Alcohol use disorder in the perioperative period: a summary and recommendations for anesthesiologists and pain physicians.

Excessive alcohol consumption and alcohol use disorder (AUD) increase the risk of perioperative morbidity and mortality. Aspiration, malnutrition, coagulopathies, seizures, and hemodynamic alterations are only a few of the major concerns related to acute alcohol intoxication and AUD. There are also numerous physiological effects, changes in medication metabolism and pharmacology, and adverse events related to chronic alcohol consumption. These are all important considerations for the anesthesiologist in the perioperative management of a patient with AUD. Pain perception and thresholds are altered in patients with acute and chronic alcohol use. Medications used to manage AUD symptoms, particularly naltrexone, can have significant perioperative implications. Patients on naltrexone who continue or stop this medication in the perioperative period are at an increased risk for undertreated pain or substance use relapse. This review highlights key considerations for the anesthesiologist and pain physician in the perioperative management of patients with active AUD (or those in recovery). It discusses the effects of acute and chronic alcohol use on pain perception and thresholds, provides guidance on the perioperative management of naltrexone and low-dose naltrexone, and reviews a multimodal approach to pain management.

Common street drug names for the anesthesiologist and pain physician.

People who use or sell drugs develop their own in-group terms and language, much like any other group of people with a common experience. Slang terms are derived from a wide variety of sources. These might include the physical appearance and/or type of drug, the place where it originates, the effect it has on users, or how it is packaged for sale. To assist and educate the clinical practitioner who may deal with this nomenclature, we have compiled a list of some of the most common street names and some explanations (when known) of their origins.

Violence in the pain clinic: the hidden pandemic.

Workplace violence is any physical assault, threatening behavior or other verbal abuse directed toward persons at work or in the workplace. The incidence of workplace violence in healthcare settings in general and more specifically the pain clinic is thought to be underestimated due to hesitancy to report, lack of support from management and healthcare systems, and lack of institutional policies as it relates to violence from patients against healthcare workers. In the following article, we explore risk factors that place clinicians at risk of workplace violence, the cost and impact of workplace violence, how to build a violence prevention program and lastly how to recover from violence in the practice setting.

Identifying Barriers to Buprenorphine Treatment for Patients with Opioid Use Disorder Among Anesthesiologists and Pain Practitioners: A Survey Study.

OBJECTIVE: The aim of the study is to investigate barriers to opioid use disorder (OUD) care among acute and chronic pain physicians and advanced practice providers, including hypothesized barriers of lack of interest in OUD care and stigma toward this patient population. METHODS: The study used an anonymous 16-item online survey through Google Forms. Respondents were 153 health practitioners across the United States and Canada, all of whom are registered in one of several pain or anesthesia professional societies. Data were analyzed with descriptive and categorical statistics. RESULTS: The most common barriers include "lack of appropriate clinical environment for prescribing by both acute and chronic pain practitioners" (48%) and "lack of administrative/departmental support" (46%). A total of 32% of respondents reported that OUD care was important but they were not interested in doing more, while 28% of practitioners believed that they treat patients with OUD differently than others in a negative way. More males reported "difficulty" in treating OUD as a barrier (45% vs 25%). Chronic pain practitioners reported poor payor mix as a barrier twice as often as their acute pain colleagues. In free response, lack of multidisciplinary OUD care was a notable barrier. CONCLUSIONS: The top barriers to OUD treatment were clinical environment, departmental support, difficulty in treating the condition, and payor mix, supporting the hypotheses. Given an OUD patient scenario, 55% of acute pain physicians and 73% of chronic pain physicians expressed a willingness to prescribe buprenorphine.

Chronic Pain, Opioid Use Disorder, and Clinical Management Among Older Adults.

Because of unique factors related to physiological changes and altered metabolism in advanced age, special attention is needed concerning chronic pain, opioid use, and opioid use disorder among older adults. Clinicians need to follow the most updated clinical guidelines regarding opioid prescribing. Routine screening and awareness are the keys to identifying opioid use disorder. Comprehensive assessments often require both pain assessment (including functional status) and substance use assessment, including the use of urine toxicological testing and structured, validated screening tools and instruments. Comprehensive, interdisciplinary efforts are critical in managing the care of older adults with chronic pain and opioid use disorder. A collaborative approach that includes substance abuse treatment and pain management (including pain subspecialty care) is often recommended. Medications for opioid use disorder have been extensively studied and have the most convincing evidence to date, and psychosocial treatments may be beneficial in some circumstances.

Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel.

BACKGROUND: The past two decades have witnessed an epidemic of opioid use disorder (OUD) in the USA, resulting in catastrophic loss of life secondary to opioid overdoses. Medication treatment of opioid use disorder (MOUD) is effective, yet barriers to care continue to result in a large proportion of untreated individuals. Optimal analgesia can be obtained in patients with MOUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected OUD at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives. METHODS: The Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, American Academy of Pain Medicine, American Society of Addiction Medicine and American Society of Health System Pharmacists approved the creation of a Multisociety Working Group on Opioid Use Disorder, representing the fields of pain medicine, addiction, and pharmacy health sciences. An extensive literature search was performed by members of the working group. Multiple study types were included and reviewed for quality. A modified Delphi process was used to assess the literature and expert opinion for each topic, with 100% consensus being achieved on the statements and each recommendation. The consensus statements were then graded by the committee members using the United States Preventive Services Task Force grading of evidence guidelines. In addition to the consensus recommendations, a narrative overview of buprenorphine, including pharmacology and legal statutes, was performed. RESULTS: Two core topics were identified for the development of recommendations with >75% consensus as the goal for consensus; however, the working group achieved 100% consensus on both topics. Specific topics included (1) providing recommendations to aid physicians in the management of patients receiving buprenorphine for MOUD in the perioperative setting and (2) providing recommendations to aid physicians in the initiation of buprenorphine in patients with suspected OUD in the perioperative setting. CONCLUSIONS: To decrease the risk of OUD recurrence, buprenorphine should not be routinely discontinued in the perioperative setting. Buprenorphine can be initiated in untreated patients with OUD and acute pain in the perioperative setting to decrease the risk of opioid recurrence and death from overdose.

Clinical Manifestations and Diagnostic Evaluation of Opioid Allergy Labels - A Review.

While opioids represent one of the most common medication allergy labels, these labels are often unsubstantiated in clinical practice. The removal of erroneous opioid allergy labels has a unique importance in the population with acute or chronic pain. The current approach to patients with pseudo-allergy to opioids is switching to an alternative opioid with less histamine release. Thus, allergy labels to relatively lower potency opioids such as codeine may be feasibly result in the prescription of stronger medications like fentanyl that would otherwise not be indicated.This narrative review provides an overview of the epidemiology and clinical manifestations of opioid allergy labels commonly encountered by pain management practitioners along with recommendations for evaluation and management.A literature search of PubMed was performed using the comprehensive MeSH term, "Opioid Allergy".In recent years, it has become apparent that a substantial proportion of patients labeled as opioid allergic are found to be tolerant of these agents. Opioid skin testing and IgE assays are of limited application. DPT is the yet underutilized gold standard for diagnosis. There is also an increasing call for studies evaluating basophil activation testing in opiate allergy.Opioid allergy labels require a closer look especially in view of the current opioid epidemic. The low likelihood of true reactivity, combined with the conceivable clinical relevance of an opioid allergy label, calls for further characterization of this label in populations with acute or chronic pain diagnoses. Future directions should include larger prospective studies with systematic evaluation and classification of opioid allergy labels to determine future viability of opioid use.AbbreviationsEHRelectronic health recordNMBAneuromuscular blocking agentIgEimmunoglobulin EMCmast cellGPCRG-protein coupled receptorMRGPRX2mas-related G-protein receptorQAIquaternary ammonium ionsSCARsevere cutaneous adverse reactionAGEPacute generalized exanthematous pustulosisSDRIFEsymmetrical drug-related intertriginous and flexural exanthemaBATbasophil activation testingDPTdrug provocation testing.