Pain Management of Patients with Substance Abuse in the Ambulatory Setting.

PURPOSE OF REVIEW: Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction. RECENT FINDINGS: Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient's outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate NSAIDs, tricyclics, gabapentinoids, anticonvulsants, opioid tapering, and regional anesthesia can help alleviate high postoperative pain control requirements. In conjunction with such medication management, setting realistic expectations for pain control with preoperative counseling may be highly beneficial. For postoperative pain refractory to other strategies, the use of inpatient low-dose ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated pain service.

Perioperative Complications in Patients with Systemic Sclerosis: A Comparative Cohort Analysis.

Background: Systemic sclerosis (SSc) is a rare autoimmune disorder with pathological manifestations affecting multiple organ systems. Few studies have examined perioperative outcomes in patients with this disorder. The primary aim of this retrospective single-center comparative cohort analysis was to estimate the incidence of select perioperative complications in a population of SSc patients. In an exploratory analysis, we analyzed the relationship between SSc and susceptibility to select perioperative complications when treated at a large quaternary-care institution. Methods: We conducted a single-center retrospective, comparative cohort study to compare perioperative outcomes in a SSc (n=258) and a frequency matched control cohort (n=632). We analyzed for the presence of major composite infection (MCI), major adverse cardiac events (MACE), 30-day readmission, 30-day mortality, in-hospital complications, length of stay and airway management outcomes. Results: MCI was higher in the SSc compared to the control cohort [adjusted odds ratio (ORadj)=5.02 (95%CI: 2.47-10.20) p<0.001]. Surgical site infection (3.5% vs. 0%, p<0.001), and other infection types (5% vs. 0%, p<0.001) were higher in the SSc cohort. MACE was not significantly different between SSc vs. Control groups [6.2% vs. 7.9%, ORadj=1.33 (95%CI: 0.61-2.91) p=0.48]. Higher rates of limited cervical range of motion (13.6% vs. 3.5%, p<0.001), microstomia (11.5% vs. 1.3%, p<0.001) and preoperative difficult airway designation (8.7% vs. 0.5%, p<0.001) were observed in the SSc cohort. Bag mask ventilation grade was similar between groups (p=0.44). After adjustment, there was no between-group difference in Cormack-Lehane grade 3 and 4 view on direct laryngoscopy in SSc patients [ORadj = 1.86 (95%CI: 0.612 -5.66) p=0.18] but evidence of higher rates of video laryngoscopy [ORadj= 1.87 (95%CI:1.07 - 3.27) p=0.03]. Length of stay [median: 0.2 vs. 0.3 days, p=0.08], 30-day mortality [1.2% vs. 0.6%, ORadj=2.79 (95%CI: 0.50-15.6) p=0.24] and readmission [11.5% vs. 8.1%, ORadj=1.64 (95%CI: 0.96 - 2.82) p=0.07] were not statistically significant. Conclusions: SSc patients demonstrate mostly similar rates of MACE, 30-day mortality, length of stay intraoperative and airway complications. There is evidence of increased risk of overall 30-day MCI risk and readmission after endoscopic procedures.

Acute pain in undergraduate medical education: an unfinished chapter!

Inadequately treated acute pain is a global healthcare problem that causes significant patient suffering and disability, risk of chronicity, increased resource utilization, and escalating healthcare costs. Compounding the problem is the lack of adequate instruction in acute pain management available in medical schools worldwide. Incorporating acute pain diagnosis and management as an integral part of the medical school curriculum will allow physicians to develop a more comprehensive, compassionate approach to treating patients with acute pain syndromes and should be considered a healthcare imperative. In this article, we review the current status of pain education in educational institutions across the world, focusing on achievements, lacunae, and inadequacies. We appeal to all concerned--pain management specialists, health educators, and policymakers--to consider incorporating education on acute pain and its management at undergraduate medical levels in an integrated manner.

COVID-19 Impact on Resident Mental Health and Well-Being.

Columbia University's Papper Symposium, a virtual event held on March 20, 2021, was dedicated to the coronavirus disease-2019 (COVID-19) pandemic. This article summarizes a lecture by Dr. Roberta Hines, Nicholas M. Greene Professor of Anesthesiology and Department Chair and Chief of Anesthesiology at Yale-New Haven Hospital titled "The impact of COVID-19 on trainees: lessons learned and unanticipated opportunities," in addition draws from experiences at Columbia University Irving Medical Center and a focused review of the literature on the toll of the pandemic on trainee well-being and mental health. Early research has demonstrated that rates of burnout and acute stress were higher among health care providers who cared for COVID-19 patients than those who did not and that COVID-19 frontline health care providers are at high risk for common psychological disorders, including depression, anxiety, and post-traumatic stress disorder. Trainees working on the frontlines may be at particularly high risk for these mental health disorders and are less likely to access resources available to them. Program directors and hospital graduate medical education leaders should be aware of the threats to physiological and psychological safety and take action to prevent further detrimental effects. The rates of burnout and mental health disorders among trainees are expected to rise as a result of the pandemic, making screening programs and increased access to mental health treatment an essential feature of all residency and fellowship programs.

The Impact of COVID-19 on Trainees: Lessons Learned and Unanticipated Opportunities.

Dr. Emanuel Martin Papper was a Professor and Department Chair at Columbia University whose top passion was training the next generation of anesthesiologists. As such, a fitting topic for discussion at Columbia University Department of Anesthesiology's Papper Symposium was the "The Impact of the COVID-19 Pandemic on Trainees: Lessons Learned and Unanticipated Opportunities," presented by Dr. Roberta L. Hines, Nicholas M. Greene Professor of Anesthesiology and Department Chair and Chief of Anesthesiology at Yale-New Haven Hospital. The pandemic led to abrupt changes at the national, hospital, and training program levels, all of which impacted trainees in anesthesiology and other disciplines. Nationally, there were sweeping regulatory changes that helped to shape the coronavirus disease-2019 response by medical front line workers. At each individual hospital, coronavirus disease-2019 units were created and teams were restructured to keep up with patient care demands. Educational programs adapted their curricula and trainees lost valuable clinical and academic opportunities. The innovative educational responses, including a pivot to virtual learning and virtual recruitment, provided a silver lining to the health care crisis. Another bright spot was that anesthesiology as a specialty rose to the forefront of patient care. Anesthesiologists displayed impactful leadership during the pandemic, paving the way for future growth and broadened reach of our specialty.

Activation of complement factor B contributes to murine and human myocardial ischemia/reperfusion injury.

The pathophysiology of myocardial injury that results from cardiac ischemia and reperfusion (I/R) is incompletely understood. Experimental evidence from murine models indicates that innate immune mechanisms including complement activation via the classical and lectin pathways are crucial. Whether factor B (fB), a component of the alternative complement pathway required for amplification of complement cascade activation, participates in the pathophysiology of myocardial I/R injury has not been addressed. We induced regional myocardial I/R injury by transient coronary ligation in WT C57BL/6 mice, a manipulation that resulted in marked myocardial necrosis associated with activation of fB protein and myocardial deposition of C3 activation products. In contrast, in fB-/- mice, the same procedure resulted in significantly reduced myocardial necrosis (% ventricular tissue necrotic; fB-/- mice, 20 ± 4%; WT mice, 45 ± 3%; P < 0.05) and diminished deposition of C3 activation products in the myocardial tissue (fB-/- mice, 0 ± 0%; WT mice, 31 ± 6%; P<0.05). Reconstitution of fB-/- mice with WT serum followed by cardiac I/R restored the myocardial necrosis and activated C3 deposition in the myocardium. In translational human studies we measured levels of activated fB (Bb) in intracoronary blood samples obtained during cardio-pulmonary bypass surgery before and after aortic cross clamping (AXCL), during which global heart ischemia was induced. Intracoronary Bb increased immediately after AXCL, and the levels were directly correlated with peripheral blood levels of cardiac troponin I, an established biomarker of myocardial necrosis (Spearman coefficient = 0.465, P < 0.01). Taken together, our results support the conclusion that circulating fB is a crucial pathophysiological amplifier of I/R-induced, complement-dependent myocardial necrosis and identify fB as a potential therapeutic target for prevention of human myocardial I/R injury.

Patient considerations in the use of tapentadol for moderate to severe pain.

Poorly controlled acute and chronic pain can increase morbidity, impair quality of life and prolong disability. Over 80 percent of post surgical patients report moderate to severe uncontrolled postoperative pain. Over-reliance on potent opioid agonists can lead to several opioid related side effects such as gastrointestinal intolerability, respiratory depression and cognitive impairment. A recently approved dual acting central analgesic tapentadol may offer improved tolerability over traditional opioid agonists while having multimodal opioid and nonopioid analgesic benefits. Tapentadol, classified by the US Food and Drug Administration as a class 2 opioid, is currently marketed in the United States as immediate release (IR) NUCYNTA® for moderate to severe acute pain in tablets of 50 mg, 75 mg, and 100 mg, and as extended release (ER) NUCYNTA ER® for the treatment of chronic moderate to severe pain in tablets of 50 mg, 100 mg, 150 mg, 200 mg, and 250 mg. Tapentadol is a low affinity mu opioid receptor agonist and a norepinephrine reuptake inhibitor. Tapentadol has no active metabolites and this property makes it useful in patients with hepatic and renal failure. Clinical trials with tapentadol IR showed that there was improved gastrointestinal tolerability and similar pain relief as compared to oxycodone IR. Tapentadol ER allows for twice daily dosing. Clinical trials showed that tapentadol ER could effectively relieve moderate to severe chronic pain and was associated with significantly fewer gastrointestinal adverse effects as compared to oxycodone controlled release. Tapentadol ER is indicated and has Food and Drug Administration approval for the treatment of chronic painful diabetic neuropathy. The most common side effects of tapentadol are nausea (30%), vomiting (18%), dizziness (24%), and somnolence (15%). Tapentadol, due to its potential synergistic effects on norepinephrine levels, is contraindicated in patients who have taken monoamine oxidase inhibitors within the last 14 days. Caution has to be exercised with the use of tapentadol IR and tapentadol ER in the presence of other central nervous system depressants such as neuroleptics, opioids, illicit drugs, muscle relaxants, sedatives, and anxiolytics.

Peripheral opioid receptor agonists for analgesia: a comprehensive review.

BACKGROUND: It is established that opioid receptors are present in the dorsal root ganglia and the central as well as peripheral terminals ofprimary afferent neurons. Now, it has been shown that peripheral terminals of afferent nerves can be the sites of the intrinsic modulation of nociception and that opioid analgesia can be mediated by peripheral opioid receptors as well. AIM: This review focuses on two areas: the first on describing the peripheral opioidergic system, and the second on the review of the current state of development of peripherally active opioid receptor agonists with theirpotential clinical applications. METHODS: Online and manual search using key words such as peripheral opioid receptors, peripheral (or peripherally restricted) opioid agonists, and peripheral mu-, kappa-, and delta-opioid receptor agonists, followed by full-text access and further cross-referencing. RESULTS: The obvious theoretical advantage of using these molecules is that analgesia is achieved while avoiding the bothersome-to-dangerous centrally mediated adverse effects of centrally acting opioids. Molecules knownum for their central action (e.g.,, morphine) have been used in peripheral tissues (joints, bone, teeth) with reasonable but varied success. Over the last 10-15 years, several molecules with peripherally restricted opioid agonist activity have been developed and several more are in the "clinical pipeline. "Although none is available as an approved medication till date, a few (e.g.; the peripherally restricted kappa-agonist FE200665, also known as CR665) have completed phase I clinical trials and currently in phase II. Others such as loperamide, which is approved for use as an antidiarrheal drug, have been found to be variably useful as a peripherally acting opioid analgesic. CONCLUSIONS: Substantive research is currently underway and this is an exciting research area for both basic and applied clinical fields. Various ways to enhance peripheral opioid analgesia are suggested.

Management of chronic pain in the elderly: focus on transdermal buprenorphine.

Chronic pain in the elderly is a significant problem. Pharmacokinetic and metabolic changes associated with increased age makes the elderly vulnerable to side effects and overdosing associated with analgesic agents. Therefore the management of chronic cancer pain and chronic nonmalignant pain in this growing population is an ongoing challenge. New routes of administration have opened up new treatment options to meet this challenge. The transdermal buprenorphine matrix allows for slow release of buprenorphine and damage does not produce dose dumping. In addition the long-acting analgesic property and relative safety profile makes it a suitable choice for the treatment of chronic pain in the elderly. Its safe use in the presence of renal failure makes it an attractive choice for older individuals. Recent scientific studies have shown no evidence of a ceiling dose of analgesia in man but only a ceiling effect for respiratory depression, increasing its safety profile. It appears that transdermal buprenorphine can be used in clinical practice safely and efficaciously for treating chronic pain in the elderly.

Buprenorphine: a unique opioid with broad clinical applications.

The analgesic potential of buprenorphine, a high-affinity partial mu agonist, has been a subject of study for several decades. The drug is now widely recognized as being extremely effective in relieving perioperative pain, with little of the addictive potential or risk associated with pure I agonists. Studies have suggested that buprenorphine produces adequate analgesia via almost any route of administration, including transdermal and subcutaneous. It has also been used, with positive results, in the treatment of opioid addiction, and potential remains for research into other roles, e.g., as an anti-inflammatory agent or an antihyperalgesic medication.

A case series of low-dose fenoldopam in seventy cardiac surgical patients at increased risk of renal dysfunction.

OBJECTIVE: To evaluate the usefulness of low-dose fenoldopam mesylate in patients at risk of developing renal dysfunction after cardiac surgery requiring cardiopulmonary bypass. DESIGN: A prospective, single-center, observational study. SETTING: University teaching hospital. PARTICIPANTS: Seventy patients scheduled for elective cardiac surgery with one or more predefined risk factors for renal dysfunction. INTERVENTIONS: After induction of anesthesia, fenoldopam (0.03 microg/kg/min) was administered throughout surgery and into the postoperative period, until the patient was stable and weaned from all other vasoactive agents. Perioperatively, fenoldopam was also used as a second-line antihypertensive agent as required. MEASUREMENTS AND MAIN RESULTS: No patient developed renal failure that required dialysis, whereas 7.1% (5/70) developed non-dialysis-dependent renal dysfunction. Four out of these 5 patients had 2 or more risk factors (9.5%). Higher preoperative creatinine levels, a history of hypertension, myocardial infarction within 5 days of surgery, and a preoperative diagnosis of chronic renal insufficiency were all good predictors of postoperative non-dialysis-dependent renal dysfunction. Discharge serum creatinine levels were lower than preoperative levels (1.16 +/- 0.36 mg/dL v 1.26 +/- 0.34 mg/dL, p < 0.05). CONCLUSION: These findings suggest that renal function was preserved in patients at increased risk for renal dysfunction after cardiac surgery when low-dose fenoldopam was used in the perioperative period. However, a randomized, controlled trial is required to establish efficacy.

Faculty and finances of United States anesthesiology training programs: 2002-2003.

Between February, 2000 and August, 2002 three surveys have been submitted to the program directors of the anesthesiology training programs in the United States (U.S.) to assess the departments' needs for faculty and financial support from their institutions. In this article we present the results of a fourth follow-up survey. This survey also asked questions regarding the need for additional support to meet the new 80-h workweek resident requirement and asked the average academic time offered to faculty. The average department has 40 faculty members with 3.7 open faculty positions in the 78% of departments with open positions. Only 25% of the departments planned to add personnel to comply with the 80-h resident workweek. Fifty-one percent of the departments had a positive financial margin of 15,908 dollars/full-time equivalent (FTE) faculty anesthesiologist (faculty FTE), whereas 34% had a negative margin of 42,603 dollars/faculty FTE. The overall institutional support was 85,607 dollars/faculty FTE, which is a 43% increase over the previous year. The average academic time provided to faculty was 13.8%, a decline from 20% in 2000. Twenty-five percent of departments have closed an anesthetizing location as a result of a lack of faculty in 2003. Open faculty positions in U.S. training programs have remained fairly constant at 8% to 10% from 2000 to 2003. Institutional support for training departments has more than doubled since 2000, reaching approximately 85,000 dollars/faculty in 2003.

Mannitol and dopamine in patients undergoing cardiopulmonary bypass: a randomized clinical trial.

UNLABELLED: In this prospective, randomized, placebo-controlled, double-blinded study, we determined the effects of two commonly used adjuncts, mannitol and dopamine, on beta(2)-microglobulin (beta(2)M) excretion rates in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass (CPB). beta(2)M excretion rate has been described as a sensitive marker of proximal renal tubular function. One-hundred patients with a preoperative serum creatinine level