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Feeney ME, Law AC, Walkey AJ, Bosch NA. Variation in Use of Medications for Opioid Use Disorder in Critically Ill Patients Across the United States. Crit Care Med 2024; 52:e365-e375. [PMID: 38501933 PMCID: PMC11176030 DOI: 10.1097/ccm.0000000000006257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To describe practice patterns surrounding the use of medications to treat opioid use disorder (MOUD) in critically ill patients. DESIGN Retrospective, multicenter, observational study using the Premier AI Healthcare Database. SETTING The study was conducted in U.S. ICUs. PATIENTS Adult (≥ 18 yr old) patients with a history of opioid use disorder (OUD) admitted to an ICU between 2016 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 108,189 ICU patients (658 hospitals) with a history of OUD, 20,508 patients (19.0%) received MOUD. Of patients receiving MOUD, 13,745 (67.0%) received methadone, 2,950 (14.4%) received buprenorphine, and 4,227 (20.6%) received buprenorphine/naloxone. MOUD use occurred in 37.9% of patients who received invasive mechanical ventilation. The median day of MOUD initiation was hospital day 2 (interquartile range [IQR] 1-3) and the median duration of MOUD use was 4 days (IQR 2-8). MOUD use per hospital was highly variable (median 16.0%; IQR 10-24; range, 0-70.0%); admitting hospital explained 8.9% of variation in MOUD use. A primary admitting diagnosis of unintentional poisoning (aOR 0.41; 95% CI, 0.38-0.45), presence of an additional substance use disorder (aOR 0.66; 95% CI, 0.64-0.68), and factors indicating greater severity of illness were associated with reduced odds of receiving MOUD in the ICU. CONCLUSIONS In a large multicenter, retrospective study, there was large variation in the use of MOUD among ICU patients with a history of OUD. These results inform future studies seeking to optimize the approach to MOUD use during critical illness.
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Affiliation(s)
| | - Anica C. Law
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
| | - Allan J. Walkey
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
| | - Nicholas A. Bosch
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
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Sevcik B, Lobay K, Luu H, Martins KJB, Vu K, Nguyen PU, Bohlouli S, Eurich DT, Lester ELW, Williamson T, Richer L, Klarenbach SW. Analgesic Use Among Adults with a Trauma-Related Emergency Department Visit: A Retrospective Cohort Study from Alberta, Canada. Pain Ther 2023; 12:1039-1053. [PMID: 37269501 PMCID: PMC10289951 DOI: 10.1007/s40122-023-00521-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/25/2023] [Indexed: 06/05/2023] Open
Abstract
INTRODUCTION A better understanding of current acute pain-driven analgesic practices within the emergency department (ED) and upon discharge will provide foundational information in this area, as few studies have been conducted in Canada. METHODS Administrative data were used to identify adults with a trauma-related ED visit in the Edmonton area in 2017/2018. Characteristics of the ED visit included time from initial contact to analgesic administration, type of analgesics dispensed during and upon being discharged home directly from the ED (≤ 7 days after), and patient characteristics. RESULTS A total of 50,950 ED visits by 40,505 adults with trauma were included. Analgesics were administered in 24.2% of visits, of which non-opioids were dispensed in 77.0% and opioids were dispensed in 49.0%. Time to analgesic initiation occurred more than 2 h after first contact. Upon discharge, 11.5% received a non-opioid and 15.2% received an opioid analgesic, among whom 18.5% received a daily dose ≥ 50 morphine milligram equivalents (MME) and 30.2% received > 7 days of supply. Three hundred and seventeen adults newly met criteria for chronic opioid use after the ED visit, among whom 43.5% received an opioid dispensation upon discharge; of these individuals, 26.8% had a daily dose ≥ 50 MME and 65.9% received > 7 days of supply. CONCLUSIONS Findings can be used to inform optimization of analgesic pharmacotherapy practices for the treatment of acute pain, which may include reducing the time to initiation of analgesics in the ED, as well as close consideration of recommendations for acute pain management upon discharge to provide ideal patient-centered, evidence-informed care.
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Affiliation(s)
- Bill Sevcik
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kevin Lobay
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Huong Luu
- Real World Evidence Unit, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Karen J B Martins
- Real World Evidence Unit, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Khanh Vu
- Real World Evidence Unit, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Phuong Uyen Nguyen
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Solmaz Bohlouli
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Erica L W Lester
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lawrence Richer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Scott W Klarenbach
- Department of Medicine and Real World Evidence Unit, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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Smith K, Wang M, Abdukalikov R, McAullife A, Whitesell D, Richard J, Sauer W, Quaye A. Pain Management Considerations in Patients with Opioid Use Disorder Requiring Critical Care. J Clin Pharmacol 2021; 62:449-462. [PMID: 34775634 DOI: 10.1002/jcph.1999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/07/2021] [Indexed: 11/07/2022]
Abstract
The opioid epidemic has resulted in increased opioid-related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit (ICU) clinician with guidance and treatment options, including non-opioid analgesia, for patients receiving medications for opioid use disorder (MOUD) and for patients actively misusing opioids. Verification and continuation of the patient's outpatient MOUD regimen, specifically buprenorphine and methadone formulations, assessment of pain and opioid withdrawal, and treatment of acute pain with non-opioid analgesia, nonpharmacologic strategies, and short-acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and to reduce the risk of unplanned discharge and other associated morbidity. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kathryn Smith
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Michelle Wang
- Department of Pharmacy, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Ruslan Abdukalikov
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Amy McAullife
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Dena Whitesell
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Janelle Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - William Sauer
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.,Spectrum Healthcare Partners, 324 Gannett Dr, Suite 200, South Portland, ME, 04106, USA.,Department of Critical Care, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.,Spectrum Healthcare Partners, 324 Gannett Dr, Suite 200, South Portland, ME, 04106, USA
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Domínguez-Franco A, Méndez-Flores S, Ramírez-Marín HA, Olvera-Rodriguez V, Domínguez-Cherit JG. Pain Management in Patients with Severe Pemphigus Vulgaris. J Pain Palliat Care Pharmacother 2021; 35:278-282. [PMID: 34519607 DOI: 10.1080/15360288.2021.1963906] [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: 10/20/2022]
Abstract
To describe the pain management and clinical course of patients with severe Pemphigus Vulgaris (PV) admitted to a third-level Intensive Care Unit (ICU). This was a retrospective cohort study conducted in the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán over the period 2013-2020. Study population comprised patients with severe PV admitted to the ICU. Eleven patients with severe PV were included. Mean age of presentation was 43.6 years. Percentage of the total body surface area affected ranged from 70 to 85% (mean: 80%). Visual Analogue Scale was used for pain assessment upon admission. Nine patients (72%) reported a 10/10 pain. The median Morphine Equivalent Daily Dose was 200 mg (range: 90-518 mg). Mortality was 27% during the ICU stay. One patient (9%) continued to experience severe pain and consume opioids after discharge. PV is a life-threatening disease characterized by painful, persistent erosions and ulcers. Integrated and multidisciplinary approach is often required. Opioids remain the mainstay for acute pain control in patients with severe PV. Biological, psychological, and social factors influence patients' daily opioid requirements and dose escalation. Successful pain management contributes to improving the quality of life, and the suppression and remission of PV.
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Eaton EF, Vettese T. Management of Opioid Use Disorder and Infectious Disease in the Inpatient Setting. Infect Dis Clin North Am 2021; 34:511-524. [PMID: 32782099 DOI: 10.1016/j.idc.2020.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acute bacterial infections such as endocarditis and skin and soft tissue infections are a common cause of hospitalization among persons with opioid use disorder (OUD). These interactions with acute care physicians provide an opportunity to diagnose OUD and treat patients with medications for OUD, including buprenorphine. When available, Addiction Medicine Consultation can be effective at linking patients to addiction treatment and also engaging patients in care for acute bacterial infections. In health systems without access to addiction medicine experts, infectious diseases providers, hospitalists, and other clinicians serve a valuable role in the diagnosis and treatment of OUD.
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Affiliation(s)
- Ellen F Eaton
- Division of Infectious Disease, University of Alabama at Birmingham, 845 19th Street South, Birmingham, AL 35205, USA.
| | - Theresa Vettese
- Division of General Medicine and Geriatrics, Emory University School of Medicine, 49 Jesse Hill Drive, Atlanta, GA 30303, USA.
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Liu Y, Hu Q, Yang J. Oliceridine for the Management of Acute Postoperative Pain. Ann Pharmacother 2021; 55:1283-1289. [PMID: 33423508 DOI: 10.1177/1060028020987679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To review the pharmacological characteristics, clinical evidence, and place in the management of acute postoperative pain severe enough to require an intravenous opioid. DATA SOURCES A comprehensive literature search was conducted in PubMed (January 2000 to December 1, 2020). Key search terms included oliceridine or acute postoperative pain. Other sources were derived from product labeling and ClinicalTrials.gov. STUDY SELECTION AND DATA EXTRACTION All English-language articles identified from the data sources were reviewed and evaluated. Phase I, II, and III clinical trials were included. DATA SYNTHESIS Oliceridine is a novel selective µ-receptor G-protein pathway modulator. It has the property of activating G-protein signaling while causing low β-arrestin recruitment to the µ-receptor. Intravenous oliceridine showed statistically superior analgesia than placebo in patients with moderate or severe pain after surgery, with a favorable safety and tolerability profile regarding respiratory and gastrointestinal adverse effects, compared with morphine. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The analgesic capacity of oliceridine is at least comparable to that of morphine at clinically relevant dosages, with a rapid onset of action. Also, it may be associated with a lower incidence of adverse events at dosing regimens associated with comparable analgesia. These data suggest that oliceridine may provide an important new treatment option for the management of moderate to severe postoperative pain where an intravenous opioid is warranted. CONCLUSION Oliceridine has obvious analgesic effects in patients with moderate or severe pain after surgery; additionally, it has a favorable safety and tolerability profile.
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Affiliation(s)
- Yang Liu
- Linyi Central Hospital, Shandong, China
| | - Qiang Hu
- Linyi Central Hospital, Shandong, China
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Management of Acute Pain Due to Traumatic Injury in Patients with Chronic Pain and Pre-injury Opioid Use. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
The rapid rise in the opioid epidemic has had a deleterious impact across the United States. This increase has drawn the attention of the critical care community not only because of the surge in acute opioid overdose-related admissions, but also due to the increase in the number of opioid-dependent and opioid-tolerant patients being treated in the intensive care unit (ICU). Opioid-related issues relevant to the critical care physician include direct care of patients with opioid overdoses, the provision of sufficient analgesia to patients with opioid dependence and tolerance, and the task of preventing long-term opioid dependence in patients who survive ICU care. This review identifies the challenges facing the ICU physician working with patients presenting with opioid-related complications, discusses current solutions, and suggests future areas of research and heightened ICU clinician attention.
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Mosher H, Herzig SJ, Danovitch I, Boutsicaris C, Hassamal S, Wittnebel K, Dashti A, Nuckols T. The Evaluation of Medical Inpatients Who Are Admitted on Long-term Opioid Therapy for Chronic Pain. J Hosp Med 2018; 13:249-255. [PMID: 29240853 DOI: 10.12788/jhm.2889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Individuals who are on long-term opioid therapy (LTOT) for chronic noncancer pain are frequently admitted to the hospital with acute pain, exacerbations of chronic pain, or comorbidities. Consequently, hospitalists find themselves faced with complex treatment decisions in the context of uncertainty about the effectiveness of LTOT as well as concerns about risks of overdose, opioid use disorders, and adverse events. Our multidisciplinary team sought to synthesize guideline recommendations and primary literature relevant to assessing medical inpatients on LTOT, with the objective of assisting practitioners in balancing effective pain treatment and opioid risk reduction. We identified no primary studies or guidelines specific to assessing medical inpatients on LTOT. Recommendations from outpatient guidelines on LTOT and guidelines on pain management in acute-care settings include the following: evaluate both pain and functional status, differentiate acute from chronic pain, investigate the preadmission course of opioid therapy, obtain a psychosocial history, screen for mental health conditions, screen for substance use disorders, check state prescription drug monitoring databases, order urine drug immunoassays, detect use of sedative-hypnotics, and identify medical conditions associated with increased risk of overdose and adverse events. Although approaches to assessing medical inpatients on LTOT can be extrapolated from related guidelines, observational studies, and small studies in surgical populations, more work is needed to address these critical topics for inpatients on LTOT.
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Affiliation(s)
- Hilary Mosher
- Department of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Iowa City VA Medical Center, Iowa City, Iowa, USA
| | - Shoshana J Herzig
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Itai Danovitch
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christina Boutsicaris
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sameer Hassamal
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karl Wittnebel
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Azadeh Dashti
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Teryl Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
- RAND Corporation, Santa Monica, California, USA
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Pergolizzi JV, Taylor R, LeQuang JA, Raffa RB. Managing severe pain and abuse potential: the potential impact of a new abuse-deterrent formulation oxycodone/naltrexone extended-release product. J Pain Res 2018; 11:301-311. [PMID: 29445297 PMCID: PMC5810535 DOI: 10.2147/jpr.s127602] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Proper management of severe pain represents one of the most challenging clinical dilemmas. Two equally important goals must be attained: the humanitarian/medical goal to relieve suffering and the societal/legal goal to not contribute to the drug abuse problem. This is an age-old problem, and the prevailing emphasis placed on one or the other goal has resulted in pendulum swings that have resulted in either undertreatment of pain or the current epidemic of misuse and abuse. In an effort to provide efficacious strong pain relievers (opioids) that are more difficult to abuse by the most dangerous routes of administration, pharmaceutical companies are developing products in which the opioid is manufactured in a formulation that is designed to be tamper resistant. Such a product is known as an abuse-deterrent formulation (ADF). ADF opioid products are designed to deter or resist abuse by making it difficult to tamper with the product and extracting the opioid for inhalation or injection. To date, less than a dozen opioid formulations have been approved by the US Food and Drug Administration to carry specific ADF labeling, but this number will likely increase in the coming years. Most of these products are extended-release formulations.
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Affiliation(s)
| | | | | | - Robert B Raffa
- University of Arizona College of Pharmacy, Tucson, AZ, USA.,Temple University School of Pharmacy, Philadelphia, PA, USA
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