A qualitative study of chronic pain and opioid use: The impact of restrictive prescribing.

OBJECTIVES: To explore the continuum of pain and addiction for patients with chronic pain (CP) who used opioids during a time of restrictive opioid prescribing in West Virginia. DESIGN: This qualitative descriptive study used a content analysis of semistructured interviews. Themes were identified through a reflective, iterative coding process. Consolidated criteria for reporting qualitative research guidelines were followed. SETTING: West Virginia. PARTICIPANTS: Twenty people who used opioids to treat a CP condition, 10 pharmacists, 10 primary care providers, and 10 specialists. INTERVENTION: Semistructured interviews. MAIN OUTCOME MEASURE: To better understand the impact of restrictive prescribing measures on people who used opioids for CP. RESULTS: Patients initiated opioids for acute, painful conditions and described how long-term use led to physical dependence and, for some, opioid use disorder. Restrictive opioid prescribing laws led to care interruptions and decreased access and availability of prescribed opioid pain medication, driving some patients to seek illicit drugs. Economic considerations influenced drug use as the price of purchasing prescription opioids on the street went up, making heroin a cheaper alternative. Patients who transitioned to buprenorphine/naloxone as a treatment for pain or opioid use disorder viewed it as a positive change and a "life saver." CONCLUSIONS: Opioid use for CP is complex and multifaceted. The continuum of pain and opioid use disorder can begin with a prescription for acute pain and continue for the treatment of CP. Patients described how continued opioid use was not to "get high" but for pain control to improve their quality of life, continue to work, and be productive. For those who experience physical dependence on opioids, access to treatment is vital to recovery and pain management. KEY MESSAGE: Without individualized managed care, people confronted with a sudden interruption in prescription opioids may turn to illicit drugs to mitigate symptoms of opioid withdrawal and physical dependence.

The Grapefruit Effect: Interaction between Cytochrome P450 and Coumarin Food Components, Bergamottin, Fraxidin and Osthole. X-ray Crystal Structure and DFT Studies.

Coumarins are plant-derived secondary metabolites. The crystal structure of three coumarins-bergamottin, osthole and fraxidin-are described and we analyze intermolecular interactions and their role in crystal formation. Bergamottin is a furanocoumarin found in citrus plants, which is a strong inhibitor of the principal human metabolizing enzyme, cytochrome P450 3A4 (CYP3A4). The crystal structure determinations of three coumarins give us the geometrical parameters and reveal the parallel-displaced π-π stacking and hydrogen bonding intermolecular interactions used for molecular assembly in the crystal structure. A quite strong (less than 3.4 Å) stacking interaction of bergamottin appears to be a determining feature that distinguishes it from other coumarins studied in this work. Our DFT computational studies on the three natural products of the same coumarin family docked into the active site of CYP3A4 (PDB 4D78) show different behavior for these coumarins at the active site. When the substrate is bergamottin, the importance of π-π stacking and hydrogen bonding, which can anchor the substrate in place, appears fundamental. In contrast, fraxidin and osthole show carbonyl coordination to iron. Our docking calculations show that the bergamottin tendency towards π-π stacking is important and likely influences its interactions with the heme group of CYP3A4.

Nursing Management of Patients Requiring Acute Mechanical Circulatory Support Devices.

TOPIC: The growing use of acute mechanical circulatory support devices to provide hemodynamic support that has accompanied the increasing prevalence of heart failure and cardiogenic shock, despite significant improvement in the treatment of acute myocardial infarction. CLINICAL RELEVANCE: The critical care nurse plays a crucial role in managing patients receiving acute mechanical circulatory support devices and monitoring for potential complications. PURPOSE: To review the anatomical placement and mechanics of each type of device so that nurses can anticipate patients' hemodynamic responses and avoid complications whenever possible, thereby improving patients' clinical outcomes. CONTENT COVERED: Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation.

The perianesthesia experience from the patient's perspective.

The purpose of this study was to investigate the perianesthesia experience from the patient's perspective. An existential phenomenological approach using Pollio's interpretive framework was used. Interpretations were conducted, in part, in a research group. The purpose of the interpretation was to recognize patterns or themes in an experience. Participants were asked to describe specific experiences that stood out for them because experiences which stand out are those that are meaningful. Ten participants (5 males, 5 females) ranging in age from 23 to 66 years were interviewed using phenomenological techniques. The interpretation found the perianesthesia experience to be grounded in self, others, and time, which become figural through experiences of control. Each participant relinquished control, lost control, or strove to gain or maintain control during their surgical experience. The perception of death lurking crossed into figural experiences as well. Images of death, while grouped predominantly with self, were interpreted as the ultimate loss of self, others, and time. Loss of control of self, the relinquishing of control to others, and the temporal experience of control may contribute to perianesthesia stress and anxiety. Nurses in the perianesthesia period have many opportunities to help patients with issues of control.