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Peiró AM, Grimby-Ekman A, Barrachina J, Escorial M, Margarit C, Selva-Sevilla C, Gerónimo-Pardo M. Health-Related Quality of Life in Chronic Pain Treated With Tapentadol Versus Oxycodone/Naloxone and Its Determinants: A Real-World, Single-Center Retrospective Cohort Study in Spain. Value Health Reg Issues 2024; 44:101013. [PMID: 38981175 DOI: 10.1016/j.vhri.2024.101013] [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: 09/20/2023] [Revised: 04/16/2024] [Accepted: 05/08/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVES A substantial proportion of patients with chronic noncancer pain (CNCP) are treated with tapentadol (TAP) or oxycodone/naloxone (OXN) to improve their perceived physical and mental health over time. METHODS A cross-sectional study was conducted in 135 CNCP outpatients with usual prescribing (TAP: n = 58, OXN: n = 77) at a tertiary-care Spanish Hospital to compare health-related quality-of-life (HRQoL) records. Health utility was derived from the EQ-5D-3L. Regression models were performed to search for other HRQoL determinants. Pain intensity, relief, analgesic prescription, adverse events, inpatient stays, emergency department visits, and change to painkiller prescriptions were registered from electronic records. RESULTS Health utility (0.43 ± 0.24 scores, from -0.654 to 1) was similar for both opioids, although TAP showed a significantly low daily opioid dose requirement, neuromodulators use, and constipation side effect compared with OXN. After multivariable adjustment, the significant predictors of impaired HRQoL were pain intensity (β = -0.227, 95% CI -0-035 to -0.005), number of adverse events (β = -0.201, 95% CI -0.024 to -0.004), and opioid daily dose (β = -0.175, 95% CI -0.097 to -0.012). Male sex (β = -0.044) and pain relief (β = 0.158) should be taken into account for future studies. CONCLUSIONS HRQoL was similar for TAP and OXN in real-world patients with CNCP, albeit with a TAP opioid-sparing effect. More work is needed to explore HRQoL determinants in relation to long-term opioid use in CNCP.
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Affiliation(s)
- Ana M Peiró
- Neuropharmacology Applied to Pain (NED), Clinical Pharmacology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Institute of Bioengineering, University Miguel Hernández, Avda. Elche, Spain.
| | - Anna Grimby-Ekman
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jordi Barrachina
- Neuropharmacology Applied to Pain (NED), Clinical Pharmacology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Mónica Escorial
- Neuropharmacology Applied to Pain (NED), Clinical Pharmacology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - César Margarit
- Neuropharmacology Applied to Pain (NED), Clinical Pharmacology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Pain Unit, Alicante Department of Health, General Hospital, Alicante, Spain
| | - Carmen Selva-Sevilla
- Department of Applied Economy, Faculty of Economic and Business Sciences, University of Castilla-La Mancha, Albacete, Spain
| | - Manuel Gerónimo-Pardo
- Department of Anesthesiology, Integrated Care Management of Albacete, Albacete, Spain
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Cunico D, Rossi A, Verdesca M, Principi N, Esposito S. Pain Management in Children Admitted to the Emergency Room: A Narrative Review. Pharmaceuticals (Basel) 2023; 16:1178. [PMID: 37631093 PMCID: PMC10459115 DOI: 10.3390/ph16081178] [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: 06/30/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.
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Affiliation(s)
- Daniela Cunico
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | - Arianna Rossi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | - Matteo Verdesca
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
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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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Sivaraj LB, Truong K, Basco WT. Racial/Ethnic Patterns in Opioid Dispensing among Medicaid-Funded Young Children. Healthcare (Basel) 2023; 11:1910. [PMID: 37444744 DOI: 10.3390/healthcare11131910] [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: 04/15/2023] [Revised: 06/13/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Racial differences in opioid dispensing for diseases of the respiratory system (RESP) and injury (INJURY) outpatient visits among patients ≤ 3 years old were examined. Outpatient claims data of South Carolina Medicaid children were analyzed over three three-year periods. The variable of interest was the triennial rate of dispensed opioid prescriptions per 1000 visits for RESP and INJURY diagnoses across racial/ethnic groups. Overall, dispensed opioid prescription rates related to RESP declined for all racial/ethnic categories. White children had the highest dispensing rate for RESP indications in the first period (5.6), followed by Black (4.5), and Hispanic (4.1). The likelihood of White children being prescribed opioids was higher than Blacks, and this was persistent over the studied time (rate ratios from 1.24 to 1.22, respectively). Overall opioid dispensing rates related to injury declined during the studied time. Hispanics had the highest dispensing rate for INJURY (20.1 to 14.8 to 16.1, respectively) followed by White (16.1 to 13.1 to 10.4, respectively). Relative differences in the dispensing rates across groups increased over time (Hispanics vs. White: rate ratios from 1.25 to 1.55, Hispanics vs. Black: from 1.52 to 2.24, and White vs. Black: from 1.24 to 1.44, respectively). There are considerable differences in the dispensing rates across racial/ethnic groups, especially in injury-related prescribing.
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Affiliation(s)
- Laksika B Sivaraj
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
- Addiction Medicine Center, Prisma Health, Greenville, SC 29601, USA
| | - Khoa Truong
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
| | - William T Basco
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA
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Chen YH, Sadhasivam S, DeMedal S, Visoiu M. Short-acting versus long-acting opioids for pediatric postoperative pain management. Expert Rev Clin Pharmacol 2023; 16:813-823. [PMID: 37531096 PMCID: PMC10529420 DOI: 10.1080/17512433.2023.2244417] [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: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Opioids are potent analgesics commonly used to manage children's moderate to severe perioperative pain in children. A wide range of short and long-acting opioids are used to treat surgical pain and will be reviewed in this article. AREAS COVERED Both short- and long-acting opioids contain unique therapeutic benefits and adverse effects; however, due to the side effect profile and safety concerns, lack of familiarity, and evidence with long-acting opioids to treat surgical pain, shorter-acting opioids have traditionally been used in children. Almost all opioids work by binding to the mu receptor. Methadone, a long-acting opioid, is an exception because it also has beneficial N-methyl-D-aspartate antagonist properties. Clinically methadone's properties could translate to improved analgesic outcomes, reduced risk of adverse events, less risk for acute hyperalgesia, tolerance and abuse potential, faster recovery, and reduced risk for chronic persistent surgical pain. This review article summarizes and compares the evidence of commonly used short and long-acting opioids for perioperative pain control in the pediatric population. EXPERT OPINION Individualized methadone therapy using pharmacogenomics has the potential to transform opioid use in pain management by improving patient safety and analgesic outcomes, thereby addressing the gaps in current standardized ERAS protocols.
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Affiliation(s)
- Yun Han Chen
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Spencer DeMedal
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mihaela Visoiu
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
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Okubo Y, Uda K, Miyairi I. Trends in Influenza and Related Health Resource Use During 2005-2021 Among Children in Japan. Pediatr Infect Dis J 2023; Publish Ahead of Print:00006454-990000000-00474. [PMID: 37310897 DOI: 10.1097/inf.0000000000003966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND To determine the epidemiological trends in pediatric influenza and changes in healthcare resource use from 2005 to 2021 using nationally representative outpatient database in Japan. METHODS We conducted a retrospective cohort study consisting of 3.5 million children with 177 million person-months during 2005-2021 using Japan Medical Data Center claims database in Japan. We investigated trends in incidence rates of influenza and changes in healthcare resource use (eg, use of antivirals) over 17 years. Generalized estimation equations were used to investigate the impact of the 2009 influenza pandemic and the coronaviral disease 2019 (COVID-19) pandemic on incidence rates of influenza and related healthcare utilization. RESULTS Annual incidence rates of influenza were estimated at 55 cases per 1000 person-years with a 93% relative increase [95% confidence interval (CI): 80%-107%] during the 2009 influenza pandemic and a 99.4% relative reduction (95% CI: 99.3%-99.4%) during the COVID-19 pandemic. Similar patterns were observed for health resource use, total healthcare costs, admission rates and antiviral agent use. Approximately 80% of children with influenza received prescriptions for antivirals. The most prescribed antivirals were oseltamivir, but we observed a temporal increase in zanamivir use during 2007-2009, an increasing trend in laminamivir use during 2010-2017, a temporal increase in baloxavir use in 2018. Symptomatic medications with serious side effects (codeine, salicylate, sedative antihistamine) showed decreasing trends over the study period. CONCLUSIONS Influenza incidence and healthcare resource use were largely affected by the 2009 influenza pandemic and the COVID-19 pandemic. Our study indicates improvement of quality in healthcare delivered to children.
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Affiliation(s)
- Yusuke Okubo
- From the Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kazuhiro Uda
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
- Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, TN
- Department of Pediatrics, Hamamatsu University School of Medicine, Shizuoka, Japan
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Basco WT, Bundy DG, Garner SS, Ebeling M, Simpson KN. Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000-2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095681. [PMID: 37174201 PMCID: PMC10178489 DOI: 10.3390/ijerph20095681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/15/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023]
Abstract
Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0-18 years old between 2000-2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran-Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926-0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000-2020, adolescents 12-18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.
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Affiliation(s)
- William T Basco
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - David G Bundy
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Sandra S Garner
- Department of Clinical Pharmacy and Outcome Sciences, College of Pharmacy, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Myla Ebeling
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kit N Simpson
- Department of Healthcare Leadership & Management, College of Health Professions, The Medical University of South Carolina, Charleston, SC 29425, USA
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Skaggs CS, Logue BA. The Prevalence of Opioids in US Drinking Water Sources Detected Using Direct-Injection High-Performance Liquid Chromatography-Tandem Mass Spectrometry. ENVIRONMENTAL TOXICOLOGY AND CHEMISTRY 2022; 41:2658-2666. [PMID: 35920352 DOI: 10.1002/etc.5453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/15/2022] [Accepted: 07/31/2022] [Indexed: 06/15/2023]
Abstract
Active pharmaceutical ingredient (API) contamination of water sources, including opioid contamination, has become more common in recent years. Although drinking water-treatment plants help mitigate API infiltration, API contamination remains in some drinking water sources. Therefore, the ability to detect APIs at ultratrace concentrations is vital to ensure safe drinking water. A method for the ultratrace determination of fentanyl, hydrocodone, and codeine in drinking water via direct injection and high-performance liquid-chromatography tandem mass spectrometry (HPLC-MS/MS) was developed and validated. Drinking water samples (10 ml) are simply syringe-filtered and then analyzed by HPLC-MS/MS. A wide linear range (0.25-100 ng/L) and ultratrace limits of detection (80, 150, and 500 pg/L for fentanyl, hydrocodone, and codeine, respectively) were features of the method. The method produced excellent aggregate accuracies of 90%-115% and precisions of ≤11% for the three analytes tested. This method was used to test drinking water samples from 53 US locations, with hydrocodone and codeine detected in approximately 40% of the samples tested at concentrations between 0.3 and 20 ng/L. Codeine was detected at higher concentrations than hydrocodone (up to 7.3 times) for each sample containing these APIs. Fentanyl was not detected in any field drinking water sample. The detection of opioids in a large fraction of the US drinking water samples tested is cause for concern, and these levels should continue to be monitored to ensure that they do not become a threat to human health. Environ Toxicol Chem 2022;41:2658-2666. © 2022 SETAC.
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Affiliation(s)
| | - Brian A Logue
- Department of Chemistry and Biochemistry, South Dakota State University, Brookings, South Dakota, USA
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Mashat GD, Hazique M, Khan KI, Ramesh P, Kanagalingam S, Ul Haq Z, Victory Srinivasan N, Khan AI, Khan S. Comparing the Effectiveness of Honey Consumption With Anti-Cough Medication in Pediatric Patients: A Systematic Review. Cureus 2022; 14:e29346. [PMID: 36284810 PMCID: PMC9583571 DOI: 10.7759/cureus.29346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
Coughing is one of the most prevalent symptoms in children presenting at outpatient departments. This systematic review aimed to review previous literature in order to compare the use of honey and antitussive medications for treating coughs in children. Literature was screened across five databases using Medical Subject Heading (MeSH) strategy, keywords, and inclusion and exclusion criteria. The remaining literature was evaluated using a quality appraisal tool checklist. This review includes systematic reviews, meta-analyses, randomized controlled trials (RCTs), observational studies, cross-sectional studies, and articles without a defined methodology section. This review suggests that honey is effective in treating children above 12 months of age, while cold and cough medications (CCMs) are safe if administered at therapeutic doses. Since fatalities can occur in children under two years of age, further RCT studies on CCMs are required to establish safety across all age groups.
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Thal AG, Ahmed S, Kim S, Yang CJ, Gao Q, Gangar M, Mehta V. Assessing Impact: Implementing an Opioid Prescription Protocol in Otolaryngology. J Patient Saf 2022; 18:e992-e998. [PMID: 35093975 PMCID: PMC11221781 DOI: 10.1097/pts.0000000000000970] [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: 11/26/2022]
Abstract
OBJECTIVE A lack of guidance for pain control after otolaryngology surgery can lead to overprescription of opioids. We implemented a postoperative site-specific opioid prescription protocol and analyzed the impact on opioid prescriptions. METHODS This is a retrospective cohort study. A postoperative opioid prescription protocol was implemented within our otolaryngology department at a tertiary academic medical center on January 1, 2020. Retrospective chart review was completed for all patients undergoing otolaryngology surgery from November 1, 2019, to February 29, 2020 (2 months before and after initiation of intervention; n = 1070). The primary outcome was change in the amount of opioid prescribed for the preintervention and postintervention cohorts. Unplanned contact related to pain and opioid refills were tracked to assess pain control. RESULTS A total of 940 cases were included; adult and pediatric data were analyzed separately. There were 489 pediatric cases, 250 preintervention and 239 postintervention. There was a significant decrease in the amount of opioid prescribed per pediatric patient in the postintervention cohort (2.7 versus 0.32 morphine milligram equivalents, P = 0.02), and 99% of patients were not prescribed opioids at all. There was no significant change in unplanned contact, and no refills were required. There were 451 adult cases, 200 preintervention and 251 postintervention. There was no statistically significant decrease in the amount of opioid prescribed per adult patient (56.8 versus 51.7 morphine milligram equivalents, P = 0.23). There was no significant increase in unplanned contact or refills. CONCLUSIONS A postoperative opioid prescribing protocol can reduce the amount of opioid prescribed without increasing unplanned contact or opioid refills.
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Affiliation(s)
- Arielle G. Thal
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center
| | - Sadia Ahmed
- Albert Einstein College of Medicine, The Bronx, New York
| | - Stanley Kim
- Albert Einstein College of Medicine, The Bronx, New York
| | - Christina J. Yang
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center
| | - Qi Gao
- Albert Einstein College of Medicine, The Bronx, New York
| | - Mona Gangar
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center
| | - Vikas Mehta
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center
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Raymond M, Critchlow E, Rice SM, Wodoslawsky S, Berger SI, Hegde M, Empey PE, Al-Kouatly HB. Fetal pharmacogenomics: A promising addition to complex neonatal care. Mol Genet Metab 2022; 137:140-145. [PMID: 36029725 DOI: 10.1016/j.ymgme.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/06/2022] [Accepted: 08/07/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Pharmacogenomics (PGx) characterizes genetic variation in medication response. 85-95% of the population carries actionable PGx variants. No prior studies have demonstrated the application and feasibility of PGx in prenatal testing. We assessed parental desire for PGx findings from fetal exome sequencing (ES), evaluated PGx variants, and reviewed implications for medically complex neonates. METHODS A prospective cohort undergoing ES for nonimmune hydrops fetalis were offered PGx results as a secondary finding. Seven pharmacogenes with Level A evidence, defined by Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines, were tested and reported to patients and referring providers. Medication administration records were reviewed. RESULTS Most participants (36/40, 90%) desired PGx testing. 32/36 (89%) had potentially actionable PGx diplotypes in six genes: CYP2C19 (20/36, 56%), CYP2C9 (16/36, 44%), CYP2D6 (10/36, 28%), SLCO1B1 (13/36, 36%), TPMT (6/36, 17%), UGT1A1 (4/36, 11%). 12/13 (92%) live births had PGx variants. Neonatal chart review indicated that three medications with CPIC Level A evidence were administered to four neonates. None of the patients received a medication that aligned with an actionable pharmacogenetic variant as defined by Level A CPIC guidance. CONCLUSION Most participants opted to receive PGx results. 89% had actionable variants, consistent with population estimates. Obtaining fetal PGx data is feasible for medically complex neonates. Further studies are needed for broad clinical application of PGx in fetuses with major congenital abnormalities. Our study demonstrates the potential of PGx as useful preemptive clinical information that could be obtained at the time of fetal exome sequencing for other indications. CLINICALTRIALS gov Registration: NCT03911531.
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Affiliation(s)
- Megan Raymond
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth Critchlow
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephanie M Rice
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sascha Wodoslawsky
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Seth I Berger
- Center for Genetic Medicine Research at Children's National, Washington, DC, USA
| | | | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA.
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Jia Y, Zhou R, Li Z, Wang Y, Chen S, Zhao L, Shao Y, Qi J. Analgesic Effects and Safety of Dexmedetomidine Added to Nalbuphine or Sufentanil Patient-Controlled Intravenous Analgesia for Children After Tonsillectomy Adenoidectomy. Front Pharmacol 2022; 13:908212. [PMID: 35600878 PMCID: PMC9117536 DOI: 10.3389/fphar.2022.908212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Tonsillectomy is a frequently performed surgical procedure in children, requiring post-operative analgesia. This study evaluated the efficacy and safety of nalbuphine or sufentanil combined with dexmedetomidine for patient-controlled intravenous analgesia (PCIA) after pediatric tonsillectomy adenoidectomy. A total of 400 patients undergoing tonsillectomy with and without adenoidectomy were included in the study. Patients received a PCIA pump (0.5 mg/kg nalbuphine, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group ND (n = 200). Patients received a PCIA pump (2 μg/kg sufentanil, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group SD (n = 200). More stable hemodynamic changes were noted in Group ND than Group SD from 1 h to 48 h after operation. At 6, 12, 24, and 48 h after operation, the children in Group ND had higher Ramsay sedation scores than those in Group SD. The times to push the PCIA button in Group ND and Group SD were 2.44 ± 0.74 and 2.62 ± 1.00, showing significant differences (p = 0.041). The VASR scores of children in Group ND were significantly lower within 6, 12, and 24 h than those in Group SD (p < 0.05). The VASC scores of children in Group ND were significantly lower within four time points (2, 6, 12, and 24 h) than those in Group SD (p < 0.05). At 1st day after surgery, the children in Group ND had lower levels of serum ACTH, IL-6, and COR levels than those in Group SD (p < 0.001). The incidence rates of nausea and vomiting, and pruritus were significantly higher in Group SD than Group ND (5.00% vs. 11.00%, p = 0.028; 1.00% vs. 4.50%, p = 0.032). The total incidence rate of adverse reactions was significantly higher in Group SD than Group ND (15.00% vs. 31.00%, p = 0.0001). The study demonstrated that dexmedetomidine added to nalbuphine PCIA enhanced the analgesic effects, attenuated the postoperative pain, and reduced the stress response after pediatric tonsillectomy adenoidectomy.
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13
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Ballester P, Muriel J, Peiró AM. CYP2D6 phenotypes and opioid metabolism: the path to personalized analgesia. Expert Opin Drug Metab Toxicol 2022; 18:261-275. [PMID: 35649041 DOI: 10.1080/17425255.2022.2085552] [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: 11/04/2022]
Abstract
INTRODUCTION Opioids play a fundamental role in chronic pain, especially considering when 1 of 5 Europeans adults, even more in older females, suffer from it. However, half of them do not reach an adequate pain relief. Could pharmacogenomics help to choose the most appropriate analgesic drug? AREAS COVERED The objective of the present narrative review was to assess the influence of cytochrome P450 2D6 (CYP2D6) phenotypes on pain relief, analgesic tolerability, and potential opioid misuse. Until December 2021, a literature search was conducted through the MEDLINE, PubMed database, including papers from the last 10 years. CYP2D6 plays a major role in metabolism that directly impacts on opioid (tramadol, codeine, or oxycodone) concentration with differences between sexes, with a female trend toward poorer pain control. In fact, CYP2D6 gene variants are the most actionable to be translated into clinical practice according to regulatory drug agencies and international guidelines. EXPERT OPINION CYP2D6 genotype can influence opioids' pharmacokinetics, effectiveness, side effects, and average opioid dose. This knowledge needs to be incorporated in pain management. Environmental factors, psychological together with genetic factors, under a sex perspective, must be considered when you are selecting the most personalized pain therapy for your patients.
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Affiliation(s)
- Pura Ballester
- Neuropharmacology on Pain (NED) group, Alicante Institute for Health and Biomedical Research (ISABIAL Foundation), Alicante, Spain
| | - Javier Muriel
- Neuropharmacology on Pain (NED) group, Alicante Institute for Health and Biomedical Research (ISABIAL Foundation), Alicante, Spain
| | - Ana M Peiró
- Neuropharmacology on Pain (NED) group, Alicante Institute for Health and Biomedical Research (ISABIAL Foundation), Alicante, Spain.,Clinical Pharmacology Unit, Department of Health of Alicante, General Hospital, Alicante, Spain
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14
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Jones W, Kaoser R, Rudoler D, Fischer B. Trends in dispensing of individual prescription opioid formulations, Canada 2005-2020. J Pharm Policy Pract 2022; 15:27. [PMID: 35351208 PMCID: PMC8966300 DOI: 10.1186/s40545-022-00423-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/15/2022] [Indexed: 12/02/2022] Open
Abstract
Background Canada has experienced a distinctly bifurcated pattern of (strong) opioid utilization post-2000, with multifold increases rendering it one of the world’s highest opioid consumption rates, followed by subsequent substantive declines since 2011/2012. Several interventions to control especially high-risk opioid use have been implemented post-2010 at different levels, yet with their effects assessed mostly for overall opioid utilization. Little knowledge exists for over-time patterns of individual opioid formulations. Methods Raw information on community-based prescription opioid dispensing for years 2005–2020 were obtained from a large national database based on a stratified sample of 6500 retail pharmacies across Canada (IQVIA/Compuscript), These data were converted into Defined-Daily-Doses/1000 population/day (DDD/1000/day) for individual (strong and weak) opioid formulations—specifically: fentanyl, hydromorphone, hydrocodone, morphine, oxycodone, codeine—per standard methods. Descriptive data on individual opioid dispensing were computed, and segmented regression (or ‘broken-stick’) analysis was applied to the overtime dispensing towards assessing potentially significant ‘breakpoints’ interrupting linear utilization trends. Akaike information criterion (AIC) values were computed to assess the resulting models’ quality-of-fit. Results Five of the six opioid formulations featured a lower dispensing level in 2020 compared with 2005, but mostly with peak values in years between, contributing to the overall inversion pattern. For five of the six opioid formulations, a three-segmented model emerged as the best fit for the dispensing observed; only hydrocodone presented a linear (downward) dispensing trend. Among the five interrupted trend models for individual formulations, four (fentanyl, morphine, oxycodone, codeine but not hydromorphone) indicated their initial breakpoint during 2011–2014 introducing a downward dispensing trend. Inconsistently, morphine also featured a recent breakpoint (2018) towards a dispensing increase. Conclusions While all opioids showed marked declines, we found heterogeneous patterns of dispensing for individual opioid formulations. While we cannot estimate direct causal effects, opioid control interventions appear to have had differential impacts on dispensing of individual formulations. The earliest breakpoint occurred towards substantive decreases for oxycodone dispensing in 2011; subsequently, there were increases in dispensing of hydromorphone and fentanyl likely due to substitution effects, followed by across-the-board declines post-2015/2016. Recent ‘safer opioid’ distribution programs to reduce illicit/toxic opioid exposure linked with high levels of poisoning fatalities seem to fuel resurgences in select opioid (e.g., morphine) dispensing.
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Affiliation(s)
- Wayne Jones
- Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Suite 2400, 515 W. Hastings Street, Vancouver, BC, V6B5K3, Canada
| | - Ridhwana Kaoser
- Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Suite 2400, 515 W. Hastings Street, Vancouver, BC, V6B5K3, Canada
| | - David Rudoler
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Oshawa, ON, L1H 7K4, Canada
| | - Benedikt Fischer
- Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Suite 2400, 515 W. Hastings Street, Vancouver, BC, V6B5K3, Canada. .,Centre for Applied Research in Mental Health & Addiction, Faculty of Health Sciences, Simon Fraser University, 515 W. Hastings St., Vancouver, BC, V6B5K3, Canada. .,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, Canada. .,Department of Psychiatry, Federal University of São Paulo (UNIFESP), R. Sena Madureira, 1500, Vila Clementino, São Paulo, Brazil.
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15
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Lavingia R, Mondragon E, McFarlane-Johansson N, Shenoi RP. Improving Opioid Stewardship in Pediatric Emergency Medicine. Pediatrics 2021; 148:183393. [PMID: 34851415 DOI: 10.1542/peds.2020-039743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Poor opioid stewardship contributes to opioid misuse and adverse health outcomes. We sought to decrease opioid prescriptions in children 0 to 18 years treated for pain after fractures and cutaneous abscess drainage from 13.5% to 8%. Our secondary aims were to reduce opioid prescriptions written for >3 days from 41% to 10%, eliminate codeine prescriptions, increase safe opioid storage and disposal discharge instructions from 0% to 70%, and enroll all emergency department (ED) physicians in the state prescription drug monitoring program. METHODS We implemented an intervention bundle on the basis of 4 key drivers at a pediatric ED: ED-wide education, changes in the electronic medical record, discharge resources, and process standardization. Two plan-do-study-act cycles were performed. Interventions included provider feedback on prescribing, safe opioid storage and disposal instructions, and streamlined electronic medical record functions. Run charts were used to analyze the effect of interventions on outcomes. Our balance measure was return ED or clinic visits for inadequate analgesia within 3 days. RESULTS During the intervention period, 249 of 3402 (7.3%) patients with fractures and cutaneous abscesses were prescribed opioids. The percentage of opioid prescriptions >3 days decreased from 41% to 13.2% (P < .0001), codeine prescription dropped from 1.1% to 0% (P = .09), opioid discharge instructions increased 0% to 100% (P < .0001), and all physicians enrolled in the prescription drug monitoring program. There was no change in return visits for uncontrolled analgesia compared with the baseline (P = .79). CONCLUSIONS A comprehensive opioid stewardship program can improve opioid prescribing practices of ED physicians and deliver information on safe storage and disposal of prescription opioids with a negligible effect on return visits for uncontrolled pain.
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Affiliation(s)
| | | | - Nina McFarlane-Johansson
- Section of Emergency Medicine, Department of Pediatrics.,Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Rohit P Shenoi
- Section of Emergency Medicine, Department of Pediatrics.,Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
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16
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Chua KP, Conti RM. Prescriptions for Codeine or Hydrocodone Cough and Cold Medications to US Children and Adolescents Following US Food and Drug Administration Safety Communications. JAMA Netw Open 2021; 4:e2134142. [PMID: 34762115 PMCID: PMC8586901 DOI: 10.1001/jamanetworkopen.2021.34142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This cross-sectional study uses national prescription data to assess whether safety communications from the US Food and Drug Administration (FDA) issued in 2017 and 2018 were associated with changes in prescriptions for codeine and hydrocodone cough and cold medications to children and adolescents.
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Affiliation(s)
- Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Rena M. Conti
- Department of Markets, Public Policy, and Law, Institute for Health System Innovation and Policy, Boston University Questrom School of Business, Boston, Massachusetts
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17
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Hamina A, Handal M, Fredheim O, Clausen T, Chen L, Skurtveit S. Filled prescriptions for opioids among children and adolescents - A nationwide study from 2010 to 2018. Acta Anaesthesiol Scand 2021; 65:1475-1483. [PMID: 34374072 DOI: 10.1111/aas.13968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prescribing opioids for children and adolescents should be reserved for advanced life-limiting diseases and moderate-to-severe acute pain. Pediatric codeine use is discouraged by several authorities, but the effects of these recommendations are not fully known. We investigated opioid utilization trends among 0-18-year-olds and characterized those who filled ≥1 opioid prescriptions, with emphasis on those who did so >3 times within a year. METHODS The prevalence of filled opioid prescriptions among 0-18-year-old Norwegians in 2010-2018 (N = 77,942) was measured from nationwide healthcare registries. Characteristics, healthcare utilization, and other drug use of those who newly filled 1, 2-3, or >3 opioid prescriptions in 2011-2014 were compared to 2015-2018, excluding persons with cancer. RESULTS From 2010 to 2018, the prevalence of opioid use decreased from 9.0 to 7.0 per 1000 persons. The largest decrease was among children <12 years, from 4.1 to 0.4 per 1000 persons, mainly due to decreasing codeine use. The proportion of those who filled >3 opioid prescriptions was 2.1% in 2011-2014 and 3.1% in 2015-2018. Those with >3 dispensations had a median of 4 contacts/year with secondary healthcare (interquartile range 2-7); the most frequent diagnoses indicated post-surgery follow-up. Most commonly dispensed other drugs were non-steroidal anti-inflammatory drugs. CONCLUSIONS Opioid dispensations for the young have declined in recent years. Multiple opioid dispensations were rare and associated with frequent healthcare utilization. Reducing codeine is in line with recommendations, but the effects of decreased opioid use on the quality of pain management remain unknown.
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Affiliation(s)
- Aleksi Hamina
- Norwegian Centre for Addiction Research (SERAF) Institute of Clinical Medicine University of Oslo Oslo Norway
- School of Pharmacy Faculty of Health Sciences University of Eastern Finland Kuopio Finland
| | - Marte Handal
- Department of Mental Disorders Division of Mental and Physical Health the Norwegian Institute of Public Health Oslo Norway
| | - Olav Fredheim
- Department of Circulation and Medical Imaging Faculty of Medicine and Health Sciences Norwegian University of Science and Technology Trondheim Norway
- Norwegian Advisory Unit on Complex Symptom Disorders St. Olav University Hospital Trondheim Norway
- Department of Palliative Medicine Akershus University Hospital Lørenskog Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF) Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Li‐Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety Division of Pharmacy and Optometry School of Health Sciences Faculty of Biology, Medicine and Health University of ManchesterManchester Academic Health Science Centre Manchester UK
| | - Svetlana Skurtveit
- Norwegian Centre for Addiction Research (SERAF) Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Mental Disorders Division of Mental and Physical Health the Norwegian Institute of Public Health Oslo Norway
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18
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McDonough M, Hathi K, Corsten G, Chin CJ, Campisi P, Cavanagh J, Chadha N, Graham ME, Husein M, Johnson LB, Jones J, Korman B, Manoukian J, Nguyen LHP, Sommer DD, Strychowsky J, Uwiera T, Yunker W, Hong P. Choosing Wisely Canada - pediatric otolaryngology recommendations. J Otolaryngol Head Neck Surg 2021; 50:61. [PMID: 34715936 PMCID: PMC8557011 DOI: 10.1186/s40463-021-00533-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/19/2021] [Indexed: 11/10/2022] Open
Abstract
The Choosing Wisely Canada campaign raises awareness amongst physicians and patients regarding unnecessary or inappropriate tests and treatments. Using an online survey, members of the Pediatric Otolaryngology Subspecialty Group within the Canadian Society of Otolaryngology – Head & Neck Surgery developed a list of nine evidence based recommendations to help physicians and patients make treatment decisions regarding common pediatric otolaryngology presentations: (1) Don’t routinely order a plain film x-ray in the evaluation of nasal fractures; (2) Don’t order imaging to distinguish acute bacterial sinusitis from an upper respiratory infection; (3) Don’t place tympanostomy tubes in most children for a single episode of otitis media with effusion of less than 3 months duration; (4) Don’t routinely prescribe intranasal/systemic steroids, antihistamines or decongestants for children with uncomplicated otitis media with effusion; (5) Don’t prescribe oral antibiotics for children with uncomplicated tympanostomy tube otorrhea or uncomplicated acute otitis externa; (6) Don’t prescribe codeine for post-tonsillectomy/adenoidectomy pain relief in children; (7) Don’t administer perioperative antibiotics for elective tonsillectomy in children; (8) Don’t perform tonsillectomy for children with uncomplicated recurrent throat infections if there have been fewer than 7 episodes in the past year, 5 episodes in each of the past 2 years, or 3 episodes in each of the last 3 years; and (9) Don’t perform endoscopic sinus surgery for uncomplicated pediatric chronic rhinosinusitis prior to failure of maximal medical therapy and adenoidectomy.
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Affiliation(s)
| | - Kalpesh Hathi
- Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
| | - Gerard Corsten
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, Dalhousie University, 5850/5920 University Ave, Halifax, Nova Scotia, B3K 6R8 PO Box 9700, Canada
| | - Christopher J Chin
- Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada.,Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, Dalhousie University, 5850/5920 University Ave, Halifax, Nova Scotia, B3K 6R8 PO Box 9700, Canada
| | - Paolo Campisi
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Cavanagh
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Newfoundland, Canada
| | - Neil Chadha
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - M Elise Graham
- Department of Otolaryngology - Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Murad Husein
- Department of Otolaryngology - Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Liane B Johnson
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, Dalhousie University, 5850/5920 University Ave, Halifax, Nova Scotia, B3K 6R8 PO Box 9700, Canada
| | - Jodi Jones
- Department of Otolaryngology - Head & Neck Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bruce Korman
- Department of Surgery, Otolaryngology/Head & Neck Surgery Division, McMaster University, Hamilton, Ontario, Canada
| | - John Manoukian
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Lily H P Nguyen
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Doron D Sommer
- Department of Surgery, Otolaryngology/Head & Neck Surgery Division, McMaster University, Hamilton, Ontario, Canada
| | - Julie Strychowsky
- Department of Otolaryngology - Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Trina Uwiera
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Warren Yunker
- Section of Otolaryngology - Head & Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Paul Hong
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, Dalhousie University, 5850/5920 University Ave, Halifax, Nova Scotia, B3K 6R8 PO Box 9700, Canada.
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19
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Jones W, Kaoser R, Fischer B. Patterns, trends and determinants of medical opioid utilization in Canada 2005-2020: characterizing an era of intensive rise and fall. Subst Abuse Treat Prev Policy 2021; 16:65. [PMID: 34521418 PMCID: PMC8438558 DOI: 10.1186/s13011-021-00396-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Into the 21st century, the conflation of high rates of chronic pain, systemic gaps in treatment availability and access, and the arrival of potent new opioid medications (e.g., slow-release oxycodone) facilitated strong increases in medical opioid dispensing in Canada. These persisted until post-2010 alongside rising opioid-related adverse (e.g., morbidity/mortality) outcomes. We examine patterns, trends and determinants of opioid dispensing in Canada, and specifically its 10 provinces, for the years 2005-2020. METHODS Raw data on prescription opioid dispensing were obtained from a large national community-based pharmacy database (IQVIA/Compuscript), converted into Defined-Daily-Doses/1,000 population/day for 'strong' and 'weak' opioid categories per standard methods. Dispensing by opioid category and formulations by province/year was assessed descriptively; regression analysis was applied to examine possible segmentation of over-time strong opioid dispensing. RESULTS All provinces reported starkly increasing strong opioid dispensing peaking 2011-2016, and subsequent marked declines. About half reported lower strong opioid dispensing in 2020 compared to 2005, with continuous inter-provincial differences of > 100 %; weak opioids also declined post-2011/12. Segmented regression suggests breakpoints for strong opioids in 2011/12 and 2015/16, coinciding with main interventions (e.g., selective opioid delisting, new prescribing guidelines) towards more restrictive opioid utilization control. CONCLUSIONS We characterized an era of marked rise and fall, while featuring stark inter-provincial heterogeneity in opioid dispensing in Canada. While little evidence for improvements in pain care outcomes exists, the starkly inverting opioid utilization have been associated with extensive population-level harms (e.g., misuse, morbidity, mortality) over-time. This national case study raises fundamental questions for opioid-related health policy and practice.
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Affiliation(s)
- Wayne Jones
- Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Suite 2400, 515 W. Hastings Street, British Columbia, Vancouver, Canada
| | - Ridhwana Kaoser
- Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Suite 2400, 515 W. Hastings Street, British Columbia, Vancouver, Canada
| | - Benedikt Fischer
- Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Suite 2400, 515 W. Hastings Street, British Columbia, Vancouver, Canada.
- Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Auckland, 1023, Grafton, New Zealand.
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario, Canada.
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), R. Sena Madureira, 1500 - Vila Clementino, São Paulo, Brazil.
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20
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Jensen DR. Pharmacologic management of post-tonsillectomy pain in children. World J Otorhinolaryngol Head Neck Surg 2021; 7:186-193. [PMID: 34430826 PMCID: PMC8356107 DOI: 10.1016/j.wjorl.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/18/2021] [Indexed: 12/19/2022] Open
Abstract
Tonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.
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Affiliation(s)
- Daniel R. Jensen
- Division of Otolaryngology, Children's Mercy Hospital, Kansas City, MO, USA
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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21
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Packiasabapathy S, Zhang X, Ding L, Aruldhas BW, Pawale D, Sadhasivam S. Quantitative Pupillometry as a Predictor of Pediatric Postoperative Opioid-Induced Respiratory Depression. Anesth Analg 2021; 133:991-999. [PMID: 34029273 DOI: 10.1213/ane.0000000000005579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Safe postoperative pain relief with opioids is an unmet critical medical need in children. There is a lack of objective, noninvasive bedside tool to assess central nervous system (CNS) effects of intraoperative opioids. Proactive identification of children at risk for postoperative respiratory depression (RD) will help tailor analgesic therapy and significantly improve the safety of opioids in children. Quantitative pupillometry (QP) is a noninvasive, objective, and real-time tool for monitoring CNS effect-time relationship of opioids. This exploratory study aimed to determine the association of QP measures with postoperative RD, as well as to identify the best intraoperative QP measures predictive of postoperative RD in children. METHODS After approval from the institutional review board and informed parental consent, in this prospective, observational study of 220 children undergoing tonsillectomy, QP measures were collected at 5 time points: awake preoperative baseline before anesthesia induction (at the time of enrollment [T1]), immediately after anesthesia induction before morphine administration (T2), 3 minutes after intraoperative morphine administration (T3), at the end of surgery (T4), and postoperatively when awake in postanesthesia recovery unit (PACU) (T5). Intraoperative use of opioid and incidence of postoperative RD were collected. Analyses were aimed at exploring correlations of QP measures with the incidence of RD and, if found significant, to develop a predictive model for postoperative RD. RESULTS Perioperative QP measures of percentage pupil constriction (CONQ, P = .027), minimum pupillary diameter (MIN, P = .027), and maximum pupillary diameter (MAX, P = .034) differed significantly among children with and without postoperative RD. A predictive model including the minimum pupillary diameter 3 minutes after morphine administration (MIN3), minimum pupillary diameter normalized to baseline (MIN31), and percentage pupillary constriction after surgery (T4) standardized to baseline (T1) (CONQ41), along with the weight-based morphine dose performed the best to predict postoperative RD in children (area under the curve [AUC], 0.76). CONCLUSIONS A model based on pre- and intraoperative pupillometry measures including CONQ, MIN, along with weight-based morphine dose-predicted postoperative RD in our cohort of children undergoing tonsillectomy. More studies with a larger sample size are required to validate this finding.
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Affiliation(s)
- Senthil Packiasabapathy
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Lili Ding
- Division of Human Genetics.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Blessed W Aruldhas
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana.,Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, India
| | - Dhanashri Pawale
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Senthilkumar Sadhasivam
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
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22
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Kolesar JM, Vermeulen LC. Precision medicine: Opportunities for health-system pharmacists. Am J Health Syst Pharm 2021; 78:999-1003. [PMID: 33693532 PMCID: PMC7989629 DOI: 10.1093/ajhp/zxab084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- Jill M Kolesar
- Markey Cancer Center, Lexington, KY.,University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Lee C Vermeulen
- University of Kentucky College of Pharmacy, Lexington, KY, USA.,UK HealthCare, Lexington, KY
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Lawrence A, Cooper JN, Deans KJ, Minneci PC, Wrona SK, Chisolm DJ. Effects of the FDA Codeine Safety Investigation on Racial and Geographic Disparities in Opioid Prescribing after Pediatric Tonsillectomy and/or Adenoidectomy. Glob Pediatr Health 2021; 8:2333794X20987444. [PMID: 33506076 PMCID: PMC7812397 DOI: 10.1177/2333794x20987444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 11/23/2020] [Accepted: 12/18/2020] [Indexed: 11/15/2022] Open
Abstract
Objective. Our objective was to examine the impact of the U.S. FDA’s 2013 black box warning against codeine on codeine and other opioid prescription filling after pediatric tonsillectomy and/or adenoidectomy (T/A) overall and by child race and provider urbanity/rurality. Methods. Patients ≤ 18 who underwent T/A in 8/2011 to 8/2016 were identified in Ohio Medicaid claims. Interrupted time series analyses were used to evaluate the impact of the FDA warning on codeine or other opioid prescription filling post-T/A. Results. In August 2011, codeine prescription filling was lower among black than white children (P < .001) and among children treated at institutions in metropolitan counties than less populous counties (P < .001). The FDA warning was associated with a 24.0% drop in codeine prescription filling (P < .001) and 5.5% increase in alternative opioid prescription filling (P = .046). At conclusion, there remained geographic but no longer racial disparities in codeine prescribing. Conclusion. Codeine prescribing after pediatric T/A decreased after the FDA’s black box warning. However, geographic disparities in codeine prescribing remain.
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Affiliation(s)
- Amy Lawrence
- Nationwide Children's Hospital, Columbus, OH, USA
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Fizeșan I, Rusu ME, Georgiu C, Pop A, Ștefan MG, Muntean DM, Mirel S, Vostinaru O, Kiss B, Popa DS. Antitussive, Antioxidant, and Anti-Inflammatory Effects of a Walnut ( Juglans regia L.) Septum Extract Rich in Bioactive Compounds. Antioxidants (Basel) 2021; 10:119. [PMID: 33467612 PMCID: PMC7830861 DOI: 10.3390/antiox10010119] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 02/07/2023] Open
Abstract
The antitussive, antioxidant, and anti-inflammatory effects of a walnut (Juglans regia L.) septum extract (WSE), rich in bioactive compounds were investigated using the citric acid aerosol-induced cough experimental model in rodents. Wistar male rats were treated orally for three days with distilled water (control), codeine (reference), and WSE in graded doses. On the third day, all rats were exposed to citric acid aerosols, the number of coughs being recorded. Each animal was sacrificed after exposure, and blood and lung tissue samples were collected for histopathological analysis and the assessment of oxidative stress and inflammatory biomarkers. The results of the experiment showed a significant antitussive effect of WSE, superior to codeine. This activity could be due to cellular protective effect and anti-inflammatory effect via the stimulation of the antioxidant enzyme system and the decrease of IL-6 and CXC-R1 concentration in the lung tissue of WSE-treated animals. The antioxidant and anti-inflammatory effects of WSE were confirmed by biochemical assays and histopathological analysis. This is the first scientific study reporting the antitussive effect of walnut septum, a new potential source of non-opioid antitussive drug candidates, and a valuable bioactive by-product that could be used in the treatment of respiratory diseases.
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Affiliation(s)
- Ionel Fizeșan
- Department of Toxicology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania; (I.F.); (A.P.); (M.-G.Ș.); (B.K.); (D.-S.P.)
| | - Marius Emil Rusu
- Department of Pharmaceutical Technology and Biopharmaceutics, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania; (M.E.R.); (D.-M.M.)
| | - Carmen Georgiu
- Department of Pathological Anatomy, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania
| | - Anca Pop
- Department of Toxicology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania; (I.F.); (A.P.); (M.-G.Ș.); (B.K.); (D.-S.P.)
| | - Maria-Georgia Ștefan
- Department of Toxicology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania; (I.F.); (A.P.); (M.-G.Ș.); (B.K.); (D.-S.P.)
| | - Dana-Maria Muntean
- Department of Pharmaceutical Technology and Biopharmaceutics, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania; (M.E.R.); (D.-M.M.)
| | - Simona Mirel
- Department of Medical Devices, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania;
| | - Oliviu Vostinaru
- Department of Pharmacology, Physiology and Physiopathology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania
| | - Béla Kiss
- Department of Toxicology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania; (I.F.); (A.P.); (M.-G.Ș.); (B.K.); (D.-S.P.)
| | - Daniela-Saveta Popa
- Department of Toxicology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes, 400012 Cluj-Napoca, Romania; (I.F.); (A.P.); (M.-G.Ș.); (B.K.); (D.-S.P.)
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Coté CJ. Obstructive sleep apnoea and polymorphisms: implications for anaesthesia care. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s2.2513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With a worldwide obesity pandemic, the incidence of obstructive sleep apnoea (OSA) is increasing; obesity is the most significant risk factor in children. Increasing evidence suggests that OSA is in part mediated through markers of inflammation. Systemic and pulmonary hypertension, right ventricular hypertrophy, prediabetes, and other conditions are common. Adenotonsillectomy improves only ~70% of children; 30% require other interventions, e.g. weight loss programs. The gold standard for diagnosis is a sleep-polysomnogram which are expensive and not readily available. The McGill oximetry score (saw-tooth desaturations during obstruction and arousal) is more cost-effective.
Repeated episodes of desaturation alter the opioid receptors such that analgesia is achieved at much lower levels of opioid than in patients undergoing the same procedure but without OSA. This response is of great concern because a standard dose of opioids may be a relative overdose.
Polymorphism variations in cytochrome CYP2D6 have major effects upon drug efficacy and side effects. Codeine, hydrocodone, oxycodone, and tramadol are all prodrugs that require CYP2D6 for conversion to the active compound. CYP2D6 is quite variable and patients can be divided into 4 classes: For codeine for example, poor metaboliser (PM) have virtually no conversion to morphine, intermediate metabolisers (IM) have some conversion to morphine, extensive metabolisers (EM) have a normal rate of conversion to morphine, and ultra-rapid metabolisers (RM) convert excessive amounts of codeine to morphine. Such variations result in some patients achieving no analgesia because there is reduced conversion to the active moiety whereas others convert an excessive amount of drug to the active compound thus resulting in relative or actual overdose despite appropriate dosing.
Thus, OSA patients may have both opioid sensitivity due to recurrent desaturations and altered drug metabolism resulting in higher than intended blood levels of opioid. OSA patients should only receive one-third to half the usual dose of opioid. In those under the age of six, an effort should be made to avoid opioids altogether and use opioid sparing techniques such as alternating acetaminophen and ibuprofen.
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Silveira D, Prieto-Garcia JM, Boylan F, Estrada O, Fonseca-Bazzo YM, Jamal CM, Magalhães PO, Pereira EO, Tomczyk M, Heinrich M. COVID-19: Is There Evidence for the Use of Herbal Medicines as Adjuvant Symptomatic Therapy? Front Pharmacol 2020; 11:581840. [PMID: 33071794 PMCID: PMC7542597 DOI: 10.3389/fphar.2020.581840] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/28/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Current recommendations for the self-management of SARS-Cov-2 disease (COVID-19) include self-isolation, rest, hydration, and the use of NSAID in case of high fever only. It is expected that many patients will add other symptomatic/adjuvant treatments, such as herbal medicines. AIMS To provide a benefits/risks assessment of selected herbal medicines traditionally indicated for "respiratory diseases" within the current frame of the COVID-19 pandemic as an adjuvant treatment. METHOD The plant selection was primarily based on species listed by the WHO and EMA, but some other herbal remedies were considered due to their widespread use in respiratory conditions. Preclinical and clinical data on their efficacy and safety were collected from authoritative sources. The target population were adults with early and mild flu symptoms without underlying conditions. These were evaluated according to a modified PrOACT-URL method with paracetamol, ibuprofen, and codeine as reference drugs. The benefits/risks balance of the treatments was classified as positive, promising, negative, and unknown. RESULTS A total of 39 herbal medicines were identified as very likely to appeal to the COVID-19 patient. According to our method, the benefits/risks assessment of the herbal medicines was found to be positive in 5 cases (Althaea officinalis, Commiphora molmol, Glycyrrhiza glabra, Hedera helix, and Sambucus nigra), promising in 12 cases (Allium sativum, Andrographis paniculata, Echinacea angustifolia, Echinacea purpurea, Eucalyptus globulus essential oil, Justicia pectoralis, Magnolia officinalis, Mikania glomerata, Pelargonium sidoides, Pimpinella anisum, Salix sp, Zingiber officinale), and unknown for the rest. On the same grounds, only ibuprofen resulted promising, but we could not find compelling evidence to endorse the use of paracetamol and/or codeine. CONCLUSIONS Our work suggests that several herbal medicines have safety margins superior to those of reference drugs and enough levels of evidence to start a clinical discussion about their potential use as adjuvants in the treatment of early/mild common flu in otherwise healthy adults within the context of COVID-19. While these herbal medicines will not cure or prevent the flu, they may both improve general patient well-being and offer them an opportunity to personalize the therapeutic approaches.
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Affiliation(s)
- Dâmaris Silveira
- Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil
| | - Jose Maria Prieto-Garcia
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Fabio Boylan
- School of Pharmacy and Pharmaceutical Sciences and Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Omar Estrada
- Biophysics and Biochemistry Center, Venezuelan Institute of Scientific Research, Caracas, Venezuela
| | | | | | | | - Edson Oliveira Pereira
- Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil
| | - Michal Tomczyk
- Faculty of Pharmacy, Medical University of Bialystok, Bialystok, Poland
| | - Michael Heinrich
- Pharmacognosy and Phytotherapy, School of Pharmacy, University College of London, London, United Kingdom
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Non-steroidal or opioid analgesia use for children with musculoskeletal injuries (the No OUCH study): statistical analysis plan. Trials 2020; 21:759. [PMID: 32883371 PMCID: PMC7469310 DOI: 10.1186/s13063-020-04503-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 06/11/2020] [Indexed: 11/29/2022] Open
Abstract
Background Pediatric musculoskeletal injuries cause moderate to severe pain, which should ideally be addressed upon arrival to the emergency department (ED). Despite extensive research in ED-based pediatric pain treatment, recent studies confirm that pain management in this setting remains suboptimal. The No OUCH study consist of two complementary, randomized, placebo-controlled trials that will run simultaneously for patients presenting to the ED with an acute limb injury and a self-reported pain score of at least 5/10, measured via a verbal numerical rating scale (vNRS). Caregiver/parent choice will determine whether patients are randomized to the two-arm or three-arm trial. In the two-arm trial, patients will be randomized to receive either ibuprofen alone or ibuprofen in combination with acetaminophen. In the three-arm trial, patients can also be randomized to a third arm where they would receive ibuprofen in combination with hydromorphone. This article details the statistical analysis plan for the No OUCH study and was submitted before the trial outcomes were available for analysis. Methods/design The primary endpoint of the No OUCH study is self-reported pain at 60 min, recorded using a vNRS. The principal safety outcome is the presence of any adverse event related to study drug administration. Secondary effectiveness endpoints include pain measurements using the Faces Pain Scale-Revised and the visual analog scale, time to effective analgesia, requirement of a rescue analgesic, missed fractures, and observed pain reduction using different definitions of successful analgesia. Secondary safety outcomes include sedation measured using the Ramsay Sedation Score and serious adverse events. Finally, the No OUCH study investigates the reasons given by the caregiver for selecting the two-arm (Non-Opioid) or three-arm (Opioid) trial, caregiver satisfaction, physician preferences for analgesics, and caregiver comfort with at-home pain management. Discussion The No OUCH study will inform the relative effectiveness of acetaminophen and hydromorphone, in combination with ibuprofen, and ibuprofen alone as analgesic agents for patients presenting to the ED with an acute musculoskeletal injury. The data from these trials will be analyzed in accordance with this statistical analysis plan. This will reduce the risk of producing data-driven results and bias in our reported outcomes. Trial registration ClinicalTrials.gov NCT03767933. Registered on December 7, 2018.
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Phang KG, Roberts JR, Ebeling M, Garner SS, Basco WT. Opioids or Steroids for Pneumonia or Sinusitis. Pediatrics 2020; 146:e20193690. [PMID: 32616629 PMCID: PMC7397734 DOI: 10.1542/peds.2019-3690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To compare the frequency of opioid and corticosteroid prescriptions dispensed for children with pneumonia or sinusitis visits on the basis of location of care. METHODS We evaluated 2016 South Carolina Medicaid claims data for 5 to 18 years olds with pneumonia or sinusitis. Visits were associated with 1 of 3 locations: the emergency department (ED), urgent care, or the ambulatory setting. RESULTS Inclusion criteria were met by 31 838 children. Pneumonia visits were more often linked to an opioid prescription in the ED (34 of 542 [6.3%]) than in ambulatory settings (24 of 1590 [1.5%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (106 of 542 [19.6%]) than in ambulatory settings (196 of 1590 [12.3%]; P ≤ .0001). Sinusitis visits were more often linked to an opioid prescription in the ED (202 of 2705 [7.5%]) than in ambulatory settings (568 of 26 866 [2.1%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (510 of 2705 [18.9%]) than in ambulatory settings (1922 of 26 866 [7.2%]; P ≤ .0001). In logistic regression for children with pneumonia, the ED setting was associated with increased odds of receiving an opioid (adjusted odds ratio [aOR] 4.69) or steroid (aOR 1.67). Similarly, patients with sinusitis were more likely to be prescribed opioids (aOR 4.02) or steroids (aOR 3.05) in the ED than in ambulatory sites. CONCLUSIONS School-aged children received opioid and steroid prescriptions for pneumonia or sinusitis at a higher frequency in the ED versus the ambulatory setting.
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Affiliation(s)
| | - James R Roberts
- Medical University of South Carolina, Charleston, South Carolina
| | - Myla Ebeling
- Medical University of South Carolina, Charleston, South Carolina
| | - Sandra S Garner
- Medical University of South Carolina, Charleston, South Carolina
| | - William T Basco
- Medical University of South Carolina, Charleston, South Carolina
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Ali S, Rajagopal M, Klassen T, Richer L, McCabe C, Willan A, Yaskina M, Heath A, Drendel AL, Offringa M, Gouin S, Stang A, Sawyer S, Bhatt M, Hickes S, Poonai N. Study protocol for two complementary trials of non-steroidal or opioid analgesia use for children aged 6 to 17 years with musculoskeletal injuries (the No OUCH study). BMJ Open 2020; 10:e035177. [PMID: 32565458 PMCID: PMC7311068 DOI: 10.1136/bmjopen-2019-035177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/16/2020] [Accepted: 05/07/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Musculoskeletal (MSK) injuries are a frequent cause for emergency department (ED) visits in children. MSK injuries are associated with moderate-to-severe pain in most children, yet recent research confirms that the management of children's pain in the ED remains inadequate. Clinicians are seeking better oral analgesic options for MSK injury pain with demonstrated efficacy and an excellent safety profile. This study aims to determine the efficacy and safety of adding oral acetaminophen or oral hydromorphone to oral ibuprofen and interpret this information within the context of parent/caregiver preference. METHODS AND ANALYSIS Using a novel preference-informed complementary trial design, two simultaneous trials are being conducted. Parents/caregivers of children presenting to the ED with acute limb injury will be approached and they will decide which trial they wish to participate in: an opioid-inclusive trial or a non-opioid trial. Both trials will follow randomised, double-blind, placebo-controlled, superiority-trial methodology and will enrol a minimum of 536 children across six Canadian paediatric EDs. Children will be eligible if they are 6 to 17 years of age and if they present to the ED with an acute limb injury and a self-reported verbal Numerical Rating Scale pain score ≥5. The primary objective is to determine the effectiveness of oral ibuprofen+oral hydromorphone versus oral ibuprofen+oral acetaminophen versus oral ibuprofen alone. Recruitment was launched in April 2019. ETHICS AND DISSEMINATION This study has been approved by the Health Research Ethics Board (University of Alberta), and by appropriate ethics boards at all recruiting centres. Informed consent will be obtained from parents/guardians of all participants, in conjunction with assent from the participants themselves. Study data will be submitted for publication regardless of results. This study is funded through a Canadian Institutes of Health Research grant. TRIAL REGISTRATION NUMBER NCT03767933, first registered on 07 December 2018.
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Affiliation(s)
- Samina Ali
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Terry Klassen
- Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence Richer
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Andy Willan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Maryna Yaskina
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Anna Heath
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluation Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amy L Drendel
- Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Martin Offringa
- Child Health Evaluation Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Serge Gouin
- Pediatrics, Universite de Montreal, Montreal, Québec, Canada
| | - Antonia Stang
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Scott Sawyer
- Pediatrics and Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maala Bhatt
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Serena Hickes
- Parent Partner, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Naveen Poonai
- Paediatrics and Internal Medicine, Schulich School of Medicine & Dentistry, London Health Sciences Centre, London, Ontario, Canada
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Meyers RS, Thackray J, Matson KL, McPherson C, Lubsch L, Hellinga RC, Hoff DS. Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List. J Pediatr Pharmacol Ther 2020; 25:175-191. [PMID: 32265601 DOI: 10.5863/1551-6776-25.3.175] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The safe use of medications in pediatric patients requires practitioners to consider the unique pharmacokinetics and pharmacodynamics of drugs prescribed in this age group. In an effort to create a standard of care for the safe use of medications in this population, a list of drugs that are potentially inappropriate for use in pediatric patients has been developed and titled the "KIDs List." METHODS A panel of 7 pediatric pharmacists from the Pediatric Pharmacy Association were recruited to evaluate primary, secondary, and tertiary literature; FDA Pediatric Safety Communications; the Lexicomp electronic database; and product information for drugs that should be considered potentially inappropriate for use in pediatric patients. Information was rated using predefined criteria. A PubMed search was conducted using the following terms: adverse drug events OR adverse drug reactions. The search was limited to humans; age <18 years; case reports, observational studies, or clinical trials; and English language. No date range was used. Results were used to create an evidence-based list of candidate drugs that was then peer-reviewed and subjected to a 30-day public comment period prior to being finalized. RESULTS A PubMed search yielded 4049 unique titles, of which 210 were deemed relevant for full review. Practitioner recommendations highlighted an additional 77 drugs. FDA Pediatric Safety Communications and the Lexicomp database yielded 22 and 619 drugs, respectively. After critical analysis, peer review, and public review the final KIDs List contains 67 drugs and/or drug classes and 10 excipients. CONCLUSIONS This extensive effort led to compilation of the first list of drugs that are potentially inappropriate for prescribing in all or in a select subgroup of pediatric patients. If avoidance is not clinically possible, the drug should be used with caution and accompanied by appropriate monitoring.
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Strayer RJ, Hawk K, Hayes BD, Herring AA, Ketcham E, LaPietra AM, Lynch JJ, Motov S, Repanshek Z, Weiner SG, Nelson LS. Management of Opioid Use Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2020; 58:522-546. [DOI: 10.1016/j.jemermed.2019.12.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/19/2019] [Accepted: 12/24/2019] [Indexed: 11/28/2022]
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Jain A, Bhardwaj N. Need to replace codeine for management of paediatric post operative pain. Indian J Anaesth 2020; 64:83. [PMID: 32001920 PMCID: PMC6967372 DOI: 10.4103/ija.ija_696_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 11/05/2022] Open
Affiliation(s)
- Aditi Jain
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Neerja Bhardwaj
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
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Foster AA, Porter JJ, Bourgeois FT, Mannix R. The use of opioids in low acuity pediatric trauma patients. PLoS One 2019; 14:e0226433. [PMID: 31841556 PMCID: PMC6913969 DOI: 10.1371/journal.pone.0226433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/26/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To describe temporal trends and factors associated with opioid administration among children discharged from the emergency department (ED) after a trauma visit. METHODS This was a cross-sectional study of ED visits for children <19 years old who received a trauma-related diagnosis and were discharged from the ED. Data were obtained from the National Hospital Ambulatory Medical Care Survey 2006-2015. OUTCOME MEASURES Administration of an opioid medication either during the ED visit or as a discharge prescription. Survey-adjusted regression analyses were used to determine the probability of a patient receiving an opioid medication. RESULTS During the study period, there were 19,241 pediatric trauma visits discharged from the ED, of which 14% were associated with an opioid. Opioid administration decreased by nearly 30% during the study period (p<0.001 for trend). In multivariable analysis, patient factors associated with opioid administration were adolescent age, evening visit, region of the country, and severe pain score. The diagnosis associated with the most opioids was ankle sprain and the diagnosis with the highest rate of opioid administration was radius fracture. The most common opioid administered to children under 12 years of age was acetaminophen-codeine. CONCLUSIONS Opioid administration appears to be decreasing among pediatric patients presenting to the ED with trauma, but a high number of children continue to be exposed to opioids every year. Further education on opioid sparing pain management strategies may be warranted to decrease opioid exposure, including the inappropriate use of codeine, in this low risk trauma population.
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Affiliation(s)
- Ashley A. Foster
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - John J. Porter
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Florence T. Bourgeois
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Abstract
The cytochromes P450 comprise a family of enzymes that are responsible for around three-quarters of all drug metabolism reactions that occur in human populations. Many isoforms of cytochrome P450 exist but most reactions are undertaken by CYP2C9, CYP2C19, CYP2D6 and CYP3A4. This brief review focusses on the first three isozymes which exhibit polymorphism of phenotype.If there is a wide variation in drug metabolising capacity within the population, this may precipitate clinical consequences and influence the drug treatment of patients. Such problems range from a lack of efficacy to unanticipated toxicity. In order to minimise untoward events and "personalise" a patient's treatment, efforts have been made to discover an individual's drug metabolism status. This requires knowledge of the subject's phenotype at the time of clinical treatment. Since such testing is difficult, time-consuming and costly, the simpler approach of genotyping has been advocated.However, the correlation between genotype and phenotype is not good, with values of up to 50% misprediction being reported. Genotype-assisted forecasts cannot therefore be used with confidence to replace actual phenotype measurements. Obfuscating factors discussed include gene splicing, single nucleotide polymorphisms, epigenetics and microRNA, transcription regulation and multiple gene copies.
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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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Sloan VS, Jones A, Maduka C, Bentz JWG. A Benefit Risk Review of Pediatric Use of Hydrocodone/Chlorpheniramine, a Prescription Opioid Antitussive Agent for the Treatment of Cough. Drugs Real World Outcomes 2019; 6:47-57. [PMID: 31073977 PMCID: PMC6520422 DOI: 10.1007/s40801-019-0152-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Hydrocodone/chlorpheniramine is a prescription opioid licensed in the USA for the relief of cough and upper respiratory symptoms associated with allergy or cold in adults, previously contraindicated in children aged < 6 years. We present findings from a modern benefit risk review of hydrocodone/chlorpheniramine use as an antitussive agent in patients aged 6 to < 18 years. A cumulative search of the manufacturer’s pharmacovigilance database covering 1 January 1900–7 August 2017 identified all individual case safety reports (ICSRs) associated with product family name “hydrocodone/chlorpheniramine.” The search was inclusive of all MedDRA system organ classes, stratified by age (< 18 years). A comprehensive review of the scientific literature was conducted on safety and efficacy of opioids for pediatric treatment of cough. Three hundred and ninety-one ICSRs associated with hydrocodone/chlorpheniramine were identified; 35/391 ICSRs were in patients < 18 years of age; 18 were considered serious. Four fatalities were reported in patients 6 to < 18 years; two fatalities involved co-suspect medication azithromycin and two were poorly documented. Our literature search identified no robust efficacy data for hydrocodone/chlorpheniramine in the relief of cough and upper respiratory symptoms associated with allergy or cold in patients aged 6 to < 18 years. As we found no evidence of hydrocodone/chlorpheniramine efficacy in the pediatric population, we conclude that the benefit risk profile is unfavorable. This evidence contributed to the US Food and Drug Administration’s (FDA’s) recent decision that hydrocodone-containing cough and cold medications should no longer be indicated for treatment of cough in patients < 18 years, highlighting the value of proactive re-evaluation of the benefit risk profile of older established drugs. Plain Language Summary People often use medicines containing opioids to treat cough symptoms. The US Food and Drug Administration (FDA) recently decided that cough medicines containing opioids should not be used by children under 18 years old. Part of this decision was a review of the benefits and risks of using cough medicines that contain the opioid hydrocodone in children. Why was this review carried out? Most cough medicines that doctors can prescribe were approved several decades ago. Since then, rules for the approval of medicines have become stricter. In this review, researchers looked at the safety of hydrocodone, and how well this opioid relieves cough symptoms in children. Up-to-date information and modern research methods were used. The two key pieces of evidence found were:We could not locate any clinical trials providing robust evidence for the use of hydrocodone for cough relief in children under 18 years of age. (Outside the scope of this review, a number of clinical trials of hydrocodone-containing cough medicines in adults aged 18 years and over have shown the medicine to be effective in these patients.) Cough medicines containing opioids can cause harmful side effects in children such as breathing problems. In the research reported here, ten children died after taking a hydrocodone-containing cough medicine. Nine of these deaths were due to overdose.
This evidence was used to draw the following conclusions:In children under 18 years of age, the risks of using hydrocodone for cough relief are greater than any benefits. Older medicines should be reviewed regularly to look at their safety and how well they are working using up-to-date evidence.
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Affiliation(s)
- Victor S Sloan
- UCB BioSciences Inc., Raleigh, NC, USA. .,Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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Parikh JM, Amolenda P, Rutledge J, Szabova A, Vidya Chidambaran. An update on the safety of prescribing opioids in pediatrics. Expert Opin Drug Saf 2019; 18:127-143. [PMID: 30650988 PMCID: PMC6446903 DOI: 10.1080/14740338.2019.1571037] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/14/2019] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The opioid abuse epidemic and its toll on the adolescent population have heightened awareness for safer opioid prescribing practices in pediatric pain management. Opioids remain the mainstay of therapy for severe pain, although there is an emphasis on multimodal therapy. Areas covered: In this update, the authors present information on parenteral/oral opioids commonly used in pediatrics. Recommendations for opioid use in special circumstances including neonates and developmental pharmacokinetic concerns are discussed. Due to noticeable interindividual variability, pharmacogenomics may be important for tailoring pain regimens. In particular, the role of CYP2D6 phenotypes on opioid selection/dosing and clinical implications are discussed. A summary of adverse effects and opioid safety data, and the role of regulations, risk assessment, Centers for Disease Control and Prevention guidelines, follow-up, and monitoring for compliance in opioid prescribing, are detailed. Expert opinion: 'One size does not fit all' describes the need for public policies focused on pediatric pain and opioid use, as children are not 'little adults.' Clinical trials to evaluate pharmacokinetics-pharmacodynamics of opioids are currently lacking. Development of novel biased opioid agonists, clinical integration of genetics in informed decision-making, and emphasis on top-down approaches to pain management will be key to decrease opioid reliance.
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Lam YWF. Principles of Pharmacogenomics. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Chung CP, Callahan ST, Cooper WO, Dupont WD, Murray KT, Franklin AD, Hall K, Dudley JA, Stein CM, Ray WA. Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events. Pediatrics 2018; 142:peds.2017-2156. [PMID: 30012559 PMCID: PMC6072590 DOI: 10.1542/peds.2017-2156] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known about opioid prescribing for children without severe conditions. We studied the prevalence of and indications for outpatient opioid prescriptions and the incidence of opioid-related adverse events in this population. METHODS This retrospective cohort study between 1999 and 2014 included Tennessee Medicaid children and adolescents aged 2 to 17 without major chronic diseases, prolonged hospitalization, institutional residence, or evidence of a substance use disorder. We estimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid-related adverse events, defined as an emergency department visit, hospitalization, or death related to an opioid adverse effect. RESULTS There were 1 362 503 outpatient opioid prescriptions; the annual mean prevalence of opioid prescriptions was 15.0%. The most common opioid indications were dental procedures (31.1% prescriptions), outpatient procedure and/or surgery (25.1%), trauma (18.1%), and infections (16.5%). There were 437 cases of opioid-related adverse events confirmed by medical record review; 88.6% were related to the child's prescription and 71.2% had no recorded evidence of deviation from the prescribed regimen. The cumulative incidence of opioid-related adverse events was 38.3 of 100 000 prescriptions. Adverse events increased with age (incidence rate ratio = 2.22; 95% confidence interval, 1.67-2.96; 12-17 vs 2-5 years of age) and higher opioid doses (incidence rate ratio = 1.86 [1.45-2.39]; upper versus lower dose tertiles). CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute, self-limited conditions. One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (71.2% of which were related to therapeutic use of the prescribed opioid).
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Affiliation(s)
| | | | | | | | | | - Andrew D. Franklin
- Anesthesia, School of Medicine, Vanderbilt University, Nashville, Tennessee
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He T, Lardieri AB, Morgan JA. Pharmacist and Pediatrician Knowledge of Codeine Use in Children. J Pediatr Pharmacol Ther 2018; 23:293-297. [PMID: 30181719 DOI: 10.5863/1551-6776-23.4.293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES In 2011, approximately 1.7 million pediatric patients had a codeine-containing prescription filled at a US retail pharmacy. Numerous cases involving serious adverse effects or fatalities have been reported in children who have been prescribed codeine. In 2013, the US Food and Drug Administration added a boxed warning to avoid codeine in children after a tonsillectomy. The purpose of this study is to determine pharmacists' and pediatricians' knowledge of the boxed warning for codeine in children. METHODS Two separate surveys were administered to community pharmacists in Maryland, pediatricians, and pediatric residents at a single institution in Maryland. Both surveys consisted of questions regarding knowledge of the boxed warning for codeine in children. RESULTS There was no difference in the awareness of the boxed warning between pharmacists (48.9%, n = 43) and pediatricians (51.3%, n = 41, p = 0.88). More pharmacists knew that ultrarapid metabolizers have the risk for increased adverse events from codeine (39.5% pharmacists vs. 20% pediatricians, p = 0.01). In addition, 36% of pharmacists and 33% of pediatricians noted that it was never appropriate to use codeine in a child (p = 0.73). CONCLUSIONS Only half of pharmacists and pediatricians surveyed were aware of the boxed warning for codeine. One third of pharmacists and pediatricians in this study would never use codeine in a child. Therefore, more education is needed for pharmacists and pediatricians regarding the dangers of using codeine in children.
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Hales CM, Kit BK, Gu Q, Ogden CL. Trends in Prescription Medication Use Among Children and Adolescents-United States, 1999-2014. JAMA 2018; 319:2009-2020. [PMID: 29800213 PMCID: PMC6583241 DOI: 10.1001/jama.2018.5690] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Access to appropriate prescription medications, use of inappropriate or ineffective treatments, and adverse drug events are public health concerns among US children and adolescents. OBJECTIVE To evaluate trends in use of prescription medications among US children and adolescents. DESIGN, SETTING, AND PARTICIPANTS US children and adolescents aged 0 to 19 years in the 1999-2014 National Health and Nutrition Examination Survey (NHANES)-serial cross-sectional, nationally representative surveys of the civilian noninstitutionalized population. EXPOSURES Sex, age, race and Hispanic origin, household income and education, insurance status, current health status. MAIN OUTCOMES AND MEASURES Use of any prescription medications or 2 or more prescription medications taken in the past 30 days; use of medications by therapeutic class; trends in medication use across 4-year periods from 1999-2002 to 2011-2014. Data were collected though in-home interview and direct observation of the prescription container. RESULTS Data on prescription medication use were available for 38 277 children and adolescents (mean age, 10 years; 49% girls). Overall, use of any prescription medication in the past 30 days decreased from 24.6% (95% CI, 22.6% to 26.6%) in 1999-2002 to 21.9% (95% CI, 20.3% to 23.6%) in 2011-2014 (β = -0.41 percentage points every 2 years [95% CI, -0.79 to -0.03]; P = .04), but there was no linear trend in the use of 2 or more prescription medications (8.5% [95% CI, 7.6% to 9.4%] in 2011-2014). In 2011-2014, the most commonly used medication classes were asthma medications (6.1% [95% CI, 5.4% to 6.8%]), antibiotics (4.5% [95% CI, 3.7% to 5.5%]), attention-deficit/hyperactivity disorder (ADHD) medications (3.5% [95% CI, 2.9% to 4.2%]), topical agents (eg, dermatologic agents, nasal steroids) (3.5% [95% CI, 3.0% to 4.1%]), and antihistamines (2.0% [95% CI, 1.7% to 2.5%]). There were significant linear trends in 14 of 39 therapeutic classes or subclasses, or in individual medications, with 8 showing increases, including asthma and ADHD medications and contraceptives, and 6 showing decreases, including antibiotics, antihistamines, and upper respiratory combination medications. CONCLUSIONS AND RELEVANCE In this study of US children and adolescents based on a nationally representative survey, estimates of prescription medication use showed an overall decrease in use of any medication from 1999-2014. The prevalence of asthma medication, ADHD medication, and contraceptive use increased among certain age groups, whereas use of antibiotics, antihistamines, and upper respiratory combination medications decreased.
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Affiliation(s)
- Craig M. Hales
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Brian K. Kit
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
- Currently with the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Qiuping Gu
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Cynthia L. Ogden
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
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Don CG, Smieško M. Out‐compute drug side effects: Focus on cytochrome P450 2D6 modeling. WILEY INTERDISCIPLINARY REVIEWS-COMPUTATIONAL MOLECULAR SCIENCE 2018. [DOI: 10.1002/wcms.1366] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Charleen G. Don
- Department of Pharmaceutical SciencesUniversity of BaselBaselSwitzerland
| | - Martin Smieško
- Department of Pharmaceutical SciencesUniversity of BaselBaselSwitzerland
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Codeine and opioid metabolism: implications and alternatives for pediatric pain management. Curr Opin Anaesthesiol 2018; 30:349-356. [PMID: 28323671 DOI: 10.1097/aco.0000000000000455] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Use of perioperative opioids for surgical pain management of children presents clinical challenges because of concerns of serious adverse effects including life-threatening respiratory depression. This is especially true for children with history of obstructive sleep apnea. This review will explore current knowledge of clinically relevant factors and genetic polymorphisms that affect opioid metabolism and postoperative outcomes in children. RECENT FINDINGS Within the past several years, an increasing number of case reports have illustrated clinically important respiratory depression, anoxic brain injuries and even death among children receiving appropriate weight-based dosages of codeine and other opioids for analgesia at home setting particularly following tonsillectomy. Several national and international organizations have issued advisories on use of codeine in pediatrics, based on cytochrome P450 family 2 subfamily D type 6 (CYP2D6) pharmacogenetics. We have discussed the pros and cons of alternatives to codeine for pain management. SUMMARY Although routine preoperative genotyping to identify children at risk and personalized opioid use for pediatric perioperative pain management is still a distant reality, current known implications of CYP2D6 pharmacogenetics on codeine use shows that pharmacogenetics has the potential to guide anesthesia providers on perioperative opioid selection and dosing to maximize efficacy and safety.
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Chua KP, Shrime MG, Conti RM. Effect of FDA Investigation on Opioid Prescribing to Children After Tonsillectomy/Adenoidectomy. Pediatrics 2017; 140:peds.2017-1765. [PMID: 29146621 DOI: 10.1542/peds.2017-1765] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In August 2012, the Food and Drug Administration investigated the safety of codeine use by children after tonsillectomy and/or adenoidectomy, culminating in a black box warning in February 2013. The objective of this study was to evaluate the association between the investigation and opioid prescribing to children undergoing these surgeries. METHODS We identified 362 992 privately insured children in the 2010-2015 Truven MarketScan Commercial Claims and Encounters database who underwent tonsillectomy and/or adenoidectomy. Using an interrupted time series design, we estimated level and slope changes in the proportion of children with ≥1 prescription fills for codeine and ≥1 fills for an alternative opioid, such as hydrocodone, within 7 days of surgery. RESULTS The investigation was associated with a significant -13.3 (95% confidence interval: -14.5 to -12.1) percentage point level change in the proportion of children with ≥1 prescription fills for codeine after tonsillectomy and/or adenoidectomy. Despite this drop, 5.1% of children had ≥1 prescription fills for codeine in December 2015. The investigation was not associated with significant level changes in alternative opioid prescribing, although the proportion of children receiving alternative opioids increased during the study period because of other factors. CONCLUSIONS The Food and Drug Administration investigation substantially decreased codeine prescribing to children after tonsillectomy and/or adenoidectomy. However, 1 in 20 children undergoing these surgeries were still prescribed codeine in December 2015 despite its well-documented safety and efficacy issues.
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Affiliation(s)
- Kao-Ping Chua
- Section of Academic Pediatrics, Departments of Pediatrics, .,Public Health Sciences and.,Department of Pediatrics and Communicable Diseases, Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Mark G Shrime
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, and.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Rena M Conti
- Public Health Sciences and.,Pediatric Hematology/Oncology, University of Chicago, Chicago, Illinois
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Chhabra N, Aks SE. Current Opiate and Opioid Hazards in Children and Adolescents. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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A combinatorial approach for the discovery of cytochrome P450 2D6 inhibitors from nature. Sci Rep 2017; 7:8071. [PMID: 28808272 PMCID: PMC5556109 DOI: 10.1038/s41598-017-08404-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 07/10/2017] [Indexed: 12/31/2022] Open
Abstract
The human cytochrome P450 2D6 (CYP2D6) enzyme is part of phase-I metabolism and metabolizes at least 20% of all clinically relevant drugs. Therefore, it is an important target for drug-drug interaction (DDI) studies. High-throughput screening (HTS) assays are commonly used tools to examine DDI, but show certain drawbacks with regard to their applicability to natural products. We propose an in silico - in vitro workflow for the reliable identification of natural products with CYP2D6 inhibitory potential. In order to identify candidates from natural product-based databases that share similar structural features with established inhibitors, a pharmacophore model was applied. The virtual hits were tested for the inhibition of recombinant human CYP2D6 in a bioluminescence-based assay. By controlling for unspecific interferences of the test compounds with the detection reaction, the number of false positives were reduced. The success rate of the reported workflow was 76%, as most of the candidates identified in the in silico approach were able to inhibit CYP2D6 activity. In summary, the workflow presented here is a suitable and cost-efficient strategy for the discovery of new CYP2D6 inhibitors with natural product libraries.
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Agarwal R, Riefe J, Houck CS. Fifty years of the American Academy of Pediatrics Section on Anesthesiology: a history of our specialty. Paediatr Anaesth 2017; 27:560-570. [PMID: 28332249 DOI: 10.1111/pan.13121] [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] [Accepted: 01/08/2017] [Indexed: 11/26/2022]
Abstract
The American Academy of Pediatrics Section on Anesthesiology and Pain Medicine celebrated its 50th Anniversary in 2015. The Section was one of the first and only subspecialty organizations in anesthesiology at the time. This special article will focus on the contributions of the Section to the practice of pediatric anesthesiology in the areas of advocacy, education and member contributions. In 1986, the Section created the Robert M. Smith Award to honor those members who had made significant advances in the practice of pediatric anesthesiology. It is named after one of the Section founders, an influential educator, inventor, and researcher in our field. We will focus the latter part of the article on the Robert M. Smith award winners to illustrate the contributions of the Section and its members to the development of the field of pediatric anesthesiology.
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Affiliation(s)
- Rita Agarwal
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer Riefe
- Section on Anesthesiology and Pain Medicine, American Academy of Pediatrics, Elk Grove Village, IL, USA
| | - Constance S Houck
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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Allen JD, Casavant MJ, Spiller HA, Chounthirath T, Hodges NL, Smith GA. Prescription Opioid Exposures Among Children and Adolescents in the United States: 2000-2015. Pediatrics 2017; 139:peds.2016-3382. [PMID: 28320869 DOI: 10.1542/peds.2016-3382] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES This study analyzes and compares exposures to prescription opioids among children and adolescents younger than 20 years old in the United States. METHODS Data from the National Poison Data System for 2000 through 2015 were analyzed. RESULTS Poison control centers received reports of 188 468 prescription opioid exposures among children aged <20 years old from 2000 through 2015. The annual number and rate of exposures increased early in the study period, but declined after 2009, except for buprenorphine exposures, which increased during the last 3 study years. Hydrocodone accounted for the largest proportion of exposures (28.7%), and 47.1% of children exposed to buprenorphine were admitted to a health care facility (HCF). The odds of being admitted to an HCF were higher for teenagers than for children aged 0 to 5 years (odds ratio [OR]: 2.86; 95% confidence interval [CI]: 2.78-2.94) or children aged 6 to 12 years (OR: 6.62; 95% CI: 6.06-7.02). Teenagers also had greater odds of serious medical outcomes than did children aged 0 to 5 years (OR: 3.03; 95% CI: 2.92-3.15) or children aged 6 to 12 years (OR: 4.59; 95% CI: 4.21-5.00). The rate of prescription opioid-related suspected suicides among teenagers increased by 52.7% during the study period. CONCLUSIONS Prescription opioid-related HCF admissions and serious medical outcomes were higher among teenagers. Contrary to trends for other prescription opioids, exposures to buprenorphine have increased in recent years; children aged 0 to 5 years accounted for almost 90% of buprenorphine exposures. These findings indicate that additional prevention efforts are needed.
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Affiliation(s)
- Jakob D Allen
- Center for Injury Research and Policy of the Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Marcel J Casavant
- Center for Injury Research and Policy of the Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Central Ohio Poison Center, Columbus, Ohio; and.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Henry A Spiller
- Central Ohio Poison Center, Columbus, Ohio; and.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Thiphalak Chounthirath
- Center for Injury Research and Policy of the Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Nichole L Hodges
- Center for Injury Research and Policy of the Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Gary A Smith
- Center for Injury Research and Policy of the Research Institute at Nationwide Children's Hospital, Columbus, Ohio; .,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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