Is maternal opioid use hazardous to breast-fed infants?

Efficacy of continuous preperitoneal ropivacaine infusion in women with cesarean section: A prospective, randomized controlled, single blinded study

Background

Adequate postoperative pain management after cesarean section is important for the prognosis of both mother and infant. However, excessive prescription of opioid analgesics has become a concern. This study evaluated the efficacy of local continuous subfascial infusion of ropivacaine in relieving postoperative pain and reducing opioid requirements in postpartum women with cesarean section.

Methods

Seventy eligible women undergoing cesarean section were randomly allocated to the ropivacaine and the normal saline group for continuous subfascial wound infiltration. All patients received additional fentanyl through an intravenous patient-controlled analgesia pump. Pain score using the visual analog scale, opioid consumption through pump, and requirements for other analgesics were postoperatively measured within 8 h, 1 day, and 2 days after surgery. Statistical analysis was performed with independent t-tests for continuous variables and Chi-square tests for categorical variables. Paired Wilcoxon and student's t-tests were used for paired samples.

Results

Sixty-nine patients (35 in the study and 34 in the control group) were analyzed. The mean VAS scores were lower in the study group all three periods, with significance achieved at day 2 (2.74 ± 0.95 versus 3.41 ± 1.33, p = 0.028). The intravenous fentanyl consumptions were significantly lower in the study group at all three periods. Total administration of additional non-opioid analgesics including ketorolac, propacetamol, and pethidine was higher in the control group.

Conclusions

Continuous subfascial ropivacaine infusion is effective in relieving pain and reducing opioid-based analgesia and other analgesics requirements.

Epidemiology of Opioid Prescribing After Discharge From Surgical Procedures Among Adults

Importance

Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs.

Objective

To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States.

Design, Setting, and Participants

This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023.

Main Outcomes and Measures

The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years.

Results

Among 1 040 934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663 609 [63.7%] female patients), 457 016 (43.9%) occurred among individuals aged 18 to 44 years and 583 918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503 058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11 418 658 of 58 825 364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5 885 305 of 60 591 564 MMEs]; arthroscopy of knee, 6.5% [3 912 616 MMEs]).

Conclusions and Relevance

In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.

A Series of 8 Illicit Fentanyl Intoxication Deaths in Infants and Toddlers

ABSTRACT

We report 8 children younger than 2 years who died from acute illicit fentanyl intoxications in Connecticut between 2020 and 2022.The Connecticut Office of the Chief Medical Examiner (CT OCME) investigates all unexpected, violent, and suspicious deaths in Connecticut. The CT OCME's electronic database was searched for fentanyl deaths by age. All underwent autopsies and toxicology testing.The ages ranged from 28 days to 2 years (mean age, 12 months). The causes of death involved acute fentanyl intoxications with 1 having xylazine, 1 having para-fluorofentanyl, and 1 having cocaine and morphine. All the manners of death were certified as homicide. The postmortem fentanyl blood concentrations ranged from 0.40 to 46 ng/mL. Most of the children were found unresponsive after being put to sleep. Three were co-sleeping with adults (2 in bed; 1 on a recliner). There was a known history of parental/caregiver drug abuse in 7 of 8 of the fatalities.We summarize the key investigative, autopsy, and toxicological findings. As illicit fentanyl use increases, there is a potential for infant exposure and death. The investigation and certification of these deaths and the role of intentional administration versus inadvertent exposure due to caregiver neglect in the context of the certification of the manner of death are described.

Brief Assessment of Patient Phenotype to Explain Variability in Postsurgical Pain and Opioid Consumption after Cesarean Delivery: Performance of a Novel Brief Questionnaire Compared to Long Questionnaires

BACKGROUND

Understanding factors that explain why some women experience greater postoperative pain and consume more opioids after cesarean delivery is crucial to building an evidence base for personalized prevention. Comprehensive psychosocial assessment with validated questionnaires in the preoperative period can be time-consuming. A three-item questionnaire has shown promise as a simpler tool to be integrated into clinical practice, but its brevity may limit the ability to explain heterogeneity in psychosocial pain modulators among individuals. This study compared the explanatory ability of three models: (1) the 3-item questionnaire, (2) a 58-item questionnaire (long) including validated questionnaires (e.g., Brief Pain Inventory, Patient Reported Outcome Measurement Information System [PROMIS]) plus the 3-item questionnaire, and (3) a novel 19-item questionnaire (brief) assessing several psychosocial factors plus the 3-item questionnaire. Additionally, this study explored the utility of adding a pragmatic quantitative sensory test to models.

METHODS

In this prospective, observational study, 545 women undergoing cesarean delivery completed questionnaires presurgery. Pain during local anesthetic skin wheal before spinal placement served as a pragmatic quantitative sensory test. Postoperatively, pain and opioid consumption were assessed. Linear regression analysis assessed model fit and the association of model items with pain and opioid consumption during the 48 h after surgery.

RESULTS

A modest amount of variability was explained by each of the three models for postoperative pain and opioid consumption. Both the brief and long questionnaire models performed better than the three-item questionnaire but were themselves statistically indistinguishable. Items that were independently associated with pain and opioid consumption included anticipated postsurgical pain medication requirement, surgical anxiety, poor sleep, pre-existing pain, and catastrophic thinking about pain. The quantitative sensory test was itself independently associated with pain across models but only modestly improved models for postoperative pain.

CONCLUSIONS

The brief questionnaire may be more clinically feasible than longer validated questionnaires, while still performing better and integrating a more comprehensive psychosocial assessment than the three-item questionnaire.

EDITOR’S PERSPECTIVE

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Critical Care in Placenta Accreta Spectrum Disorders-A Call to Action

The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. KEY POINTS: · The rising in placenta accreta spectrum incidence highlights the need for critical care expertise.. · Emerging tools such as point-of-care ultrasound and thromboelastography/rotational thromboelastometry represent new avenues for real time optimization of hemodynamic and hematological care of patients with PAS.. · Patients with PAS should be referred to a tertiary center having an intensive care unit (ICU) with surgical expertise (or equivalent based on institutional resources)..

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

The Effectiveness of Transversus Abdominis Plane and Quadratus Lumborum Blocks in Acute Postoperative Pain Following Cesarean Section-A Randomized, Single-Blind, Controlled Trial

Acute pain intensity related to cesarean section (CS) may be extensive and is often underestimated. This may influence mothers’ quality of life and their children’s development. Regional analgesia techniques that include transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) have proven their efficacy in the postoperative period after CS. Although several randomized controlled studies and one meta-analysis have investigated the utility of TAPB and QLB in the reduction of acute and chronic pain after CS, only one study directly compared both types of regional blocks and revealed superiority of QLB over TAPB. Our study aimed to reevaluate the effectiveness of transversus TAPB and QLB in controlling acute postoperative pain after CS. We recruited 197 women with singleton pregnancies undergoing CS under spinal anesthesia. The patients were randomized to receive either TAPB or QLB after CS. The acute postoperative pain was evaluated using the visual analog scale (VAS) at 2, 4, 8, 12 and 24 h after the operation. No significant difference in acute postoperative pain intensity between the groups was found. The patients who received TAPB had a higher demand for supplemental morphine injections (p < 0.039). In our study, none of the evaluated regional blocks demonstrated an advantage over the other regarding acute postoperative pain management.

[Neuraxial Morphine for Postoperative Analgesia after Caesarean Deliveries]

The use of neuraxial morphine, in combination with nonopioid analgesic regimens for postoperative analgesia after Caesarean deliveries is common practice, especially in the Anglo-American world. Neuraxial morphine offers a longer-lasting superior analgesia than intravenous opioids or patient-controlled analgesia. If neuraxial anaesthesia is being used for a caesarean delivery, it may be recommended to concomitantly administer neuraxial morphine for the postoperative analgesia.A low dose of neuraxial morphine in a healthy parturient bears a low morbidity and mortality risk. The optimal frequency, duration and modality of respiratory monitoring for patients at low risk for respiratory depression is dependent on the dose of morphine administered and the patient-specific and obstetric risk profile.

Pediatric opioid fatalities: What can we learn for prevention?

The aim of this study was to highlight 19 cases investigated by the North Carolina Office of the Chief Medical Examiner over the last 12 years involving accidental or undetermined manner of death opioid ingestions leading to fatalities in young children. These pediatric ingestions have closely mirrored the opioid epidemic in adults transitioning from prescription medications to illicit drugs including fentanyl and fentanyl analogues. Unlike a typical adult ingestion for purposes of self-harm or pleasure, poisonings in toddlers and infants are usually the result of curiosity, exploration, a decreased sense of danger, or imitation of adult or older sibling behavior. Eleven of the decedents were between the ages of 8 and 24 months. Among the cases were 12 prescription opioid exposure deaths and 7 illicit drug poisonings. A majority of the decedents were found unresponsive in an unkept home and/or in unsafe sleeping spaces with easy access to drugs or drug materials, which stresses the importance of safe pediatric sleeping conditions. After a complete pathological investigation, several of the cases had physical or scene evidence demonstrating that foil, plastic, or paper small enough to be ingested can contain enough potent opioid to cause death. Details from the toxicological investigation are included for each case to provide postmortem whole blood drug concentrations for forensic practitioners. Accidental pediatric poisonings are preventable. Risk reduction through improving awareness and education of the dangers of opioids is a key factor in mitigating these tragedies.

Prescription Opioid Dose After Vaginal Delivery and the Risk of Serious Opioid-Related Events: A Retrospective Cohort Study

PURPOSE

Postpartum opioid use remains common among women with uncomplicated vaginal delivery and may increase the risk of serious opioid-related events. Therefore, we examined the association between the dose of the first filled opioid prescription after vaginal delivery and the subsequent risk of serious opioid-related events.

METHODS

We conducted a retrospective cohort study among women enrolled in Tennessee Medicaid with a vaginal delivery (2007-2015). We used Cox proportional hazards regression to model adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for serious opioid-related events after delivery according to the dose (morphine milligram equivalents [MME]) of the first postpartum opioid prescription, accounting for comorbidities, medication use, parity, and delivery complications. Serious opioid-related events were defined as the occurrence of persistent opioid use, a methadone or buprenorphine fill, opioid use disorder diagnosis, opioid overdose, or opioid-related death. We used filled pharmacy data to characterize the dose of the first postpartum opioid prescription filled within 4 days after delivery.

RESULTS

More than one-half of women (53.2%; n = 147,598) filled an opioid prescription within 4 days of a vaginal delivery. After accounting for baseline risk factors, filling a postpartum opioid prescription was associated with an increased risk of serious opioid-related events across all dose categories, compared with women filling none (aHR 1-99 MME, 1.52; 95% CI, 1.33-1.74; aHR 100-149 MME, 1.41; 95% CI, 1.26-1.58; aHR 150-199 MME, 1.40; 95% CI, 1.26-1.57: and aHR ≥200 MME, 1.60; 95% CI, 1.43-1.78).

CONCLUSIONS

Filling a postpartum opioid prescription after a vaginal delivery was associated with an increased risk of serious opioid-related events, regardless of dose. Prescribing guidelines should discourage the routine prescribing of opioids after vaginal delivery.

Maternal Methadone Destabilizes Neonatal Breathing and Desensitizes Neonates to Opioid-Induced Respiratory Frequency Depression

Pregnant women and developing infants are understudied populations in the opioid crisis, despite the rise in opioid use during pregnancy. Maternal opioid use results in diverse negative outcomes for the fetus/newborn, including death; however, the effects of perinatal (maternal and neonatal) opioids on developing respiratory circuitry are not well understood. Given the profound depressive effects of opioids on central respiratory networks controlling breathing, we tested the hypothesis that perinatal opioid exposure impairs respiratory neural circuitry, creating breathing instability. Our data demonstrate maternal opioids increase apneas and destabilize neonatal breathing. Maternal opioids also blunted opioid-induced respiratory frequency depression acutely in neonates; a unique finding since adult respiratory circuity does not desensitize to opioids. This desensitization normalized rapidly between postnatal days 1 and 2 (P1 and P2), the same age quantal slowing emerged in respiratory rhythm. These data suggest significant reorganization of respiratory rhythm generating circuits at P1-2, the same time as the preBötzinger Complex (key site of respiratory rhythm generation) becomes the dominant respiratory rhythm generator. Thus, these studies provide critical insight relevant to the normal developmental trajectory of respiratory circuits and suggest changes to mutual coupling between respiratory oscillators, while also highlighting how maternal opioids alter these developing circuits. In conclusion, the results presented demonstrate neurorespiratory disruption by maternal opioids and blunted opioid-induced respiratory frequency depression with neonatal opioids, which will be important for understanding and treating the increasing population of neonates exposed to gestational opioids.

Exposures Through Breast Milk: An Analysis of Exposure and Information Calls to U.S. Poison Centers, 2001-2017

Introduction: We described calls to U.S. poison centers (PCs) related to potential exposure to substances through breast milk. Materials and Methods: We analyzed National Poison Data System calls between 2001 and 2017 with "Exposure through breast milk" or "Drug use during breastfeeding" as the coded scenario. Data handling and descriptive statistics were carried out using SAS JMP 12.01. Results: U.S. PCs received 76,416 information calls and 2,319 exposure calls related to breast milk. Exposure calls were from a residence in 76% (n = 1,758), from health care facilities (HCFs) in 15.5% (n = 360), and from a workplace in 0.6% (n = 15). A total of 466 exposures (20.1%) were subsequently managed at a HCF: 269 were evaluated and released (58%), 38 were admitted to intensive care unit (8.2%), and 53 were admitted to hospital floor (11%). Medical outcomes included 1 death (0.04%), 8 major effect (0.3%), 43 moderate effect (1.9%), 170 minor effect (7.3%), and 390 no effect (16.8%). Exposure calls that reported major effects involved opioids, benzodiazepines, ethanol, cyclobenzaprine, insulin, and amphetamines. Exposure calls most commonly involved antibiotics, antifungals, benzodiazepines, opioids, and selective serotonin reuptake inhibitors (SSRIs). A total of 1,192 exposures (51.4%) had reported signs/symptoms including drowsiness, agitation, rash, and vomiting/diarrhea. Information calls most commonly involved systemic antibiotics, SSRIs, antihistamines, corticosteroids, and benzodiazepines. Conclusions: Substances common to both exposure and information calls included antibiotics, benzodiazepines, and SSRIs. Most cases of severe toxicity included potential exposures through breast milk to benzodiazepines and opioids. These data may help inform educational outreach, risk assessment, and bedside care for breastfeeding mothers.

A Case of Toxic Breast-feeding?

Opiates are frequently prescribed postpartum for pain relief after cesarean delivery, episiotomies, and headaches. It is estimated that greater than 30% of breast-feeding mothers in the United States are prescribed opiates for pain relief associated with childbirth. Many opiates are readily transferred to human milk, although life-threatening events are rare. We report a 6-day-old breast-feeding infant whose mother was taking hydromorphone for pain relief from a cesarean delivery and whose clinical course was suggestive of opiate toxicity. This case emphasizes the importance of thorough medication history taking in postpartum breast-feeding mothers whose infants may present with symptoms of opiate toxicity. Semisynthetic opiates are frequently not detected on emergency department urine toxicology screens. The pertinent literature is reviewed.

Comparison of different sufentanil-tramadol combinations for pain relief within the first 24 hours after cesarean section: a retrospective study

Introduction

Postcesarean section pain management is important for both the mother and the newborn. This study compared the analgesic effects and incidence of adverse events associated with intravenous patient-controlled analgesia (iv-PCA), using different sufentanil–tramadol combinations for postoperative pain control.

Methods

Parturients (n=5,794) who had been scheduled for cesarean section under neuraxial anesthesia and had received iv-PCA between September 2013 and March 2017 were retrospectively analyzed. These patients were assigned to three groups, based on different sufentanil–tramadol combinations: ST1 (n=1,347), ST2 (n=2,401), and ST3 (n=2,046). The analgesic efficacy, total drug consumption, and incidence of adverse effects within 24 hours after surgery were compared among the three groups.

Results

The ST3 group had lower visual analog scale pain scores at rest and with movement at all time points during the first 24 hours postoperatively than the other two groups (P<0.01, Bonferroni corrected). The sufentanil dosage administered to the ST3 group was lower, and the tramadol dosage was higher than those administered to the other groups within 24 hours after surgery (P<0.01, Bonferroni corrected). Moreover, all parturients scored 2 points on the Ramsay sedation scale. Adverse reactions such as pruritus and respiratory depression were not observed in any group. No significant differences were noted in the incidence of nausea/vomiting, abdominal distension, and dizziness among the three groups (P>0.05).

Conclusion

The visual analog scale scores for postoperative pain decreased as the concentrations of sufentanil and tramadol administered in iv-PCA moderately increased over 24 hours after surgery. This analgesic strategy resulted in a significant reduction in the total sufentanil requirement without increasing the incidence of adverse effects.

Update of the Scientific Opinion on opium alkaloids in poppy seeds

Poppy seeds are obtained from the opium poppy (Papaver somniferum L.). They are used as food and to produce edible oil. The opium poppy plant contains narcotic alkaloids such as morphine and codeine. Poppy seeds do not contain the opium alkaloids, but can become contaminated with alkaloids as a result of pest damage and during harvesting. The European Commission asked EFSA to provide an update of the Scientific Opinion on opium alkaloids in poppy seeds. The assessment is based on data on morphine, codeine, thebaine, oripavine, noscapine and papaverine in poppy seed samples. The CONTAM Panel confirms the acute reference dose (ARfD) of 10 μg morphine/kg body weight (bw) and concluded that the concentration of codeine in the poppy seed samples should be taken into account by converting codeine to morphine equivalents, using a factor of 0.2. The ARfD is therefore a group ARfD for morphine and codeine, expressed in morphine equivalents. Mean and high levels of dietary exposure to morphine equivalents from poppy seeds considered to have high levels of opium alkaloids (i.e. poppy seeds from varieties primarily grown for pharmaceutical use) exceed the ARfD in most age groups. For poppy seeds considered to have relatively low concentrations of opium alkaloids (i.e. primarily varieties for food use), some exceedance of the ARfD is also seen at high levels of dietary exposure in most surveys. For noscapine and papaverine, the available data do not allow making a hazard characterisation. However, comparison of the dietary exposure to the recommended therapeutical doses does not suggest a health concern for these alkaloids. For thebaine and oripavine, no risk characterisation was done due to insufficient data. However, for thebaine, limited evidence indicates a higher acute lethality than for morphine and the estimated exposure could present a health risk.

Migraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action

Migraine is a common and disabling primary headache disorder with a significant socioeconomic burden. The management of migraine is multifaceted and is generally dichotomized into acute and preventive strategies, with several treatment modalities. The aims of acute pharmacological treatment are to rapidly restore function with minimal recurrence, with the avoidance of side effects. The choice of pharmacological treatment is individualized, and is based on the consideration of the characteristics of the migraine attack, the patient's concomitant medical problems, and treatment preferences. Notwithstanding, a good understanding of the pharmacodynamic and pharmacokinetic properties of the various drug options is essential to guide therapy. The current approach and concepts relevant to the acute pharmacological treatment of migraine will be explored in this review.

Patterns of Opioid Prescription and Use After Cesarean Delivery

OBJECTIVE

To define the amount of opioid analgesics prescribed and consumed after discharge after cesarean delivery.

METHODS

We conducted a survey at six academic medical centers in the United States from September 2014 to March 2016. Women who had undergone a cesarean delivery were contacted by phone 2 weeks after discharge and participated in a structured interview about the opioid prescription they received on discharge and their oral opioid intake while at home.

RESULTS

A total of 720 women were enrolled; of these, 615 (85.4%) filled an opioid prescription. The median number of dispensed opioid tablets was 40 (interquartile range 30-40), the median number consumed was 20 (interquartile range 8-30), and leftover was 15 (interquartile range 3-26). Of those with leftover opioids, 95.3% had not disposed of the excess medication at the time of the interview. There was an association between a larger number of tablets dispensed and the number consumed independent of patient characteristics. The amount of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription.

CONCLUSION

The amount of opioid prescribed after cesarean delivery generally exceeds the amount consumed by a significant margin, leading to substantial amounts of leftover opioid medication. Lower opioid prescription correlates with lower consumption without a concomitant increase in pain scores or satisfaction.

Peri-operative management of caesarean section for the occasional obstetric anaesthetist – an aide memoire

Anaesthesia practice for caesarean section (CS) has evolved in the past 20 years. This article aims to update occasional obstetric anaesthesiologists, obstetricians and clinicians involved in the management of pregnant women on the latest guidelines and recommendations for anaesthesia management, including pre-operative evaluation, informed consent, intra-operative and postoperative management for CS. In addition, this article will also summarise the management of CS associated emergencies such as difficult intubation, obstetric major postpartum haemorrhage, local anaesthetic toxicity and (pre-) eclampsia. At the end of the article, a charted summary will be provided as an aide memoire.

Pharmacological treatment of migraine during pregnancy and breastfeeding

Migraine affects up to 25% of women of reproductive age. In the majority of these women, migraine improves progressively during pregnancy, but symptoms generally recur shortly after delivery. As suboptimally treated migraine in pregnancy could have negative consequences for both mother and fetus, the primary aim of clinicians should be to provide optimal treatment according to stage of pregnancy, while minimising possible risks related to drug therapy. Nonpharmacological approaches are always first-line treatment, and should also be used to complement any required drug treatment. Paracetamol is the preferred drug for acute treatment throughout pregnancy. If paracetamol is not sufficiently effective, sporadic use of sumatriptan can be considered. NSAIDs such as ibuprofen can also be used under certain circumstances, though their intake in the first and third trimesters is associated with specific risks and contraindications. Preventive treatment should only be considered in the most severe cases. In women contemplating pregnancy, counselling is essential to promote a safe and healthy pregnancy and postpartum period for the mother and child, and should involve a dialogue addressing maternal concerns and expectations about drug treatment. This Review summarizes current evidence of the safety of the most common antimigraine medications during pregnancy and breastfeeding, and provides treatment recommendations for use in clinical practice.

Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient

Background:

In our targeted review (Section 2), 12 acute medications received a strong recommendation for use in acute migraine therapy while four received a weak recommendation for use. Strong recommendations were made to avoid use of two other medications, except for exceptional circumstances. Two anti-emetics received strong recommendations for use as needed.

Objective:

To organize the available acute migraine medications into acute migraine treatment strategies in order to assist the practitioner in choosing a specific medication(s) for an individual patient.

Methods:

Acute migraine treatment strategies were developed based on the targeted literature review used for the development of this guideline (Section 2), and a general literature review. Expert consensus groups were used to refine and validate these strategies.

Results:

Based on evidence for drug efficacy, drug side effects, migraine severity, and coexistent medical disorders, our analysis resulted in the formulation of eight general acute migraine treatment strategies. These could be grouped into four categories: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. In addition, strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation. The eight general treatment strategies were coordinated with a “combined acute medication approach” to therapy which used features of both the “stratified” and the “step care across attacks” approaches to acute migraine management.

Conclusions:

The available medications for acute migraine treatment can be organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.

Acute Migraine Treatment in Adults

There are many options for acute migraine attack treatment, but none is ideal for all patients. This study aims to review current medical office-based acute migraine therapy in adults and provides readers with an organized approach to this important facet of migraine treatment. A general literature review includes a review of several recent published guidelines. Acetaminophen, 4 nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, acetylsalicylic acid [ASA], naproxen sodium, and diclofenac potassium), and 7 triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) have good evidence for efficacy and form the core of acute migraine treatment. NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics (acetaminophen, ASA, and caffeine), and several anti-emetics (metoclopramide, domperidone, and prochlorperazine) are additional evidence-based options. Opioid containing combination analgesics may be helpful in specific patients, but should not be used routinely. Clinical features to be considered when choosing an acute migraine medication include usual headache intensity, usual rapidity of pain intensity increase, nausea, vomiting, degree of disability, patient response to previously used medications, history of headache recurrence with previous attacks, and the presence of contraindications to specific acute medications. Available acute medications can be organized into 4 treatment strategies, including a strategy for attacks of mild to moderate severity (strategy one: acetaminophen and/or NSAIDs), a triptan strategy for patients with severe attacks and for attacks not responding to strategy one, a refractory attack strategy, and a strategy for patients with contraindications to vasoconstricting drugs. Acute treatment of migraine attacks during pregnancy, lactation, and for patients with chronic migraine is also discussed. In chronic migraine, it is particularly important that medication overuse is eliminated or avoided. Migraine treatment is complex, and treatment must be individualized and tailored to the patient's clinical features. Clinicians should make full use of available medications and formulations in an organized approach.

ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

The effect of intra-articular meperidine and bupivacaine 0.5% on postoperative pain of arthroscopic knee surgery; a randomized double blind clinical trial

Background:

Arthroscopic knee surgeries have a painful postoperative course, which often necessitates acute pain management. Among different analgesia techniques, Intra-articular injection is the technique of choice for many pain specialists, based on its confined effect to the surgical site (knee), lack of systemic effects and promotion of safe early ambulation.

Objectives:

The aim of this study was to compare analgesic effects of intra-articular meperidine, bupivacaine 0.5% or their combination after knee arthroscopic surgery.

Patients and Methods:

Sixty ASA class I-II patients’ candidates for arthroscopy knee surgery enrolled in a randomized double blind study to receive either 20 mL of bupivacaine 0.5%; 100 mg meperidine (diluted in normal saline) or bupivacaine 0.5% along with 100 mg meperidine. A written informed consent was obtained from all patients. Postoperative analgesia duration, VAS at 2, 6, 12 and 24 hours, the first analgesic request time, total fentanyl consumption in first 24 hours, patients’ satisfaction and adverse effects were recorded.

Results:

The bupivacaine-meperidine group had better duration of postoperative analgesia (P = 0.001), latter first analgesic request (P ≤ 0.001), lower total fentanyl consumption in first 24 hours after the operation (P = 0.001), less mean VAS at 2 hours (P = 0.001) and more patients’ overall satisfaction (P = 0.01) compared with each medication alone. VAS at 6, 12 and 24 postoperative hours were not different between the groups of study. No adverse effects were observed.

Conclusions:

Although postoperative intra-articular meperidine is a better alternative for bupivacaine, their combination could improve their analgesic effects compared with each other alone.

Recent examples on the clinical relevance of the CYP2D6 polymorphism and endogenous functionality of CYP2D6

The cytochrome P450 2D6 (CYP2D6) belongs to a group of CYPs considered of utmost importance in the metabolism of xenobiotics. Despite being of only minor abundance in the liver, it is involved in the clearance of >25% of marketed drugs. Accordingly, CYP2D6 can be very efficiently inhibited by a couple of commonly used drugs such as some antidepressants, although induction by any drug has not been observed thus far. CYP2D6 was also one of the first enzymes for which a highly polymorphic expression could be shown leading to a widespread range of functionality, from a complete lack of a functional enzyme to overexpression due to multiplication of active alleles. A clear relationship between the CYP2D6 genotype and adverse events during treatment with CNS-active drugs such as codeine, antidepressants, or antipsychotics could be demonstrated. More recently, some new aspects emerged about the potential endogenous function of CYP2D6 in terms of behavior and brain disorders.

Neonatal and longer term management following substance misuse in pregnancy

Substance misuse in pregnancy is not a new problem, but although impaired foetal growth and the risk of developing neonatal abstinence syndrome are widely appreciated, relatively little attention has been paid to longer term consequences for the infant. Available evidence indicates that prenatal exposure to opioids and other drugs of misuse is detrimental to the developing foetal brain; consistent with this, poor in utero head growth, delayed infant visual maturation and impaired general neurodevelopmental progress independent of social confounders are increasingly being recognised. This review considers current evidence and discusses best practice in the neonatal management and follow-up of affected babies. More studies are required to explore alternatives to methadone maintenance in pregnancy and to define optimal treatment for neonatal abstinence syndrome. All infants born to drug-misusing mothers must be considered vulnerable, even if they have not required treatment for neonatal abstinence syndrome.

Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants

AIM

To examine the rate and duration of breastfeeding in a cohort of women in opioid maintenance treatment (OMT) in Norway, as well as the effect of breastfeeding on the incidence and duration of neonatal abstinence syndrome (NAS).

METHODS

A national cohort of 124 women treated with either methadone or buprenorphine during pregnancy, and their neonates born between 1999 and 2009, was evaluated in three study parts. A standardized questionnaire was administered, and medical information from the hospitals and municipalities were collected to confirm self-reported data.

RESULTS

There were high initiation rates of breastfeeding (77%) for women in OMT, but also high rates of early cessation of breastfeeding. Breastfed neonates exposed to methadone prenatally had significantly lower incidence of NAS requiring pharmacotherapy (53% vs. 80%), and both the whole group of infants and the methadone-exposed neonates needed shorter pharmacological treatment of NAS (p < 0.05) than neonates who were not breastfed.

CONCLUSION

Breastfed neonates exposed to OMT medication prenatally, and methadone-exposed newborns in particular, have lower incidence of NAS and require shorter pharmacotherapy for NAS than infants who are not breastfed. The results add to the evidence regarding the benefits of breastfeeding for neonates prenatally exposed to OMT medications.

Oxycodone overdose causes naloxone responsive coma and QT prolongation

BACKGROUND

Although there are limited data on oxycodone overdose, it has been suggested that, in addition to central nervous system (CNS) depression, oxycodone may cause QT prolongation. Given the high prescription rate and increasing use of oxycodone, an understanding of its effects and treatment in overdose is necessary.

AIM

To investigate the clinical features, electrocardiogram (ECG) parameters and treatment of oxycodone overdose.

DESIGN

Retrospective review of a clinical database.

METHODS

One hundred and thirty-seven oxycodone overdoses were identified from admissions to a toxicology unit between January 2001 and May 2011. Demographic information, details of ingestion, clinical effects, ECG parameters [heart rate (HR), QT and QRS], naloxone use and length of stay (LOS) were extracted from a clinical database. QT was measured manually and plotted on a QT nomogram. LOS was extracted for all overdoses over the same period.

RESULTS

From 137 oxycodone overdoses, 79 (58%) ingested immediate release (IR) and 58 (42%) ingested sustained release (SR) or a combination of IR and SR. The median age was 40 years [interquartile range (IQR): 33-49 years], and 87 were female (64%). The median ingested dose of IR oxycodone was 70 mg (IQR: 40-100, range: 5-200), compared to 240 mg (IQR: 80-530, range: 30-1600) for SR oxycodone. Benzodiazepines were the most frequent co-ingested drug in 52 (38%) cases. No arrhythmias were recorded. Twenty-four patients (18%) had bradycardia of which five had a HR < 50 beats/min. From 116 available ECGs, the median QRS was 95 ms (IQR: 90-102 ms), and there were 20 (17%) abnormal QT-HR pairs. Naloxone boluses were required in 65 admissions (47%), and 34 (25%) required a naloxone infusion. There was higher overall naloxone use with SR and IR + SR (32/58, 55%) compared to IR oxycodone (33/79, 42%). The median LOS was 18 h (IQR: 12-35), which was greater than the median LOS for all toxicology admissions at 15 h (IQR: 8-24) over the same period. Patients requiring a naloxone infusion had an even greater LOS of 36 h (IQR: 20-62 h).

CONCLUSION

In addition to the expected CNS depression, the opioid oxycodone can cause bradycardia and QT prolongation in overdose. The SR formulation is associated with the use of naloxone infusions and a longer LOS.

Pregnancy, breast-feeding and drugs used in dentistry

BACKGROUND AND OVERVIEW

Despite advances in the study of birth defects related to drug exposures during pregnancy, medication use during pregnancy still causes anxiety and misunderstanding among both members of the public and health care professionals. This may result in a woman's unknowingly taking a medication that may harm the fetus or cause a birth defect or discontinuing medications necessary for treating chronic conditions. Using medications while breast-feeding also represents a challenge for patients and prescribers. Many mothers are told they must stop breast-feeding or "pump and discard" their breast milk if they are taking certain medications; however, in many cases, this advice-based on what may be limited education on the part of the health care provider about breast-feeding and medication use-may be incorrect. The authors review the current evidence regarding drugs that may be safe for pregnant or breast-feeding patients and medications that such patients should avoid.

CONCLUSIONS

When considering prescribing in pregnancy, the dentist must weigh the risk to the fetus versus the benefit to the mother, and the appropriate conclusion should reflect current evidence. In some cases medication dosing should be avoided or altered; however, there are times when it is unnecessary to stop the use of medications. Breast-feeding also represents a clinical challenge, the risks and benefits of which need to be understood by both the patient and practitioner before any medication is administered.

PRACTICE IMPLICATIONS

Dentists should be familiar with the risks and benefits for pregnant or breast-feeding patients posed by five types of medications: analgesics and anti-inflammatories, antibiotics, local anesthetics, sedatives and emergency medications.

Opioid Related Deaths of Infants and Young Children

The prevalence of the opioid drugs is increasing worldwide. Greater access in turn increases the risk of infants and young children being exposed to potentially fatal concentrations of these drugs, either by accident or through the negligent or deliberate actions of a caregiver. This report reviews opioid-related fatalities in this population and discusses homicidal and accidental poisonings and the possible routes of exposure, including through breastfeeding. As with adults, autopsy findings in fatal pediatric opioid toxicity are nonspecific and such cases may mimic death from natural diseases such as metabolic disorders or channelopathies. A detailed review of the case history together with a complete autopsy and toxicology testing are essential for the correct certification of these deaths. Further challenges arise from the fact that toxic ranges for opioids are not well-defined in the pediatric population, and the forensic pathologist must rely on case reports and small case series’ to assist in the determination of “how much is too much”. Resources such as the National Association of Medical Examiners Pediatric Toxicology Registry (NAME PedTox) continue to be of great value, but depend on the voluntary submission of case data from members. Emerging phar-macogenetic data are revealing genetic variations associated with altered metabolism and tissue distribution of opioids; therefore, molecular autopsy techniques should be considered in these challenging cases, especially where the manner of death is unclear.