Treatment Updates for Pain Management and Opioid Use Disorder.

The medical community has proposed several clinical recommendations to promote patient safety and health amid the opioid overdose public health crisis. For a frontline practicing physician, distilling the evidence and implementing the latest guidelines may prove challenging. This article aims to highlight pertinent updates and clinical care pearls as they relate to primary care management of chronic pain and opioid use disorder.

Buprenorphine Prescribing and Dosing Limits: Evidence and Policy Goals.

The opioid misuse epidemic is a serious public health crisis. Opioid-involved deaths continue to rise and the potency of illicitly manufactured synthetic opioids has increased, creating challenges for the healthcare system to provide multifaceted specialized care. Elements of the regulation around buprenorphine, 1 of 3 drugs approved to treat opioid use disorder (OUD), constrain treatment options for patients and providers alike. Updates to this regulatory framework, particularly around dosing and access to care, would enable providers to better treat the changing landscape of opioid misuse. Specific actions to this end are to: (1) Increase buprenorphine dosing flexibility based on FDA labeling which drives payor policies; (2) Restrict local government and institutional impositions of arbitrary access and dosing limits for buprenorphine; and (3) Liberalize buprenorphine initiation and maintenance via telemedicine for OUD.

Trigeminal Zoster with drug-induced labial angioedema leading to necrosis.

Introduction: Zoster is caused by the reactivation of a dormant viral infection, and is characterized by painful, vesicular lesions along a dermatome. Neuritic pain associated with zoster can be treated with anticonvulsant medications. Case Report: An immunocompetent adult physician developed prominent zoster lesions in the trigeminal nerve distribution. Treatment included antiviral therapy for the acute infection, and pharmacotherapy for neuritic pain. Pharmacotherapy included several anticonvulsant agents, with labial angioedema developing after initiation of oxcarbazepine. Discussion: The case is notable for the pictorial timeline of lesion development, as well as the marked incident angioedema following initiation of treatment for neuritis with oxcarbazepine. Conclusions: Clinicians should remain vigilant for drug-induced facial angioedema when treating patients with trigeminal zoster-related neuritis due to the potential for angioedema to aggravate a lesion, resulting in scarring. Angioedema of the head and neck should be closely monitored due to the potential for airway compromise.

Opioid analgesic dose and the risk of misuse, overdose, and death: A narrative review.

PURPOSE: Despite the rise in serious adverse events paralleling increased prescription opioid analgesic use in the United States over the past 2 decades, the association between opioid analgesic dose and the risk of serious adverse health outcomes is incompletely characterized. We sought to synthesize the medical literature for observational studies examining the association between opioid analgesic dose and the risk of serious adverse health outcomes, with particular attention to the outcomes of misuse, abuse, addiction, overdose, and death. METHODS: Searching MEDLINE using PubMed and bibliography review, we identified 22 observational studies published between 2000 and 2015 that assessed the association between opioid analgesic dose and the risk of serious adverse health outcomes. Some of these studies had significant methodological limitations. Twelve reviewed studies examined the outcomes of misuse, overdose, or death; no studies examining the risk of addiction or abuse met our criteria for inclusion. RESULTS: The results of multiple studies clearly indicate an increasing risk of serious adverse health outcomes associated with increasing opioid analgesic dose. In particular, the risk of misuse, overdose, and death increases with increasing opioid analgesic dose. However, there is no opioid dose inflection point beyond which the risk of these adverse health outcomes increases. No opioid analgesic dose is without risk. CONCLUSIONS: The reviewed studies show an increasing risk of serious adverse health outcomes-including misuse, overdose, and death-associated with increasing opioid analgesic dose. Further research is needed to characterize the relationship between opioid analgesic dose and the risk of addiction and abuse. This analysis could inform policy actions for regulators and clinical decision making for providers.