Establishing a Dose-Response Relationship Between Opioid Use and Hypogonadism: A Retrospective Case-Control Study

Background: Opioid-induced androgen deficiency (OPIAD) related to chronic, long-acting opioid use can be a significant detriment to patient quality of life. The aim of this study was to investigate the association between chronic opioid use and hypogonadism. Methods: A single-center, retrospective, matched case-control analysis of 357 males (94 cases, 263 controls, aiming for 1:4 matching) was performed. Study subjects were ages 18 to 80 years and had a diagnosis of chronic opioid use. Patients with a hypogonadism diagnosis were matched to patients without a hypogonadism diagnosis by age, ethnicity, and body mass index. The maximum morphine equivalent daily dose (MEDD) was compared in each group. Results: A significant linear association between MEDD and the odds of developing hypogonadism (P<0.001) in males with chronic use of opioids was observed, with an odds ratio of 1.44 (95% CI 1.16-1.78) by 100-unit difference in maximum MEDD. Conclusion: Results showed a significant, positive linear association between chronic opioid dose and the odds of developing hypogonadism in males. This higher index of suspicion of OPIAD could lead to earlier recognition of symptoms and increase the positive predictive value of diagnostic laboratory tests.

Surge in Fentanyl Toxicity Deaths in Jefferson Parish, LA, 2013-2018

Background: The opioid epidemic in the United States has resulted in a significant increase in fentanyl-related overdoses nationwide since 2013. Because of an increased rate of fentanyl-related overdoses seen in Jefferson Parish, LA, the Jefferson Parish Coroner's Office (JPCO) hypothesized that the opioid epidemic, specifically related to fentanyl, had reached this region. To test this hypothesis, JPCO analyzed fentanyl overdose deaths to determine if the deaths had increased during a 6-year period and if the change met the definition of an epidemic.

Methods: In the toxicology laboratory at JPCO, enzyme-linked immunosorbent assay screening and gas chromatography/mass spectrometry are used in-house to determine the presence of drugs. Drug-positive samples are sent to National Medical Services (NMS) Labs to quantify the analyte concentration in each sample. Data for each decedent were extracted from the Medicolegal Death Investigation Log (MDILog) database for the years 2013 through 2018.

Results: A slow increase in fentanyl-related deaths during the first 3 years of the study period was followed by a near doubling of cases in 2016, a tripling of cases in 2017, and a 6-fold increase in incidence in 2018. During the 6-year study period, fentanyl-related deaths increased from 6 in 2013, to 8 in 2014, to 14 in 2015. Twenty-five deaths in 2016 spiked to 66 in 2017 and increased to 78 fentanyl-related overdose deaths in 2018. The percentage of fentanyl-related overdose deaths increased from 4% of all drug deaths in 2013 to 45% in 2018.

Conclusion: The data validate the hypothesis that the fentanyl epidemic has affected Jefferson Parish in southeast Louisiana.

Intelligent Clinical Decision Support to Improve Safe Opioid Management of Chronic Noncancer Pain in Primary Care

BACKGROUND

Opioid prescription drug abuse is a major public health concern. Healthcare provider prescribing patterns, especially among non-pain management specialists, are a major factor. Practice guidelines recommend what to do for safe opioid prescribing but do not provide guidance on how to implement best practices.

METHODS

We describe the implementation of electronic medical record clinical decision support (EMR CDS) for opioid management of chronic noncancer pain in an integrated delivery system. This prospective cohort study will examine relationships between primary care physician compliance with EMR CDS-guided care (vs usual care), delivery of guideline-concordant care, and changes in the morphine equivalent of prescribed opioids. We report baseline characteristics of patients receiving chronic opioid therapy and organizational prescribing trends.

RESULTS

Between August and October 2016, we identified 2,759 primary care patients who received chronic opioid therapy. Of these patients, approximately 71% had chronic noncancer pain, and 62% had diagnoses of depression/anxiety. Six of 36 primary care clinics each had >100 patients receiving chronic opioid therapy. When the EMR CDS launched in October 2017, we identified 54,200 patients who had received opioid therapy for at least 14 days from various specialty and primary care providers during the prior 24 months. Of these patients, 36% had a benzodiazepine coprescription, and 13% had substance abuse diagnoses.

CONCLUSION

Health system research that examines workflow-focused strategies to improve physician knowledge and skills for safely managing opioid therapy is needed. If EMR CDS proves to be effective in increasing adherence to practice guidelines, this EMR strategy can potentially be replicated and scaled up nationwide to improve population health management.

The Relationship Between Regional Anesthesia and Cancer: A Metaanalysis

BACKGROUND

Some studies have suggested using epidural analgesia after cancer surgery to reduce metastasis. This article examines the relationship between regional anesthesia (RA) and cancer metastasis in an array of cancers.

METHODS

We conducted a review of the literature using PubMed and included 67,577 patients across 28 studies in a metaanalysis, evaluating the hazard ratios (HRs) of overall survival, recurrence-free survival, and biochemical recurrence-free survival.

RESULTS

We found no benefit to RA as it relates to cancer. The HR was 0.92 for overall survival, 1.06 for recurrence-free survival, and 1.05 for biochemical recurrence-free survival. Despite the overall analysis showing no benefit, we found some benefit when we evaluated only the randomized trials. However, we found no significant benefit of RA when we evaluated the cancers (gastrointestinal, prostate, breast, and ovarian) individually.

CONCLUSION

This metaanalysis shows that RA has no overall survival, recurrence-free survival, or biochemical recurrence-free survival benefit. However, some individual studies have shown significant benefit in terms of cancer recurrence. Further, RA reduces the use of opioids, which has led to some secondary benefits. Further studies are needed to establish the benefits of RA as it relates to cancer.

Availability and utilization of opioids for pain management: global issues

BACKGROUND

Pain can significantly influence an individual's health status and can have serious negative consequences: poor nutrition, decreased appetite, abnormal sleep patterns, fatigue, and impairment of daily living activities. Pain can cause psychological impairment and decrease healing and recovery from injuries and illness. A hallmark of many chronic conditions, pain affects more patients' lives than diabetes mellitus, heart disease, and cancer combined. However, many chronic sufferers do not have access to effective pain management for a variety of reasons, including limited access, restrictions, and personal and cultural biases.

METHODS

This review summarizes issues of access, distribution, and cultural bias with regard to opioid agents and seeks to clarify the challenges related to opioid delivery. The considerable negative physical and mental consequences of chronic pain are discussed for the general and palliative care population.

RESULTS

Opioids are an effective treatment for various intractable painful conditions, but problems in global opioid access for safe and rational use in pain management contribute to unnecessary suffering. These problems persist despite increased understanding in recent years of the pathophysiology of pain.

CONCLUSIONS

Comprehensive guidelines for goal-directed and patient-friendly chronic opiate therapy will potentially enhance the outlook for future chronic pain management. The improvement of pain education in undergraduate and postgraduate training will benefit patients and clinicians. The promise of new medications, along with the utilization of multimodal approaches, has the potential to provide effective pain relief to future generations of sufferers.

Effect of opiates, anesthetic techniques, and other perioperative factors on surgical cancer patients

BACKGROUND

Opioid pharmacotherapy is often used to treat cancer pain. However, morphine and other opioid-like substance use in patients with cancer may have significant adverse consequences, including the suppression of both innate and acquired immune responses. Although studies have examined the possibility that regional anesthesia attenuates the immunosuppressive response of surgery, the effects of morphine and other opioid-related substances on tumor progression remain unknown.

METHODS

This article presents an evidence-based review of the influence of opioids and anesthetic technique on the immune system in the context of cancer recurrence. The review focuses on the field of regional anesthesia and the setting of surgical oncologic procedures. The method for perioperative pain management and the technique of anesthesia chosen for patients in cancer surgery were explored.

RESULTS

General anesthetics have been indicated to suppress both cell-mediated immunity and humoral immunity. Evidence suggests that intravenous opioids suppress the immune system. However, the mechanisms by which anesthetics and analgesics inhibit the immune system are not understood. Compared with the alternatives, regional analgesia offers reduced blood loss and superior postoperative analgesia. Because of these advantages, the use of regional analgesia has increased in oncologic surgeries.

CONCLUSION

Immune responses from all components of the immune system, including both the humoral and cell-mediated components, appear to be suppressed by anesthetics and analgesics. The clinical anesthesiologist should consider these factors in the application of technique, especially in cancer surgery.