Perioperative Prescribing Practices of Extended-Release Opioids in Noncancer Surgical Patients, 2015-2018.

BACKGROUND: Extended-release (ER) opioids are indicated for the management of persistent moderate to severe pain in patients requiring around-the-clock opioid analgesics for an extended period of time. Concerns have been raised regarding safety of ER opioids due to its potential for abuse and dependence. However, little is known about perioperative prescribing practices of ER opioids. This study assessed perioperative prescribing practices of ER opioids in noncancer surgical patients stratified by type of opioid exposure prior to admission and examined predictors of postoperative opioid administration in oral morphine equivalents (OME). METHODS: This was a retrospective cohort study using the University of California San Francisco Medical Center electronic health record data. This study included 25,396 adult noncancer patients undergoing elective surgery under general anesthesia in the period 2015-2018. The primary study outcome was predictors of postoperative administration of opioids in hospitalized surgical patients. Secondary outcomes included patients discontinued and initiated on ER opioids during their hospital stay. RESULTS: substance use disorder diagnosis and use of opioids, surgery type, and postoperative administration of nonopioid analgesics were associated with postoperative administration of opioids (P < .0001). The estimated adjusted mean (95% confidence interval [CI]) of postoperative administration of OME prior to admission in ER opioid users (170.08 mg; 147.08-196.67) was twice the amount for opioid-naïve patients (81.36 mg; 70.7-93.63; P < .0001). One in 5 prior to admission ER opioid users were weaned off ER opioids while hospitalized without adversely affecting their postoperative pain or hospital length of stay (LOS). Four of 5 patients who used ER opioids prior to admission also received ER opioids after surgery, whereas, 1 in 100 opioid-naïve patients received ER opioids during their hospital stay. CONCLUSIONS: We found significant variability in the perioperative prescribing practices of ER opioids in hospitalized noncancer surgical patients by use of opioids prior to admission and surgery type. Pain medicine practitioners and surgeons may play a significant role tackling the surgery-related risk of exposure to ER opioids and decreasing opioid-related complications.

Evidence of fentanyl use is common and frequently missed in a cross-sectional study of emergency department patients in Baltimore, Maryland.

Objective: Fentanyl-associated deaths have risen in Maryland, but the prevalence of illicit fentanyl use is unknown. Our objective was to measure whether fentanyl is present among emergency department (ED) patients seeking care for a drug overdose.Design: The prevalence of fentanyl use was determined using a cross-sectional study of a convenience sample of adult ED patients with complaints of apparent opioid overdose, withdrawal from opioids, and/or requesting treatment for their substance use disorder (SUD) between February and April, 2018. Subjects were consented, interviewed, and underwent urine point-of-care (POC) fentanyl testing.Results: A total of 102 patients met inclusion criteria and were approached, 76 consented, 63 (83%) of whom tested positive for recent fentanyl use. 60 (80%) were male, 26 (34%) had overdosed, 41 (54%) were seeking SUD treatment, and 13 (17%) were in withdrawal (4 had multiple complaints). Of those who underwent both standard hospital urine drug screen and POC fentanyl testing, 56% (22/39) were positive for fentanyl and negative for opiates. Only 5% (4/76) reported knowledge of using fentanyl.Conclusions: Fentanyl use was common and frequently missed among these ED patients. Hospitals who treat patients taking illicit fentanyl should consider adding fentanyl to their urine drugs of abuse panel.

Perioperative use of opioids: Current controversies and concerns.

In the midst of an epidemic of opioid abuse and overdose-related morbidity and mortality, the use of opioids remains the most common means of providing analgesia in the perioperative period. In this article, we review the risks and benefits of opioid use in preoperative, intraoperative and post-operative phases of care. Furthermore, we describe the role that surgeons and anaesthesiologists can play in reducing perioperative opioid use and mitigate their adverse effects, from both an individual and a population health perspective.

Increasing heroin, cocaine, and buprenorphine arrests reported to the Maine Diversion Alert Program.

BACKGROUND: The opioid overdose crisis is especially pronounced in Maine. The Diversion Alert Program (DAP) was developed to combat illicit drug use and prescription drug diversion by facilitating communication between law enforcement and health care providers with the goal of limiting drug-related harms and criminal behaviors. Our objectives in this report were to analyze 2014-2017 DAP for: (1) trends in drug arrests and, (2) differences in arrests by offense, demographics (sex and age) and by region. METHODS: Drug arrests (N=8193, 31.3% female, age=33.1±9.9) reported to the DAP were examined by year, demographics, and location. RESULTS: The most common substances of the 10,064 unique charges reported were heroin (N=2203, 21.9%), crack/cocaine (N=945, 16.8%), buprenorphine (N=812, 8.1%), and oxycodone (N=747, 7.4%). While the overall number of arrests reported to the DAP declined in 2017, the proportion of arrests involving opioids (heroin, buprenorphine, or fentanyl) and stimulants (cocaine/crack cocaine, or methamphetamine), increased (p<.05). Women had significantly increased involvement in arrests involving sedatives and miscellaneous pharmaceuticals (e.g. gabapentin) while men had an elevation in stimulant arrests. Heroin accounted for a lower percentage of arrests among individuals age >60 (6.6%) relative to young-adults (18-29, 22.3%, p<.0001). Older-adults had significantly more arrests than younger-adults for oxycodone, hydrocodone, and marijuana. CONCLUSION: Heroin had the most arrests from 2014 to 2017. Buprenorphine, fentanyl and crack/cocaine arrests increased appreciably suggesting that improved treatment is needed to prevent further nonmedical use and overdoses. The Diversion Alert Program provided a unique data source for research, a harm-reduction tool for health care providers, and an informational resource for law enforcement.

The Opioid Debate-PRO: Opioids Have an Important Role in Pain Management in Children.

The increase in opioid-related deaths in the United States (and other countries) has prompted a national debate in medicine about the appropriateness of opioids for the treatment of acute and chronic pain, and specifically in children, if medical opioid use causes or increases the risk of opioid use disorder (OUD) later in life. Some in the medical community and in government advocate withholding opioids from children after an arbitrary number of days of treatment, regardless of diagnosis. Here, I argue that opioid experimentation and misuse is no more common in children and adolescents today than 2 or 3 decades ago, that there is no compelling evidence that appropriate medical use of opioids leads to OUD, and that the epidemic of inadequately treated pain in children remains the more compelling issue.

The Opioid Wars-CON: The Risks of Opioids for Pain Management Outweigh the Benefits.

The entire field of medicine, not just anesthesiology, has grown comfortable with the risks posed by opioids; but these risks are unacceptably high. It is time for a dramatic paradigm shift. If used at all for acute or chronic pain management, they should be used only after consideration and maximizing the use of nonopioid pharmacologic agents, regional analgesia techniques, and nonpharmacologic methods. Opioids poorly control pain, their intraoperative use may increase the risk of recurrence of some types of cancer, and they have a large number of both minor and serious side effects. Furthermore, there are a myriad of alternative analgesic strategies that provide superior analgesia, decrease recovery time, and have fewer side effects and risks associated with their use. In this article the negative consequences of opioid use for pain, appropriate alternatives to opioids for analgesia, and the available evidence in pediatric populations for both are described.

Chronic obstructive pulmonary disease (COPD) among opioid-dependent patients in agonist treatment. A diagnostic study.

AIMS: To estimate the prevalence of chronic obstructive pulmonary disease (COPD) and related risk factors in people in opioid agonist treatment (OAT), to compare airflow limitation severity and age-specific COPD prevalence rates with those in the general population, and to assess the OAT patients' willingness to adopt life-style changes and to use therapeutic offers for COPD management. DESIGN: Cross-sectional study in a random sample of OAT patients. SETTING: Out-patient centres for substance addiction medicine in Zurich, Switzerland. PARTICIPANTS: A total of 125 participants, recruited from November 2016 to April 2017 through invitation letters followed by phone or personal contact. MEASUREMENTS: Standardized questionnaires about drug use, smoking habits and medical history, completed during face-to-face interviews or from medical records. Spirometry without and-depending on the result-with bronchodilation. FINDINGS: Almost one-third [30.3%; 95% confidence interval (CI) = 22.6-39.0%] of the 119 participants with valid spirometry tests were diagnosed with COPD. Among males aged 30-59 years, the age-adjusted prevalence of at least moderate airflow limitation (GOLD grade ≥ 2) was 2.4 (95% CI = 1.3-4.4) times as high as in the ever-smoking Swiss population in the same age group. Smoking tobacco (92.0%) and substance inhalation (cannabis = 97.6%, cocaine = 69.6%, heroin = 68.0%) were highly prevalent among all participants. The participants expressed considerable interest in life-style changes and use of therapeutic offers for COPD management, with smoking cessation being least (20.2% of tobacco smokers interested) and pharmacological treatment to alleviate COPD symptoms most popular. CONCLUSIONS: In Switzerland, COPD prevalence and multiple risk factors for COPD appear to be high among people in OAT compared with the general population. Individuals in OAT appear to develop COPD at a younger average age compared with the general population and are open to life-style changes and other COPD management approaches.

Narcotic Addiction in Failed Back Surgery Syndrome.

Back pain is a common health problem that reduces the quality of life for human beings worldwide. Several treatment modalities have been reported as effective for pain relief. Generally, patients often undergo surgical interventions as pain becomes intractable, after conservative treatment. With advances in surgical techniques, those choosing spinal surgery as an option have increased over time, and instrumentation is more popular than it was years ago. However, some patients still have back pain after spinal operations. The number of patients classified as having failed back surgery syndrome (FBSS) has increased over time as has the requirement for patients receiving long-term analgesics. Because pain relief is regarded as a human right, narcotics were prescribed more frequently than before. Narcotic addiction in patients with FBSS has become an important issue. Here, we review the prevalence of FBSS, the mechanism of narcotic addiction, and their correlations. Additionally, several potentially effective strategies for the prevention and treatment of narcotic addiction in FBSS patients are evaluated and discussed.