid epidemic in the United States there has been a strong transition towards utilizing multi-modal analgesia, interventional procedures, and non-opioid medications when managing acute and chronic pain. There has also been an increased interest in utilizing buprenorphine. Buprenorphine is a novel long-acting analgesic with partial mu-opioid agonist activity that can be utilized for analgesia as well as opioid use disorder. Buprenorphine also has a unique set of side effects as well pharmacodynamic and pharmacokinetic properties that require special attention, especially if these patients require future surgical interventions. Given the increased interest in this medication we believe that there needs to be increased education and awareness regarding this medication amongst physicians, specifically pain management physicians and trainees.
Collapse
Affiliation(s)
- Jamal Hasoon
- UTHealth McGovern Medical School, Department of Anesthesia, Critical Care, and Pain Medicine
| | - Anvinh Nguyen
- Baylor College of Medicine, Department of Anesthesiology
| | - Ivan Urits
- Louisiana State University Health Shreveport, Department of Anesthesiology
| | - Christopher Robinson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Anesthesia, Critical Care, and Pain Medicine
| | - Omar Viswanath
- Louisiana State University Health Shreveport, Department of Anesthesiology
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology
| |
Collapse
|
35
|
Dickerson DM, Mariano ER, Szokol JW, Harned M, Clark RM, Mueller JT, Shilling AM, Udoji MA, Mukkamala SB, Doan L, Wyatt KEK, Schwalb JM, Elkassabany NM, Eloy JD, Beck SL, Wiechmann L, Chiao F, Halle SG, Krishnan DG, Cramer JD, Ali Sakr Esa W, Muse IO, Baratta J, Rosenquist R, Gulur P, Shah S, Kohan L, Robles J, Schwenk ES, Allen BFS, Yang S, Hadeed JG, Schwartz G, Englesbe MJ, Sprintz M, Urish KL, Walton A, Keith L, Buvanendran A. Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder. Reg Anesth Pain Med 2023:rapm-2023-104435. [PMID: 37185214 DOI: 10.1136/rapm-2023-104435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.
Collapse
Affiliation(s)
- David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Randall M Clark
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mercy A Udoji
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta VA Health Care System, Decatur, Georgia, USA
| | | | - Lisa Doan
- Department of Anesthesiology, PerioperativeCare and Pain Medicine, New York University School of Medicine, New York, New York, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperativeand Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Stacy L Beck
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Maternal Fetal Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, New York, USA
| | - Steven G Halle
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
- Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John D Cramer
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA
| | - Wael Ali Sakr Esa
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, USA
- Department of Anesthesiology, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Jaime Baratta
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | | | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shalini Shah
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California, USA
| | - Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Jennifer Robles
- Department of Urology Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian F S Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Yang
- Department of Surgery, Division of Thoracic Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | | | - Gary Schwartz
- AABP Integrative Pain Care, Melville, New York, USA
- Maimonides Medical Center, Brooklyn, New York, USA
| | | | - Michael Sprintz
- Sprintz Center for Pain and Recovery, Shenandoah, Texas, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Lauren Keith
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
36
|
Culshaw JR, Philpott CD, Garber Bradshaw P, Brizzi MB, Goodman MD, Makley AT, Reinstatler KM, Droege ME. Acute Pain Management in Traumatically Injured Patients With Outpatient Buprenorphine Therapy. J Surg Res 2023; 289:27-34. [PMID: 37079963 DOI: 10.1016/j.jss.2023.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/09/2023] [Accepted: 03/17/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Acute pain management is challenging in trauma patients undergoing outpatient buprenorphine therapy at the time of injury due to the high binding affinity of this partial agonist. The purpose of this study was to evaluate acute pain management in admitted trauma patients with discontinued versus continued outpatient buprenorphine therapy. MATERIALS AND METHODS This retrospective study included adult trauma patients admitted to a level-1 trauma center between January 2017 and August 2020 who were receiving buprenorphine prior to admission. Groups were defined as buprenorphine discontinued (BD) or continued (BC) during hospitalization. The primary outcome compared median daily morphine milligram equivalents between groups. Secondary outcomes utilized patient-reported numeric rating scale (NRS) scores to compare incidences of no pain (NRS 0), mild (NRS 1-3), moderate (NRS 4-6), and severe (NRS 7-10) pain. RESULTS A total of 57 patients were included (BD 37 [64.9%] and BC 20 [35.1%]). The median (interquartile range) outpatient daily buprenorphine dose was similar between groups (8 [8-16] mg versus 16 [8-16], P = 0.25). Median daily morphine milligram equivalents was significantly higher during admission in the BD group (103.7 [80.7-166] versus 67 [30.8-97.4], P = 0.002). Incidence of no pain (7.1% versus 5.7%, P = 0.283), mild (5.5% versus 4.3%, P = 0.295), moderate (20.2%, 19.8%, P = 0.855), or severe (67.2% versus 70.2%, P = 0.185) pain was similar between BD and BC groups, respectively. CONCLUSIONS Continuation of outpatient buprenorphine therapy in acute trauma patients is associated with decreased daily opioid requirements and similar analgesic efficacy compared to patients with BD. Based on our findings, trauma patients receiving outpatient buprenorphine and not requiring ventilator support may benefit from buprenorphine continuation within 48 h of initial presentation.
Collapse
Affiliation(s)
| | - Carolyn D Philpott
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Paige Garber Bradshaw
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | | | - Michael D Goodman
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy Teres Makley
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Kristina Marie Reinstatler
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio; University of Cincinnati College of Nursing, Cincinnati, Ohio
| | | |
Collapse
|
37
|
Stone AB, Zhong H, Poeran J, Liu J, Cozowicz C, Illescas A, Memtsoudis SG. Buprenorphine for chronic pain treatment and elective orthopaedic surgery: a US national database analysis. Br J Anaesth 2023; 130:e404-e406. [PMID: 36566125 DOI: 10.1016/j.bja.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/16/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiologist Critical Care and Perioperative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy/Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alex Illescas
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
38
|
Identifying Barriers to Buprenorphine Treatment for Patients with Opioid Use Disorder Among Anesthesiologists and Pain Practitioners: A Survey Study. J Addict Med 2023; 17:e94-e100. [PMID: 36001078 DOI: 10.1097/adm.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study is to investigate barriers to opioid use disorder (OUD) care among acute and chronic pain physicians and advanced practice providers, including hypothesized barriers of lack of interest in OUD care and stigma toward this patient population. METHODS The study used an anonymous 16-item online survey through Google Forms. Respondents were 153 health practitioners across the United States and Canada, all of whom are registered in one of several pain or anesthesia professional societies. Data were analyzed with descriptive and categorical statistics. RESULTS The most common barriers include "lack of appropriate clinical environment for prescribing by both acute and chronic pain practitioners" (48%) and "lack of administrative/departmental support" (46%). A total of 32% of respondents reported that OUD care was important but they were not interested in doing more, while 28% of practitioners believed that they treat patients with OUD differently than others in a negative way. More males reported "difficulty" in treating OUD as a barrier (45% vs 25%). Chronic pain practitioners reported poor payor mix as a barrier twice as often as their acute pain colleagues. In free response, lack of multidisciplinary OUD care was a notable barrier. CONCLUSIONS The top barriers to OUD treatment were clinical environment, departmental support, difficulty in treating the condition, and payor mix, supporting the hypotheses. Given an OUD patient scenario, 55% of acute pain physicians and 73% of chronic pain physicians expressed a willingness to prescribe buprenorphine.
Collapse
|
39
|
Coleman JR, Hanson NA. How, when and why to establish preoperative surgical risk in thoracic surgery. Curr Opin Anaesthesiol 2023; 36:68-73. [PMID: 36550607 DOI: 10.1097/aco.0000000000001215] [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: 12/24/2022]
Abstract
PURPOSE OF REVIEW Emphasizing a systems-based approach, we discuss the timing for referral for perioperative surgical consultation. This review then highlights several types of comorbidities that may complicate thoracic procedures, and references recent best practices for their management. RECENT FINDINGS Patients requiring thoracic surgeries present some of the most challenging cases for both intraoperative and postoperative management. The recent SARS-CoV-2 pandemic has only exacerbated these concerns. Effective preoperative optimization, however, provides for identification of patient comorbidities, allowing for mitigation of surgical risks. This kind of planning is multidisciplinary by nature. We believe patients benefit from early engagement of a dedicated preoperative clinic experienced for caring for complex surgical patients. SUMMARY Optimizing patients for thoracic surgery can be challenging for small and large health systems alike. Implementation of evidence-based guidelines can improve care and mitigate risk. As surgical techniques evolve, future research is needed to ensure that perioperative care continues to progress.
Collapse
Affiliation(s)
- John R Coleman
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia
| | - Neil A Hanson
- Department of Anesthesiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| |
Collapse
|
40
|
Neale KJ, Weimer MB, Davis MP, Jones KF, Kullgren JG, Kale SS, Childers J, Broglio K, Merlin JS, Peck S, Francis SY, Bango J, Jones CA, Sager Z, Ho JJ. Top Ten Tips Palliative Care Clinicians Should Know About Buprenorphine. J Palliat Med 2023; 26:120-130. [PMID: 36067137 DOI: 10.1089/jpm.2022.0399] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pain management in palliative care (PC) is becoming more complex as patients survive longer with life-limiting illnesses and population-wide trends involving opioid misuse become more common in serious illness. Buprenorphine, a generally safe partial mu-opioid receptor agonist, has been shown to be effective for both pain management and opioid use disorder. It is critical that PC clinicians become comfortable with indications for its use, strategies for initiation while understanding risks and benefits. This article, written by a team of PC and addiction-trained specialists, including physicians, nurse practitioners, social workers, and a pharmacist, offers 10 tips to demystify buprenorphine use in serious illness.
Collapse
Affiliation(s)
- Kyle J Neale
- The Lois U and Harry R Horvitz Palliative Medicine Program, Department of Palliative Medicine and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mellar P Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Justin G Kullgren
- Palliative Medicine Clinical Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sachin S Kale
- Division of Palliative Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathleen Broglio
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Collaboratory for Implementation Sciences at Dartmouth, Lebanon, New Hampshire, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sarah Peck
- Division of Palliative Medicine, Emory University Healthcare Midtown, Atlanta, Georgia, USA
| | - Sheria Y Francis
- Collaborative Care Management, University of Pittsburgh Medical Center Presbyterian Shadyside, Pittsburgh, Pennsylvania, USA
| | | | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zachary Sager
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J Janet Ho
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
41
|
Quaye A, Silvia K, Richard J, Ibrahim Y, Craig WY, Rosen C. A prospective, randomized trial of the effect of buprenorphine continuation versus dose reduction on pain control and post-operative opioid use. Medicine (Baltimore) 2022; 101:e32309. [PMID: 36595741 PMCID: PMC9794322 DOI: 10.1097/md.0000000000032309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION An increasing number of individuals are taking buprenorphine for management of opioid use disorder (OUD). Pain control can be challenging when these patients develop acute pain requiring supplemental analgesia. Buprenorphine's pharmacokinetic profile can render supplemental opioid-based analgesia ineffective. There is limited guidance on the optimal management of buprenorphine when acute pain is anticipated. Although there is growing acceptance that the risk of OUD relapse with buprenorphine discontinuation overshadows the risks of increased opioid utilization and difficult pain control with buprenorphine continuation, perioperative courses comparing buprenorphine dose reduction and full dose buprenorphine continuation have yet to be investigated. Here, we describe the protocol for our randomized controlled, prospective trial investigating the effect of buprenorphine continuation compared to buprenorphine dose reduction on pain control, post-operative opioid use, and OUD symptom management in patients on buprenorphine scheduled for elective surgery. METHODS AND ANALYSIS This is a single institution, randomized trial that aims to enroll 80 adults using 12 mg buprenorphine or greater for treatment of OUD, scheduled for elective surgery. Participants will be randomly assigned to receive 8mg of buprenorphine on the day of surgery onwards until postsurgical pain subsides or to have their buprenorphine formulation continued at full dose perioperatively. Primary outcome will be a clinically significant difference in pain scores 24 hours following surgery. Secondary outcomes will be opioid consumption at 24, 48, and 72 hours postoperatively, opioid dispensing up to 30 days following surgery, changes in mood and withdrawal symptoms, opioid cravings, relapse of opioid misuse, and continued use of buprenorphine treatment postoperatively.
Collapse
Affiliation(s)
- Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
- Spectrum Healthcare Partners, South Portland, ME
- * Correspondence: Aurora Quaye, Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102 (e-mail: )
| | - Kristen Silvia
- Division of Addiction Medicine, Maine Medical Center, Portland, ME
| | - Janelle Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
| | - Yussr Ibrahim
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
| | | | | |
Collapse
|
42
|
Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare (Basel) 2022; 11:healthcare11010034. [PMID: 36611494 PMCID: PMC9818465 DOI: 10.3390/healthcare11010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.
Collapse
Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
- Correspondence:
| | - Andrea M. Wetshtein
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, OH 44111, USA
| | - Samantha J. Grable
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| | - Michelle P. Jackson
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| |
Collapse
|
43
|
Coffin PO, Martinez RS, Wylie B, Ryder B. Primary care management of Long-Term opioid therapy. Ann Med 2022; 54:2451-2469. [PMID: 36111417 PMCID: PMC9487960 DOI: 10.1080/07853890.2022.2121417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/01/2022] Open
Abstract
The United States underwent massive expansion in opioid prescribing from 1990-2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. When providing long-term opioid therapy, clinicians should document opioid stewardship measures, including assessments, consents, medication reconciliation, and offering naloxone, along with the rationale to continue opioid therapy. Clinicians should screen regularly for opioid use disorder and arrange for or directly provide treatment. In particular, buprenorphine can be highly useful for co-morbid pain and opioid use disorder. Addressing other substance use disorders, as well as preventive health related to substance use, should be a priority in patients with opioid use disorder. Patient-centered practices, such as shared decision-making and attending to related facets of a patient's life that influence health outcomes, should be implemented at all points of care.Key messagesAlthough opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised.Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny.Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.
Collapse
Affiliation(s)
- Phillip O. Coffin
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Rebecca S. Martinez
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Brian Wylie
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Bunny Ryder
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| |
Collapse
|
44
|
Khambaty M, Silbert RE, Devalapalli AP, Kashiwagi DT, Regan DW, Sundsted KK, Mauck KF. Practice-Changing Updates in Perioperative Medicine Literature 2020-2021: A Systematic Review. Am J Med 2022; 135:1306-1314.e1. [PMID: 35820457 DOI: 10.1016/j.amjmed.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022]
Abstract
Recent literature published in a variety of multidisciplinary journals has significantly influenced perioperative patient care. Distilling and synthesizing the clinically important literature can be challenging. This review summarizes practice-changing articles in perioperative medicine from the years 2020 and 2021. Embase, Ovid, and EBM reviews databases were queried from January 2020 to December 2021. Inclusion criteria were original research, systematic review, meta-analysis, and important guidelines. Exclusion criteria were conference abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont., Canada). A modified Delphi technique was used to identify 9 practice-changing articles. We identified another 13 articles for tabular summaries, as they were relevant to an internist's perioperative evaluation of a patient. Articles were selected to highlight the clinical implications of new evidence in each field. We have also pointed out limitations of each study and clinical populations where they are not applicable.
Collapse
Affiliation(s)
- Maleka Khambaty
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN.
| | - Richard E Silbert
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Aditya P Devalapalli
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Deanne T Kashiwagi
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN; Division of Internal Medicine, Sheikh Shakhbout Medical City in partnership with Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Dennis W Regan
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Karna K Sundsted
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| |
Collapse
|
45
|
Calcaterra SL, Martin M, Bottner R, Englander H, Weinstein Z, Weimer MB, Lambert E, Herzig SJ. Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine. J Hosp Med 2022; 17:744-756. [PMID: 35880813 PMCID: PMC9474708 DOI: 10.1002/jhm.12893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 01/14/2023]
Abstract
Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.
Collapse
Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Marlene Martin
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, TX, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine and Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Zoe Weinstein
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Eugene Lambert
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
| | - Shoshana J. Herzig
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
46
|
Burns SL, Majdak P, Urman RD. Perioperative and Periprocedural anesthetic management of opioid tolerant patients and patients with active and medically treated opioid use disorder. Curr Opin Anaesthesiol 2022; 35:514-520. [PMID: 35788122 PMCID: PMC9308736 DOI: 10.1097/aco.0000000000001157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The increasing prevalence of opioid tolerant individuals, in combination with the expanding scope and utilization of nonoperating room anesthesia (NORA) necessitates ongoing investigation into best clinical practice for managing surgical/procedural pain in this population. The purpose of this article is to review recent guidelines, identify specific challenges, and offer considerations for managing pain in patients who are opioid tolerant secondary to opioid use disorder (OUD), with or without medications for the treatment of OUD. RECENT FINDINGS A comprehensive preoperative evaluation in conjunction with a multidisciplinary, multimodal pain approach is optimal. NORA adds unique situational and environmental challenges for optimizing acute on chronic pain control in tolerant individuals while maintaining safety. Direct and partial/mixed mu-agonists should typically be continued throughout the perioperative period, while mu-antagonists (naltrexone) should be held 72 h. Postprocedural discharge instructions and follow-up must be carefully arranged and ensured. SUMMARY Clinical recommendations continue to evolve as new consensus guidelines are published, although institution-specific guidelines are most often followed. This review focuses on most recent best practices, within NORA and operating room settings, for managing opioid tolerant patients, patients with OUD and those on medications for the treatment of OUD.
Collapse
Affiliation(s)
- Stacey L. Burns
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Petra Majdak
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
47
|
Balasanova AA. Incorrect application of DSM-5 criteria. Reg Anesth Pain Med 2022; 47:384. [DOI: 10.1136/rapm-2021-103439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/03/2022]
|
48
|
Kohan L, Potru S, Barreveld AM, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay S, Viscusi E. Response to incorrect application of DSM-5 criteria. Reg Anesth Pain Med 2022; 47:384-385. [DOI: 10.1136/rapm-2021-103455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 11/03/2022]
|
49
|
Abstract
PURPOSE OF REVIEW This review article aims to describe the perioperative clinical implications of opioid use or opioid use disorder (OUD) and to provide recommendations related to analgesia, anesthesia, and postoperative care for patients with this 'new medical disease'. RECENT FINDINGS Evidence suggest that 1 in 4 surgical patients will be using opioids preoperatively. Management of these patients, or those with OUD, can be challenging given their opioid tolerance, hyperalgesia, decreased pain tolerance, and increased pain sensitivity. Therefore, an individualized plan that considers how to manage OUD treatment medications, the risk of relapse, multimodal analgesia, and postoperative monitoring requirements is highly important. Fortunately, recent publications provide both insight and guidance on these topics. Postoperatively, persistent opioid utilization appears higher in patients currently using opioids and even for those with a prior history. Although numerous other adverse outcomes are also associated with opioid use or abuse, some may be modifiable with cessation. SUMMARY A coordinated, evidence-based, multidisciplinary team approach is critical when caring for patients with OUD to ensure safety, provide adequate analgesia, and reduce the risk of relapse. Enhanced postoperative monitoring, multimodal analgesia, and a plan for preoperative opioid management may help to modify the risks of adverse postoperative outcomes.
Collapse
|
50
|
Stone AB, Zhong H, Poeran J, Liu J, Cozowicz C, Illescas A, Memtsoudis SG. Trends in discontinuation of buprenorphine following elective orthopedic surgery: a national database analysis. Reg Anesth Pain Med 2022; 47:rapm-2022-103592. [PMID: 35537776 DOI: 10.1136/rapm-2022-103592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/01/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Critical Care and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Jashvant Poeran
- Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Alex Illescas
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| |
Collapse
|