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Keller M, Dinkel F, Jacoby J, Kraft B, Haas A, Rosenberger P, Meierhenrich R. Oblique subcostal transverse abdominis plane block for postoperative pain control in patients undergoing open sublay mesh hernia repair: a prospective double-blind randomized placebo-controlled clinical trial. Reg Anesth Pain Med 2024:rapm-2024-105596. [PMID: 38977282 DOI: 10.1136/rapm-2024-105596] [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: 04/25/2024] [Accepted: 06/28/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND A bilateral oblique subcostal transverse abdominis plane block may help provide perioperative analgesia and reduce opioid use in patients undergoing sublay mesh hernia repair, but its clinical value is unclear. METHODS In a single-centre, prospective, placebo-controlled, double-blind study, patients scheduled for sublay mesh hernia repair were randomized to receive oblique subcostal transverse abdominis plane blocks with either 60 ml of 0.375% ropivacaine (n=19) or isotonic saline (placebo, n=17). The primary outcome was patient-controlled total morphine consumption at 8:00 p.m. on the second postoperative day (POD), while secondary outcomes included the total morphine consumption during the post-anesthesia care unit stay and the occurrence of adverse events. RESULTS Total morphine consumption at 8:00 p.m. on the second POD was higher in patients receiving ropivacaine (39 mg, IQR 22, 62) compared with placebo (24 mg, IQR 7, 39), p value = 0.04. In contrast, the ropivacaine group received 2 mg less morphine during the post-anesthesia care unit stay (4 mg, IQR: 4, 9 mg vs 2 mg, IQR: 2,6 mg, p = 0.04). Patients receiving ropivacaine used more morphine (8:00 p.m. on the first POD until 8:00 a.m. on the second POD: 8 mg, IQR: 4, 18 mg vs 2 mg, IQR: 0, 9 mg, p = 0.01) and reported higher maximum pain scores since the last assessment (8:00 a.m. on the second POD: 5, IQR: 4, 7 vs 4, IQR: 3, 5, p = 0.03). There were no differences in adverse events between groups. CONCLUSIONS Bilateral oblique subcostal transverse abdominis plane blocks in patients undergoing sublay mesh hernia repair were not associated with a prolonged reduction in patient-controlled total morphine consumption in the evening of the second POD in this study. Rebound pain might explain the additional excess opioid required by the ropivacaine group.
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Affiliation(s)
- Marius Keller
- Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls Universität Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Friederike Dinkel
- Department of Anesthesia and Intensive Care Medicine, Diakonie-Klinikum Stuttgart, Stuttgart, Germany
- School of Medicine, Eberhard Karls Universität Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Johann Jacoby
- Institute for Clinical Epidemiology and Applied Biometry, Eberhard Karls Universität Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Barbara Kraft
- Department of General and Visceral Surgery, Diakonie-Klinikum Stuttgart, Stuttgart, Germany
| | - Anne Haas
- Dispensary, Diakonie-Klinikum Stuttgart, Stuttgart, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls Universität Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Rainer Meierhenrich
- Department of Anesthesia and Intensive Care Medicine, Diakonie-Klinikum Stuttgart, Stuttgart, Germany
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Patel E, Ben-Shlomo A. Opioid-induced adrenal insufficiency: diagnostic and management considerations. Front Endocrinol (Lausanne) 2024; 14:1280603. [PMID: 38476510 PMCID: PMC10927719 DOI: 10.3389/fendo.2023.1280603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 09/25/2023] [Indexed: 03/14/2024] Open
Abstract
The dramatic rise in opioid use over the last two decades has led to a surge in their harmful health effects. Lesser known among clinicians is the impact of opioids on the endocrine system, especially with regard to cortisol. Opioids can suppress the hypothalamus-pituitary-adrenal (HPA) axis and may result in clinically significant adrenal insufficiency, especially in those treated at higher doses and for a longer time. A high clinical suspicion is necessary in this population for early diagnosis of opioid-induced adrenal insufficiency (OAI). Diagnosis of OAI is challenging, as the symptoms are often vague and overlap with those due to opioid use or the underlying pain disorder. Traditional assays to diagnose adrenal insufficiency have not been widely studied in this population, and more investigation is needed to determine how opioids might affect assay results. Once a diagnosis of adrenal insufficiency has been made, glucocorticoid replacement in the form of hydrocortisone is likely the mainstay of treatment, and effort should be made to taper down opioids where possible. Cortisol levels should be retested periodically, with the goal of stopping glucocorticoid replacement once the HPA axis has recovered. In this review, we provide context for diagnostic challenges in OAI, suggest diagnostic tools for this population based on available data, and offer recommendations for the management of this disorder. There is a paucity of literature in this field; given the widespread use of opioids in the general population, more investigation into the effects of opioids on the HPA axis is sorely needed.
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Affiliation(s)
- Erica Patel
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Anat Ben-Shlomo
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Multidisciplinary Adrenal Program, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Oh A, Koehler A, Yonker M, Troester M. Sleep Disorders and Chronic Pain Syndromes in the Pediatric Population. Semin Pediatr Neurol 2023; 48:101085. [PMID: 38065632 DOI: 10.1016/j.spen.2023.101085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/18/2023] [Accepted: 09/13/2023] [Indexed: 12/18/2023]
Abstract
Sleep problems are widespread in children and adolescents suffering from chronic pain disorders. Sleep loss intensifies the experience of pain and is detrimental to the budding self-efficacy of a young individual with limitless horizons. Addressing sleep disorders may prevent the chronification of pain and prevent adverse health outcomes, such as functional impairment, psychiatric comorbidities and overall poor quality of life. This review will explore the cyclical nature between sleep, pain and mood, as well as the functional impact of this relationship on children and adolescents. There will be a discussion about sleep assessment and diagnostic testing, followed by a description of sleep disturbances found in specific pain conditions, ranging from headache, musculoskeletal/abdominal pain, to rheumatologic disorders. Finally, there will be a brief review of pharmacologic and behavioral interventions designed to improve sleep quality, and when possible, to alleviate pain.
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Affiliation(s)
- Ann Oh
- Division of Neurology, UCSF Pediatric Headache Center, University of California, San Francisco, UCSF Benioff Children's Hospital, Mission Hall, 550 16th Street, 5th Floor, San Francisco, CA 94158, USA.
| | - Angelina Koehler
- Division of Neurology, Pediatric Headache Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Marcy Yonker
- Division of Neurology, Pediatric Headache Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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Puig S, Xue X, Salisbury R, Shelton MA, Kim SM, Hildebrand MA, Glausier JR, Freyberg Z, Tseng GC, Yocum AK, Lewis DA, Seney ML, MacDonald ML, Logan RW. Circadian rhythm disruptions associated with opioid use disorder in synaptic proteomes of human dorsolateral prefrontal cortex and nucleus accumbens. Mol Psychiatry 2023; 28:4777-4792. [PMID: 37674018 PMCID: PMC10914630 DOI: 10.1038/s41380-023-02241-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 09/08/2023]
Abstract
Opioid craving and relapse vulnerability is associated with severe and persistent sleep and circadian rhythm disruptions. Understanding the neurobiological underpinnings of circadian rhythms and opioid use disorder (OUD) may prove valuable for developing new treatments for opioid addiction. Previous work indicated molecular rhythm disruptions in the human brain associated with OUD, highlighting synaptic alterations in the dorsolateral prefrontal cortex (DLPFC) and nucleus accumbens (NAc)-key brain regions involved in cognition and reward, and heavily implicated in the pathophysiology of OUD. To provide further insights into the synaptic alterations in OUD, we used mass-spectrometry based proteomics to deeply profile protein expression alterations in bulk tissue and synaptosome preparations from DLPFC and NAc of unaffected and OUD subjects. We identified 55 differentially expressed (DE) proteins in DLPFC homogenates, and 44 DE proteins in NAc homogenates, between unaffected and OUD subjects. In synaptosomes, we identified 161 and 56 DE proteins in DLPFC and NAc, respectively, of OUD subjects. By comparing homogenate and synaptosome protein expression, we identified proteins enriched specifically in synapses that were significantly altered in both DLPFC and NAc of OUD subjects. Across brain regions, synaptic protein alterations in OUD subjects were primarily identified in glutamate, GABA, and circadian rhythm signaling. Using time-of-death (TOD) analyses, where the TOD of each subject is used as a time-point across a 24-h cycle, we were able to map circadian-related changes associated with OUD in synaptic proteomes associated with vesicle-mediated transport and membrane trafficking in the NAc and platelet-derived growth factor receptor beta signaling in DLPFC. Collectively, our findings lend further support for molecular rhythm disruptions in synaptic signaling in the human brain as a key factor in opioid addiction.
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Affiliation(s)
- Stephanie Puig
- Department of Pharmacology, Physiology and Biophysics, Boston University School of Medicine, Boston, MA, USA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Xiangning Xue
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ryan Salisbury
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Micah A Shelton
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sam-Moon Kim
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mariah A Hildebrand
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jill R Glausier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zachary Freyberg
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Cell Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - George C Tseng
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - David A Lewis
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marianne L Seney
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew L MacDonald
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Ryan W Logan
- Department of Pharmacology, Physiology and Biophysics, Boston University School of Medicine, Boston, MA, USA.
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Department of Neurobiology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
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5
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Puig S, Xue X, Salisbury R, Shelton MA, Kim SM, Hildebrand MA, Glausier JR, Freyberg Z, Tseng GC, Yocum AK, Lewis DA, Seney ML, MacDonald ML, Logan RW. Circadian rhythm disruptions associated with opioid use disorder in the synaptic proteomes of the human dorsolateral prefrontal cortex and nucleus accumbens. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.07.536056. [PMID: 37066169 PMCID: PMC10104116 DOI: 10.1101/2023.04.07.536056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Opioid craving and relapse vulnerability is associated with severe and persistent sleep and circadian rhythm disruptions. Understanding the neurobiological underpinnings of circadian rhythms and opioid use disorder (OUD) may prove valuable for developing new treatments for opioid addiction. Previous work indicated molecular rhythm disruptions in the human brain associated with OUD, highlighting synaptic alterations in the dorsolateral prefrontal cortex (DLPFC) and nucleus accumbens (NAc)-key brain regions involved in cognition and reward, and heavily implicated in the pathophysiology of OUD. To provide further insights into the synaptic alterations in OUD, we used mass-spectrometry based proteomics to deeply profile protein expression alterations in bulk tissue and synaptosome preparations from DLPFC and NAc of unaffected and OUD subjects. We identified 55 differentially expressed (DE) proteins in DLPFC homogenates, and 44 DE proteins in NAc homogenates, between unaffected and OUD subjects. In synaptosomes, we identified 161 and 56 DE proteins in DLPFC and NAc, respectively, of OUD subjects. By comparing homogenate and synaptosome protein expression, we identified proteins enriched specifically in synapses that were significantly altered in both DLPFC and NAc of OUD subjects. Across brain regions, synaptic protein alterations in OUD subjects were primarily identified in glutamate, GABA, and circadian rhythm signaling. Using time-of-death (TOD) analyses, where the TOD of each subject is used as a time-point across a 24- hour cycle, we were able to map circadian-related changes associated with OUD in synaptic proteomes related to vesicle-mediated transport and membrane trafficking in the NAc and platelet derived growth factor receptor beta signaling in DLPFC. Collectively, our findings lend further support for molecular rhythm disruptions in synaptic signaling in the human brain as a key factor in opioid addiction.
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