Substance Use Among Iranian Cardiac Surgery Patients and Its Effects on Short-Term Outcome

Does Opioid Addiction Influence Clinical and Angiographic Outcomes in STEMI Patients Undergoing Emergency PCI?

Background

Despite recognizing the traditional coronary artery disease (CAD) risk factors, some secondary factors, such as opioid substance abuse, have to be considered. We aimed to assess the relationship between opioid consumption and emergency percutaneous coronary intervention (PCI) revascularization results, according to Thrombolysis in Myocardial Infarction (TIMI) flow and in-hospital survival outcomes in ST-elevation myocardial infarction (STEMI) patients.

Materials and Methods

This case-control study was conducted on 186 patients (93 patients in each group) with acute STEMI, who were referred to Chamran Heart Center, Isfahan, Iran. Opioid addiction was diagnosed by patients' records and confirmed by conducting an interview based on the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition (DSM-IV) criteria. Patients in both groups were evaluated and compared for angioplasty results based on the TIMI flow grade and in-hospital cardiovascular events and complications.

Results

Ninety-one patients (97.84%) of each group were male, and opioid-addicted patients were younger than the non-opioid users (52.95 9.91 vs. 57.90 12.17, P = 0.003). Among the CAD risk factors, prevalence of dyslipidemia was significantly higher in non-opioid users, whereas cigarette smoking was higher in opioid-addicted patients (P < 0.050). There was no significant difference between the two groups regarding pre- and post-procedural myocardial infarction complications as well as mortality rate (P > 0.050). Also, there were no significant differences between the opioid and non-opioid users regarding TIMI flow grading, and successful PCI rate based on achieving TIMI III was 60.21% versus 59.1% in opiate-dependent and non-opioid users, respectively (P = 0.621).

Conclusion

Opioid addiction has no effects on post-PCI angiographic results and in-hospital survival outcomes in STEMI patients which undergoing emergency PCI.

Higher Morbidity and Mortality in Trauma Intensive Care Unit Patients with Opium Addiction

BACKGROUND

Opium addiction is associated with multiple physical, psychological, and social problems. The aim of this study was to compare the risk of morbidity and mortality in opium-addicted and non-addicted trauma patients admitted to the intensive care units (ICUs) of trauma center of Kerman Province, Iran.

METHODS

In this cohort study, a total of 200 addict and non-addicted patients who were admitted due to trauma in ICUs of Shahid Bahonar Hospital in Kerman during 9 months of 2018 were included. Patients were compared in terms of mortality, incidence of pressure ulcers, incidence of organ failure, duration of mechanical ventilation, and duration of hospitalization. Data were analysed using Fisher's exact test and independent t-test at P < 0.05.

FINDINGS

Out of 197 examined patients, 161 (81.7%) individuals were men and 36 (18.3%) were women. Moreover, 98 (49.7%) patients had a history of opium abuse, while 99 (50.2%) patients had no history of opium addiction. The addicted and non-addicted groups had no significant differences in terms of age (P = 0.650) and gender (P = 0.580). In addicted patients, mortality, duration of mechanical ventilation (P = 0.027), the incidence of pressure ulcer, and organ failure were significantly higher (P < 0.001), but mean ICU stay and hospitalization time was the same in both groups.

CONCLUSION

The results of this study indicated higher mortality and morbidity in opium-addicted patients admitted to ICU than non-addicted ones. This suggests that various systems of the body are affected by opium and, in certain circumstances such as severe diseases, this will cause problems for patients. Therefore, experts should pay attention to complications and side effects of addiction in the management of critical patients with a history of opium abuse.

The effect of opium addiction on short-term postoperative outcomes after coronary artery bypass graft surgery: A prospective observational cohort study

Introduction

Opium addiction has been recently suggested as a potential risk factor for the occurrence of perioperative complications in patients undergoing coronary artery bypass graft (CABG) surgery. The aim of this study was to evaluate whether opium addiction can potentially affect patients' short-term postoperative outcomes after CABG surgery.

Material and methods

In a prospective observational cohort study, all consecutive patients who were scheduled for first-time isolated elective on pump CABG surgery were screened during the study period for opium addiction. The study was carried out between September 2015 and November 2016 at Mazandaran Heart Center, Sari, Iran. A total number of 228 patients [110 opium addicted (OA) and 118 non-addicted (NA)] were screened and included. All patients were evaluate, in terms of short-term postoperative outcomes, until hospital discharge or death.

Results

In the OA patients, the mean amount of estimated postoperative bleeding was significantly more than NA patients (535 ± 304.75 ml vs. 463.56 ± 209.77; P = 0.04). Mean ventilation time were significantly longer in the OA patients than in the NA (9.9 days vs. 8.66 days, P = 0.02). The mean duration of postoperative hospital stay was two days longer in the OA (10.83 days vs. 8.34 days, P < 0.001). Also, the mean use of packed cell during surgery and incidence of postoperative atrial fibrillation were higher in the OA patients than NA (P = 0.005).

Conclusion

The results of our study provide strong evidence that the opium addiction should be considered as a risk factors for developing perioperative complications, including higher mean postoperative bleeding, need for intraoperative packed red blood cell transfusion, ventilation time and length of hospital stay, in patients undergoing CABG surgery.

Opium and cardiovascular health: A devil or an angel?

Opioids have the highest rate of illicit drug consumption after cannabis worldwide. Opium, after tobacco, is still the most commonly abused substance in the Middle East. In addition to the ease of availability, one reason for the high consumption of opium in Asian countries might be a traditional belief among Eastern people and even medical staff that opium may have ameliorating effects on cardiovascular diseases (CVDs) as well as diabetes mellitus, hypertension, and dyslipidemia. Over the last decade, many studies have been performed on humans and animals to evaluate the interplay between opium consumption and stable coronary artery disease, acute coronary syndromes, and atherosclerosis. In this review, we conclude that opium consumption should be considered a risk factor for CVDs. Healthy individuals, as well as cardiac and diabetic patients, should be informed and educated about the hazardous effects of opium consumption on cardiovascular and other chronic diseases.

The effects of opium on the cardiovascular system: a review of side effects, uses, and potential mechanisms

BACKGROUND

In Iran, as in many other Asian and Middle Eastern countries, some believe that opium has beneficial effects on cardiovascular system. Dependent patients suppose that opium has positive effects on cardiovascular function and can prevent or improve cardiovascular diseases; however, only few comprehensive studies evaluating such effects have been performed.

OBJECTIVES

In this study, we sought to clarify the effect of opium on cardiovascular problems by incorporating the previous findings and the current information on the issue and to explain the possible mechanisms of this effect.

METHODS

The available human studies published up to October 30, 2019, were searched in different databases. Case-control, cohort, and cross-sectional studies were retrieved. Papers published in English or those with an English abstract were included. The risk of bias for each included study was assessed based on the Newcastle-Ottawa Scale (NOS). We then categorized the effects of opium on cardiovascular problems along with its probable underlying mechanisms of action.

RESULTS

In this study, most of the published articles suggested the adverse effects of opium on the cardiovascular system, including atherosclerosis, myocardial infarction, arrhythmia, low ejection fraction, and cardiovascular mortality; however, some articles reported the beneficial or impartial effects of opium on the cardiovascular system. In this article, we have categorized all the effects of opium on cardiovascular system; also, the proposed mechanisms of action of opium in each of the above-mentioned disorders are summarized.

CONCLUSION

Although the available evidences were incoherent, it was mostly suggested that opium use does not protect against or improve cardiovascular problems.

Opium use and cardiovascular diseases: a systematic review and meta-analysis

The effects of opium on cardiovascular diseases (CVDs) have been extensively studied. However, there are few studies that summarize this research comprehensively; thus, this systematic review and meta-analysis is a collection of the newest information combined with previous findings to furthermore illuminate the effects of opium on CVDs. In this systematic review, all observational studies were systematically searched using the main international databases such as PubMed/Medline, Web of Sciences, and Scopus until October 2018. After the quality assessment of the articles, the fixed or random model meta-analysis was used to pool the results. I-square test was used to assess the heterogeneity of the studies. Overall, 41 studies were identified. Based on the random model, the pooled odds ratio (OR) (95% confidence interval (CI)) of opium use and coronary artery diseases (CAD) was estimated at 2.75 (95% CI = 2.04-3.75; I²=47%). The pooled OR of opium use and CVD in-hospital mortality was not statistically significant (OR: 1.44, 95% CI = 0.88-2.36, I²  = 51%). In the stratified analysis, in the patients who had undergone heart surgery, the average of ejection fraction (EF) in the opium users was significantly lower than those not using opium (mean differences: -3.06, CI 95% = -4.40 to -1.71, I² = 60%) but in the patients with acute myocardial infarction undergoing angiography, the average EF was not significantly different in the opium users compared to non-users (mean difference: 0.30, CI: -0. 55 to 1.15). The results of this meta-analysis revealed that opium might be a risk factor for CAD and EF but not in-hospital mortality.

Comparison of Spinal Anesthesia Quality Between Patients Addicted and Not Addicted to Opium

PURPOSE

This study aimed to compare the quality of spinal anesthesia between opium-dependent and opium-naive patients.

DESIGN

A case-control study.

METHODS

Two groups of subjects including opium-dependent and opium-naive patients (30 per group) were enrolled. Spinal anesthesia was performed using 15 mg of bupivacaine. The level of anesthesia was assessed every minute for 10 min and then every 10 min for 180 min. Motor block was recorded at 10, 60, 120, and 180 minutes. The duration of anesthesia was recorded.

FINDINGS

The mean duration of spinal anesthesia was significantly shorter in opium-dependent patients (101.45 ± 28.670) than in opium-naive patients (126.14 ± 24.206) (P = .003). The mean onset of sensory block was not significantly different between the two groups (4.14 ± 1.62 vs 3.69 ± 1.36, P = .259).

CONCLUSIONS

Substance abuse affects the duration of spinal anesthesia, so it is recommended to use intravenous medications or higher doses of spinal marcaine for these patients.

Effect of intravenous patient controlled ketamine analgesiaon postoperative pain in opium abusers

Background:

Acutepostoperative pain is among the worst experience that patient scan undergo, and many analgesics have been used to suppress it; especially in chronic opium abusers. Ketamine is an N-methyl-D-aspartate antagonist analgesic, having both anesthetic and analgesic properties, which are not affected to the same extent in chronic opium abusers.

Objectives:

In this study, we assessed the analgesic effects of ketamine added to morphine as a patient-controlled analgesia method for acute pain management, compared with a placebo, inchronic maleopium abusers.

Patients and Methods:

After institutional review board approval for ethical considerations, a randomized double-blinded placebo controlled clinical trial was conducted. A total of 140 male patients aged 18-65 years, undergoing orthopedic surgery, were entered into the study after matching inclusion and exclusion criteria. All patients received the same anesthesia method; while the first group received ketamine (1mg/mL) and morphine (0.5 mg/mL) as a patient-controlled analgesia (70 patients), the second group received morphine (0.5 mg/mL) plus normal saline (70 patients). P value less than 0.05 was considered statistically significant.

Results:

The ketamine and morphine group of patients experienced less postoperative pain and required less postoperative rescue analgesia. However, the unwanted postoperative side effects were nearly the same; although increased levels of postoperative nausea and vomiting were observed in the ketamine and morphine group

Conclusions:

This study demonstrated improved analgesic effects after using intravenous patient controlled analgesia with ketamine on postoperative pain in opium abusers.

Risk factors for postoperative respiratory mortality and morbidity in patients undergoing coronary artery bypass grafting

ABSTRACT

Nowadays, coronary artery bypass grafting (CABG) is considered to be one of the most common surgical procedures. This procedure has been the main topic in many clinical research studies, which have assessed the effect of the procedure on patients’ outcomes. Like other surgical procedures, this procedure is also accompanied by a number of unwanted complications, including those of the respiratory system. Since the respiratory system plays an integral role in defining the clinical outcome of patients, improvements in studies that can assess and predict clinical outcomes of the respiratory system, assume greater importance. There are a number of predictive models which can assess patients in the preoperative period and introduce a number of risk factors, which could be considered as prognostic factors for patients undergoing CABG. The respiratory system is among the clinical systems that are assessed in many prediction scoring systems. This review assesses the main studies which have evaluated the possible risk factors for postoperative respiratory mortality and morbidity, in patients undergoing CABG.

Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis

PURPOSE

The literature was reviewed to determine the risks or benefits of short-term (less than four weeks) smoking cessation on postoperative complications and to derive the minimum duration of preoperative abstinence from smoking required to reduce such complications in adult surgical patients.

SOURCE

We searched MEDLINE, EMBASE, Cochrane, and other relevant databases for cohort studies and randomized controlled trials that reported postoperative complications (i.e., respiratory, cardiovascular, wound-healing) and mortality in patients who quit smoking within six months of surgery. Using a random effects model, meta-analyses were conducted to compare the relative risks of complications in ex-smokers with varying intervals of smoking cessation vs the risks in current smokers.

PRINCIPAL FINDINGS

We included 25 studies. Compared with current smokers, the risk of respiratory complications was similar in smokers who quit less than two or two to four weeks before surgery (risk ratio [RR] 1.20; 95% confidence interval [CI] 0.96 to 1.50 vs RR 1.14; CI 0.90 to 1.45, respectively). Smokers who quit more than four and more than eight weeks before surgery had lower risks of respiratory complications than current smokers (RR 0.77; 95% CI 0.61 to 0.96 and RR 0.53; 95% CI 0.37 to 0.76, respectively). For wound-healing complications, the risk was less in smokers who quit more than three to four weeks before surgery than in current smokers (RR 0.69; 95% CI 0.56 to 0.84). Few studies reported cardiovascular complications and there were few deaths.

CONCLUSION

At least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications. Short-term (less than four weeks) smoking cessation does not appear to increase or reduce the risk of postoperative respiratory complications.