Effectiveness of a Pre-emptive Preoperative Belladonna and Opium Suppository on Postoperative Urgency and Pain After Ureteroscopy.

PURPOSE: Postoperative ureteroscopy patients can develop bladder spasms, complaints of pain, and the urgent need to void during emergence from anesthesia. Discomfort leads to patient agitation, resulting in a risk to patient safety. The purpose of this study was to determine the effectiveness of a preemptive preoperative belladonna and opium (B + O) suppository on postoperative bladder comfort, narcotic requirements, and length of stay of ureteroscopy patients. DESIGN: A prospective double-blind study was conducted. METHODS: Fifty adult outpatients scheduled for ureteroscopy were assigned to routine care or a B + O suppository immediately after anesthesia induction. Urinary urgency and pain were assessed every 15 minutes. FINDINGS: Urgency significantly decreased in the B+O group, with less than half reporting urgency at discharge. CONCLUSIONS: Pre-emptive preoperative administration of a B + O suppository before ureteroscopy results in decreased urinary urgency during the postoperative recovery. Pre-emptive preoperative interventions can result in positive outcomes before discharge.

Lead poisoning outbreak among opium users in the Islamic Republic of Iran, 2016-2017.

OBJECTIVE: To describe an outbreak of lead poisoning among opium users in the Islamic Republic of Iran and estimate the number of affected people in the country. METHODS: We used data from the country's largest poison treatment centre to illustrate the epidemiology of an outbreak of lead poisoning in oral opium users. We describe the government's referral and treatment guidelines in response to the outbreak. Based on the number of individuals treated and previous studies on the prevalence of oral opium use we estimated the total number of people at risk of lead-contaminated opium nationwide. FINDINGS: In February 2016, we noticed a steep increase in the numbers of oral opium users referred to our poison treatment centre with abdominal pain, anaemia and constipation. Numbers peaked in June 2016 but the outbreak was ongoing in August 2017. The mean blood lead level in a sample of 80 patients was 140.3 µg/dL (standard deviation: 122.6). Analysis of an illegal opium sample showed 3.55 mg lead in 1 g opium. Treatment was exposure reduction with opioid substitutes and laxatives, or chelation therapy if indicated. Over 7 months, 4294 poison cases were seen at main referral hospitals in Tehran out of an estimated 31 914 oral opium users in the city. We estimate more than 260 000 out of 773 800 users nationwide remain untreated and at risk of poisoning. CONCLUSION: Lead-contaminated opium and heroin that has transited through the Iranian markets is a global risk and highlights a need for better monitoring of illegal drug supplies.

Randomized controlled trial of postoperative belladonna and opium rectal suppositories in vaginal surgery.

BACKGROUND: After vaginal surgery, oral and parenteral narcotics are used commonly for pain relief, and their use may exacerbate the incidence of sedation, nausea, and vomiting, which ultimately delays convalescence. Previous studies have demonstrated that rectal analgesia after surgery results in lower pain scores and less intravenous morphine consumption. Belladonna and opium rectal suppositories may be used to relieve pain and minimize side effects; however, their efficacy has not been confirmed. OBJECTIVE: We aimed to evaluate the use of belladonna and opium suppositories for pain reduction in vaginal surgery. MATERIALS AND METHODS: A prospective, randomized, double-blind, placebo-controlled trial that used belladonna and opium suppositories after inpatient or outpatient vaginal surgery was conducted. Vaginal surgery was defined as (1) vaginal hysterectomy with uterosacral ligament suspension or (2) posthysterectomy prolapse repair that included uterosacral ligament suspension and/or colporrhaphy. Belladonna and opium 16A (16.2/60 mg) or placebo suppositories were administered rectally immediately after surgery and every 8 hours for a total of 3 doses. Patient-reported pain data were collected with the use of a visual analog scale (at 2, 4, 12, and 20 hours postoperatively. Opiate use was measured and converted into parenteral morphine equivalents. The primary outcome was pain, and secondary outcomes included pain medication, antiemetic medication, and a quality of recovery questionnaire. Adverse effects were surveyed at 24 hours and 7 days. Concomitant procedures for urinary incontinence or pelvic organ prolapse did not preclude enrollment. RESULTS: Ninety women were randomly assigned consecutively at a single institution under the care of a fellowship-trained surgeon group. Demographics did not differ among the groups with mean age of 55 years, procedure time of 97 minutes, and prolapse at 51%. Postoperative pain scores were equivalent among both groups at each time interval. The belladonna and opium group used a mean of 57 mg morphine compared with 66 mg for placebo (P=.43) in 24 hours. Patient satisfaction with recovery was similar (P=.59). Antiemetic and ketorolac use were comparable among groups. Subgroup analyses of patients with prolapse and patients <50 years old did not reveal differences in pain scores. The use of belladonna and opium suppositories was uncomplicated, and adverse effects, which included constipation and urinary retention, were similar among groups. CONCLUSION: Belladonna and opium suppositories are safe for use after vaginal surgery. Belladonna and opium suppositories did not reveal lower pain or substantially lower narcotic use. Further investigation may be warranted to identify a population that may benefit optimally from belladonna and opium use.

Neglected role of hookah and opium in gastric carcinogenesis: a cohort study on risk factors and attributable fractions.

A recent study showed an association between hookah/opium use and gastric cancer but no study has investigated the relationship with gastric precancerous lesions. We examined the association between hookah/opium and gastric precancerous lesions and subsequent gastric cancer. In a population-based cohort study, 928 randomly selected, healthy, Helicobacter pylori-infected subjects in Ardabil Province, Iran, were followed for 10 years. The association between baseline precancerous lesions and lifestyle risk factors (including hookah/opium) was analyzed using logistic regression and presented as odds ratios (ORs) and 95% confidence intervals (CIs). We also calculated hazard ratios (HRs) and 95% CIs for the associations of lifestyle risk factors and endoscopic and histological parameters with incident gastric cancers using Cox regression models. Additionally, the proportion of cancers attributable to modifiable risk factors was calculated. During 9,096 person-years of follow-up, 36 new cases of gastric cancer were observed (incidence rate: 3.96/1,000 persons-years). Opium consumption was strongly associated with baseline antral (OR: 3.2; 95% CI: 1.2-9.1) and body intestinal metaplasia (OR: 7.3; 95% CI: 2.5-21.5). Opium (HR: 3.2; 95% CI: 1.4-7.7), hookah (HR: 3.4; 95% CI: 1.7-7.1) and cigarette use (HR: 3.2; 95% CI: 1.4-7.5), as well as high salt intake, family history of gastric cancer, gastric ulcer and histological atrophic gastritis and intestinal metaplasia of body were associated with higher risk of gastric cancer. The fraction of cancers attributable jointly to high salt, low fruit intake, smoking (including hookah) and opium was 93% (95% CI: 83-98). Hookah and opium use are risk factors for gastric cancer as well as for precancerous lesions. Hookah, opium, cigarette and high salt intake are important modifiable risk factors in this high-incidence gastric cancer area.

Nature cures nature: Hypericum perforatum attenuates physical withdrawal signs in opium dependent rats.

CONTEXT: Hypericum perforatum Linn. (Hypericaceae) (St. John's wort) attenuates opium withdrawal signs. AIM: To explore the therapeutic potential of Hypericum perforatum in the management of opium-induced withdrawal syndrome. MATERIALS AND METHODS: The effect of the Hypericum perforatum hydro-ethanol extract was investigated for potential to reverse naloxone (0.25 mg/kg)-induced opium withdrawal physical signs. Rats received opium extract (80-650 mg/kg) twice daily for 8 days along with Hypericum perforatum (20 mg/kg, orally) twice daily in chronic treatment and the same single dose 1 h before induction of withdrawal syndrome in the acute treated group. RESULTS: Hypericum perforatum reduced stereotype jumps and wet dog shake number in the chronic treatment compared to the saline control group (F(2, 24) = 3.968, p < 0. 05) and (F(2, 24) = 3.689, p < 0.05), respectively. The plant extract in the acutely treated group reduced diarrhea (F(2, 24) = 4.850, p < 0. 05 vs. saline). It decreased rectal temperature by chronic treatment at 30 min (F(2, 24) = 4.88, p < 0.05), 60 min (F(2, 240 = 5.364, p < 0.01) and 120 min (F(2, 24) = 4.907, p < 0.05). DISCUSSION AND CONCLUSION: This study reveals that the extract of Hypericum perforatum attenuates some physical signs of opium withdrawal syndrome possibly through direct or indirect interaction with opioid receptors. Further study is needed to clarify its mechanism.

Prophylactic belladonna suppositories on anesthetic recovery after robotic assisted laparoscopic prostatectomy.

INTRODUCTION: Two prospective trials have demonstrated prophylactic antimuscarinics following prostatectomy reduce pain from bladder spasms. Our practice adopted the routine administration of prophylactic belladonna and opium (B&O) suppositories to patients undergoing robotic assisted laparoscopic radical prostatectomy (RALP). The aim of this study is to determine if this change in clinical practice was associated with improvement of postoperative outcomes. MATERIALS AND METHODS: The medical records of 202 patients that underwent RALP surgery who were or were not administered prophylactic B&O suppositories in the immediate postoperative period were abstracted for duration of anesthesia recovery, pain and analgesic use. RESULTS: Patient and surgical characteristics between groups were similar except B&O group were slightly older (p = 0.04) and administered less opioid analgesics (p = 0.05). There was no difference between groups in the duration of phase I recovery from anesthesia (p = 0.96). Multivariable adjustments for age, body mass index, American Society of Anesthesiologists physical status, and surgical duration were made, and again it was found that suppository administration had no association with phase I recovery times (p = 0.94). The use of antimuscarinic medication for bladder spams in the B&O group was less during phase I recovery (p < 0.01), but was similar during the first 24 hours (p = 0.66). Postoperative sedation, opioid analgesic requirements and pain scales were similar during phase I recovery and the first 24 postoperative hours. Hospital length of stay was similar. DISCUSSION: The introduction of prophylactic B&O suppositories at the immediate conclusion of RALP surgery was not associated with improvements of the postoperative course.

Neonatal opiate withdrawal and rooming-in: a retrospective analysis of a single center experience.

AIM: To evaluate our treatment of neonatal abstinence syndrome (NAS), our experience with rooming-in of opiate-dependent mothers and to examine the influence of rooming-in on short term outcome of infants exposed to opiates in utero. METHOD: Retrospective analysis of maternal and perinatal data of newborn infants with NAS treated between 2004 and 2011 in a level 3 academic children's hospital in a German metropolis. Therapy of NAS and duration of therapy, length of hospital stay and costs were considered in particular. FINDINGS: Data of 77 newborns with NAS were analysed. 84.6% of infants were treated with tincture of opium (79.2% rooming-in, 88.7% no rooming-in). Infants with rooming-in (n=24) had a 17% shorter median duration of therapy [27.0 d (IQR 24.0-38.5), no rooming-in (n=53) 32.5 d (IQR 25.0-54.5)] and shorter median length of hospital stay [33.0 d (IQR 28.0-48.0), no rooming-in 41.5 d (IQR 30.3-54.5)]. Demographic data was comparable between newborns and mothers with or without rooming-in. Costs were median 13 457 € (IQR 8 967-17 494)/patient [rooming-in: 9 547 € (IQR 7 024-16 135), no rooming-in: 14 486 € (IQR 9 479-19 352)]. CONCLUSIONS: Rooming-in in NAS should be encouraged to shorten duration of therapy and length of hospital stay and thereby reduce costs. No major problems arose in the care of the infants with NAS when parents stayed with their infants but close monitoring of the newborn and strict instruction of parents are required.

Clinical value of morphine, pholcodine and poppy seed IgE assays in drug-abusers and allergic people.

BACKGROUND: The diagnosis of anaphylactic reactions due to opiates during anaesthesia can be difficult, since in most cases various drugs may have been administered. Detection of specific IgE to poppy seed might be a marker for sensitisation to opiates in allergic people and heroin-abusers. This study assessed the clinical value of morphine, pholcodine and poppy seed skin-prick and IgE determination in people suffering hypersensitivity reactions during anaesthesia or analgesia and drug-abusers with allergic symptoms. METHODS: We selected heroin abusers and patients who suffered severe reactions during anaesthesia and analgesia from a database of 23,873 patients. The diagnostic yield (sensitivity, specificity and predictive value) of prick and IgE tests in determining opiate allergy was analysed. RESULTS: Overall, 149 patients and 200 controls, mean age 32.9 ± 14.7 years, were included. All patients with positive prick to opiates showed positive prick and IgE to poppy seeds, but not to morphine or pholcodine IgE. Among drug-abusers, 13/42 patients (31%) presented opium hypersensitivity confirmed by challenge tests. Among non-drug abusers, sensitisation to opiates was higher in people allergic to tobacco (25%), P<.001. Prick tests and IgE against poppy seed had a good sensitivity (95.6% and 82.6%, respectively) and specificity (98.5% and 100%, respectively) in the diagnosis of opiate allergy. CONCLUSIONS: Opiates may be significant allergens. Drug-abusers and people sensitised to tobacco are at risk. Both the prick and specific IgE tests efficiently detected sensitisation to opiates. The highest levels were related to more-severe clinical profiles.

[The first labor analgesia with drug was already performed in late Meiji-Period (1868-1912): trace of opioid-scopolamine which was used in Akiko Yosano, back to its origins].

There have been some records of labor analgesia with intravenous or rectal anesthetics in early Showa-period (1926-1989). However, the author found that labor analgesia had been already attempted for some women in late Meiji-period (1868-1912). One of agents used was pantopon, a water-soluble opioid without serious respiratory depression as morphine. The drug was developed and produced in Germany. Some doctors applied this agent with scopolamine to labor analgesia in Europe. They also reported that this combination also conferred excellent analgesic effects without any serious complications in the mother and fetus. This combination was originally used for general surgery with inhaled anesthesia at that period. It remains uncertain how Japanese doctors got pantopon scopolamine from Germany.

Balancing between sensitization and repression: the role of opium in the life and art of Edgar Allan Poe and Samuel Taylor Coleridge.

The creative process contains both conscious and unconscious work. Therefore, artists have to face their unconscious processes and work with emotional material that is difficult to keep under control in the course of artistic creation. Bringing these contents of consciousness to the surface needs special sensitivity and special control functions while working with them. Considering these mechanisms, psychoactive substance can serve a double function in the case of artists. On the one hand, chemical substances may enhance the artists' sensitivity. On the other hand, they can help moderate the hypersensitivity and repress extreme emotions and burdensome contents of consciousness. The authors posit how the use of opiates could have influenced the life and creative work of Edgar Allan Poe and Samuel Taylor Coleridge.

Opium and Cigarette Smoking are Independently Associated with Bladder Cancer: The Findings of a Matched Case - Control Study.

BACKGROUND: Bladder cancer disproportionally affects the communities. While it is the ninth most common cancer in the world, in some parts of Iran including Kerman province it is the most common cancer among men. This study aimed to determine potential risk factors of bladder cancer in Kerman province, Iran. METHODS: During February to July 2020, in this matched hospital-based case-control study, 100 patients with bladder cancer and 200 healthy individuals (matched in age and sex) were recruited. Socio-demographics status, occupational exposures, common diet, history of drug use and family history of cancer, were collected using a structured questionnaire. Bivariable and multivariable logistic regression were applied and crude and adjusted odds ratios (AOR) along with their 95% confidence intervals (95%CI) were calculated. Data were analyzed using Stata version 14 software. RESULTS: Opium consumption, cigarette smoking and low level of income were associated with increased chance of bladder cancer. Compared to never use, use of opium up to 18000 Gram -year was associated with increased chance of bladder cancer (AOR: 6; 95% CI =2.3, 15.5). The chance was higher among those who used opium more than 18,000 Gram - year (AOR: 11.3; 95% CI =2.3, 15.5). In comparison with never smokers, the chance of bladder cancer increased among those who smoked up to 20 pack-year cigarette) (AOR: 3.4; 95%CI= 1.3, 8.9) and those who smoke ≥ 20 pack-year (AOR: 15.8; 95% CI= 5.9, 42.4). CONCLUSIONS: The observed strong dose-response association between opium consumption, cigarette smoking and bladder cancer highlights the need for extension of harm reduction programs especially in regions with high burden of disease.

[Evaluation of the adequacy of analgesia using sensometry method during sacral anesthesia in proctological operations].

Adequacy of epidural-sacral anesthesia in proctological operations was studied. Sensometry occupies a special place among the methods, estimating the sacral anesthesia adequacy, owing the advantage of possibility for quantitative estimation of such an important index, as a patient reaction on external irritants, including such of a pain. Sensometry, according to A. K. Sangaylo method, using portative apparatus "Nil - 3" was conducted in 50 patients while proctological operations performance for estimation of various variants of sacral anesthesia efficacy. There was established, that sensometry constitutes the most informative quantitative method of estimation of the anesthesia adequacy.

Effects of methadone, opium tincture and buprenorphine maintenance therapies on thyroid function in patients with OUD.

Various types of medications are used as maintenance therapies for substance use disorder; However, the side effects of these drugs are shown to restrict their use and increase the risk of relapse in patients. As a result, alternative maintenance therapies are tested in the hope for optimum therapy. Since opium tincture is a new and innovative maintenance treatment in Iran, we attempted to compare the therapeutic and side effects of opium tincture with two standard therapies, i.e., methadone and buprenorphine. Hence, thyroid function was tested in three methods of maintenance therapies with methadone, buprenorphine, and opium tincture in a cross-sectional study. In this study, 150 patients with the mean age of 51.63 ± 13.56 years and a history of opioid or opioid-derivatives use disorder, underwent the maintenance treatment with methadone, buprenorphine, and opium tincture at Bojnurd Addiction Treatment Centers in northeastern Iran. These patients were selected using convenience sampling. Then, they were placed into three treatment groups of methadone, buprenorphine, and opium tincture. The thyroid functionality was assessed with measuring TSH, fT4, fT3, T3RU, and Anti TPO, carried out in a reference laboratory. Finally, these data were analyzed by ANOVA using SPSS.16 software. The results showed that there was no significant difference in the average levels of TSH, fT3, fT4, and Anti TPO in these treatment groups; except for T3RU concentration, which was increased significantly in the opium tincture group as compared to the methadone treated group. Also, the frequency of fT4, and T3RU disorders demonstrated a significant change in three groups. The findings of the present study demonstrated that opium tincture in comparison with methadone could increase T3RU levels resulting in euthyroidism possibly through TBG.

Drug abuse profile - patient delay, diagnosis delay and drug resistance pattern - among addict patients with tuberculosis.

Socioeconomic problems limit the access of drug users to health-care services. This descriptive cross-sectional study was carried out by making use of the medical records of new case tuberculosis (TB) patients hospitalized at Masih Daneshvari Hospital, the national referral centre in Iran, from 2003 to 2006. Demographic and personal characteristics of the patients and type of disease were collected and categorized. Of the 944 patients with confirmed TB, 143 (15.1%) were drug users, among whom 140 (97.9%) were men with just three women drug users. The mean age of the drug users group was 43.04 +/- 13.81 years. The type of drug used was opium in 100 cases (69.9%), heroin in 29 (20.3%), opium and heroin together in four (2.8%) and all three, opium, heroin and crack, in two (1.4%). For 238 high-risk patients, an HIV test was performed and HIV infection was confirmed in 33 cases. Patient delay was longer in drug users (P = 0.000) against other patients, whereas diagnosis delay was shorter (P = 0.007). Drug susceptibility tests were performed for 515 patients with positive cultures. One hundred and thirty-three (14.1%) were found to have 'any resistance' to anti-TB drugs, and 10 (1.1%) individuals had multidrug-resistant TB. Twenty-six (19.5%) of the individuals who showed resistance to first-line agents were drug users. There was no significant relation between drug resistance and drug use (P = 0.4). In conclusion, it seems that active case finding for TB and HIV in addict cases must be contained in harm reduction packages. Moreover, the manifestations of the disease should be considered seriously regardless of attributing them to drug use.

Opioid Crisis Along Mexico's Northern Border: Treatment Needs Mexican Opioid Crisis.

BACKGROUND: Heroin production for external markets and low rates of use in Mexico have had a long history. A recent shift toward an increase in use and related problems calls for the evaluation of treatment needs in order to draw recommendations for policies. METHODS: The objectives were to identify predictors of choice of treatment and barriers to care among persons that had been with no treatment. The study included a convenience sample of 600 face-to-face interviews of people 18 years of age and older and a rapid HIV and HCV tests in three cities on Mexico's Northern Border: Ciudad Juárez, San Luis Río Colorado and Tijuana. The choice of treatment (methadone, other pubic or private treatments with no experience with methadone maintenance and only self-help or religious care), was analyzed though a multiple logistic multimodal regression analysis. Informed consents to be interviewed and for HIC and HIV were signed by interviewers. RESULTS: The majority of persons interviewed were males (89.7%) with an average age of 40. Having emigrated to the United States and a greater length of heroin use predicted seeking methadone treatment versus public or private treatment or informal care. The most important barriers to care were lack of information and stigma. HIC, HIV and other infectious and chronic diseases including depression were often unattended. CONCLUSIONS: There is a need to reform treatment policies in order to cover this w emerging and demanding problem.

An Exploratory Study of Units of Reporting Opium Usein Iran: Implications for Epidemiologic Studies.

BACKGROUND: Measuring the amount of opium use is a challenge in epidemiologic studies. Self-report of amount of opium use at each consumption, widely used in the literature, usually fails to provide a good estimate. The purpose of this study is to systematically study the perceived weight units of reported opium use in Iran, and compare them to the standardized units of weight measurement. METHODS: An exploratory descriptive study was conducted in six major cities of Iran. Study participants were interviewed and asked to use a Play-Doh-like material to demonstrate the amount of opium they use. To obtain an estimate of the weight of the material used, we multiplied the volume by the density of the opium product. We experimentally determined the density of the commonly used opium products. We used medians and inter-quartile ranges (IQRs) to report the typical amount of each unit. RESULTS: A total of 108 individuals participated in this study. The most frequently reported unit was "gram"; the median perceived weight for one gram (g) of opium was 0.24 (IQR: 0.16) g. The second most commonly used unit was nokhod with a median of 0.16 (IQR: 0.16) g, followed by mesghaal and hab/habeh, which were 1.28 (IQR: 0.81) and 0.16 (IQR: 0.16) g, respectively. The median perceived weight of mesghaal and gram in the studied cities was less than the expected standardized values. CONCLUSION: In conclusion, the reported amount of opium use is highly inaccurate and unreliable, and is mainly subject to underestimation.

Lead poisoning due to ingestion of lead-contaminated opium: A diagnostic study on patients' imaging findings.

OBJECTIVES: Our study attempts to determine if for patients following ingestion of lead-contaminated opium, radiographs [plain X-ray (KUB)] or unenhanced computed tomography (CT scan) of the abdomen may be predictive of lead poisoning. METHODS: Our study is concerned with patients of >21 years with elevated lead concentrations, who had undergone KUB or CT. Patients with other toxicities who had undergone similar imaging profiles but who had low blood lead level (BLL) were enrolled as controls. RESULTS: We evaluated a total of 79 cases and 79 controls with median [IQR] BLLs of 126 [97.4, 160] µg/dL and 8.7 [5.5, 15] µg/dL. All cases and eleven controls (13.9%) were addicted to oral opium, and of these cases, anemia (94.9%) and abdominal pain (92.4%) were the two most common clinical manifestations. Two radiologists reviewed the X-ray and non-contrast CTs. Fifty (63.3%) and 53 (67.1%) cases and controls underwent CT scanning with 34 (68%) vs. 6 (11.3%) positive CTs (P < 0.001) while 43 (54.4%) and 39 (43.3%) underwent X-rays with 21 (48.8%) vs. 4 (11.8%) positive X-rays, respectively (P < 0.001). Positive CT is associated with BLL between 10 and 45 µg/dL with a specificity of 96.9%, 88.7% and positive predictive value of 97.5% and 85% respectively. CONCLUSIONS: In suspected cases of lead exposure due to ingested opium, and if BLL is not readily available, a positive imaging result may guide radiologists and physicians to consider lead poisoning.