Magnesium sulfate enhances the effect of the peripheral analgesic cocktail in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

Purpose: Although magnesium sulfate (MgSO4) is widely used as an analgesic adjuvant to peripheral analgesic cocktails, its efficacy in total knee arthroplasty (TKA) is still controversial. Therefore, we systematically reviewed and meta-analyzed the literature to assess the analgesic efficacy of MgSO4 as an adjuvant to the analgesic cocktail in TKA. Methods: The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched. The meta-analysis was performed according to the PRISMA guidelines. Data were qualitatively synthesized or meta-analyzed using a random-effects model. Results: Five randomized controlled trials involving 432 patients were included. Meta-analyses detected significant differences between the MgSO4 and control groups in the visual analog scale (VAS) pain scores (rest) at 6, 12, and 24 h postoperatively; VAS pain scores (motion) at 12, 24, and 48 h postoperatively; morphine consumption within 24 h, 24-48 h, and during the total hospitalization period; time to first rescue analgesia after TKA; and length of hospital stay. Regarding the functional recovery, the meta-analysis demonstrated significant differences between groups in terms of knee range of motion on postoperative day 1; daily mobilization distance on postoperative day 1; and daily mobilization distance. There was no significant intergroup difference in surgical complications. Conclusion: The findings suggest that MgSO4 is a promising adjunct to the analgesic cocktail, achieving significant improvements in pain scores and total opioid consumption during the early postoperative period after TKA.

Medial prefrontal neuroplasticity during extended-release naltrexone treatment of opioid use disorder - a longitudinal structural magnetic resonance imaging study.

Opioid use disorder (OUD) has been linked to macroscopic structural alterations in the brain. The monthly injectable, extended-release formulation of µ-opioid antagonist naltrexone (XR-NTX) is highly effective in reducing opioid craving and preventing opioid relapse. Here, we investigated the neuroanatomical effects of XR-NTX by examining changes in cortical thickness during treatment for OUD. Forty-seven OUD patients underwent structural magnetic resonance imaging and subjectively rated their opioid craving ≤1 day before (pre-treatment) and 11 ± 3 days after (on-treatment) the first XR-NTX injection. A sample of fifty-six non-OUD individuals completed a single imaging session and served as the comparison group. A publicly available [¹¹C]carfentanil positron emission tomography dataset was used to assess the relationship between changes in cortical thickness and µ-opioid receptor (MOR) binding potential across brain regions. We found that the thickness of the medial prefrontal and anterior cingulate cortices (mPFC/aCC; regions with high MOR binding potential) was comparable between the non-OUD individuals and the OUD patients at pre-treatment. However, among the OUD patients, mPFC/aCC thickness significantly decreased from pre-treatment to on-treatment. A greater reduction in mPFC/aCC thickness was associated with a greater reduction in opioid craving. Taken together, our study suggests XR-NTX-induced cortical thickness reduction in the mPFC/aCC regions in OUD patients. The reduction in thickness does not appear to indicate a restoration to the non-OUD level but rather reflects XR-NTX's distinct therapeutic impact on an MOR-rich brain structure. Our findings highlight the neuroplastic effects of XR-NTX that may inform the development of novel OUD interventions.

Perioperative pain management interventions in opioid user patients: an overview of reviews.

BACKGROUND: Every year, many opioid users undergo surgery, experiencing increased postoperative complications, inadequate pain control, and opioid-related adverse effects. This overview aims to summarise and critically assess the systematic reviews about perioperative pain management interventions, identify the knowledge gaps, and potentially provide high-quality recommendations to improve postoperative analgesia and surgical outcomes. METHODS: A systematic search was conducted from the following databases, PubMed, Cochrane Database of Systematic Reviews, Embase, APA PsycINFO, CINAHL, AMED, Scopus, PROSPERO, ProQuest, and Epistemonikos, in June 2023. Additionally, reference lists were reviewed. The identified studies were assessed based on eligibility criteria and data extracted by a self-designed form and two independent reviewers. Qualitative data were synthesised, and all included studies were assessed by The Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) checklist. RESULTS: Nine studies were included. The methodological quality of the studies was mostly critically low. Various interventions were identified, including perioperative management of buprenorphine, ketamine administration, multimodal analgesia, higher doses of medications, patient education, and interprofessional collaboration. The level of certainty of the evidence ranged from very low to high. One high-quality study showed that ketamine administration may improve perioperative analgesia supported with moderate to very low-quality evidence, and low and critically low studies indicated the efficacy of perioperative continuation of buprenorphine with low to very low-quality evidence. CONCLUSION: Perioperative continuation of buprenorphine and ketamine administration as a multimodal analgesia approach, with moderate to very low-quality evidence, improves pain management in opioid users and decreases opioid-related adverse effects. However, high-quality systematic reviews are required to fill the identified gaps in knowledge.

Perioperative pain management intervention in older patients with hip fracture in an orthogeriatric unit. A controlled before/after study assessing an audit and feedback intervention (PAIN-AGE).

BACKGROUND: Postoperative pain delays ambulation, extends hospital stay, reduces the probability of recovery, and increases risk of long-term functional impairment. Pain management in hip fractured patients poses a challenge to the healthcare teams. Older adults are more vulnerable to opioid-associated side effect and it is primordial to minimize their exposure to opioids. Acetaminophen is associated with reduced opioid use so we need to focus on acetaminophen use in first-line analgesia. METHODS: We conducted a controlled before/after study to assess the ability of an audit and feedback (A&F) intervention built with nurses to improve the quality of perioperative pain management in older patients hospitalized for hip fracture in an orthogeriatric unit (experimental group) versus a conventional orthopedic unit (no A&F intervention). The primary endpoint was the percentage of patients who received 3 g/day of acetaminophen during the three postoperative days, before and after the A&F intervention. Secondary endpoints included nurses' adherence to medical prescriptions, clinical data associated with patients and finally factors associated with intervention. The significative level was set at 0.05 for statistical analysis. RESULTS: We studied data from 397 patients (mean age 89 years, 75% female). During the postoperative period, 16% of patients from the experimental group received 3 g/day of acetaminophen before the A&F intervention; the percentage reached 60% after the intervention. The likelihood of receiving 3 g/day of acetaminophen during the postoperative period and adhering to the medical prescription of acetaminophen were significantly increased in the experimental group as compared with the control group. The patient's functional status at discharge (assessed by Activities of Daily Living scores) was significantly better and the length of hospital stay significantly reduced after the A&F intervention. CONCLUSION: Our controlled before/after study showed that an A&F intervention significantly improved perioperative pain management in older adults hospitalized for hip fracture. Involving teams in continuous education programs appears crucial to improve the quality of pain management and ensure nurses' adherence to medical prescriptions.

Disparities in Medication Use for Criminal Justice System-Referred Opioid Use Disorder Treatment.

Importance: Individuals with opioid use disorder (OUD) and criminal justice system involvement experience high rates of overdose death. Historical data point to limited use of medications for opioid use disorder (MOUD) in criminal justice system-referred treatment for OUD as playing a role. However, how MOUD use among those referred to treatment by the criminal justice system has changed relative to other referral sources over time is still unclear, as well as how it varies across states. Objective: To examine disparities in the use of MOUD between individuals referred to treatment by the criminal justice system compared to other referral sources over time. Design, Setting, and Participants: This cross-sectional study included admissions to specialty substance use treatment facilities for OUD in the national Treatment Episodes Dataset-Admissions from 2014 to 2021. Logistic regression models were used to examine trends in the probability of MOUD use among individuals with and without criminal justice referrals for OUD treatment, as well as any differential trends by state. The data were analyzed from September 2023 to August 2024. Main Outcome and Measure: The main outcome was the probability that treatment for individuals with OUD included MOUD. Results: A total of 3 235 445 admissions were analyzed in the study data. Among individuals referred to OUD treatment by the criminal justice system, the probability that treatment included MOUD increased by 3.42 percentage points (pp) (95% CI, 3.37 pp to 3.47 pp) annually from 2014 to 2021. This was faster than the increase in the probability of MOUD use for noncriminal justice-referred admissions (2.49 pp [95% CI, 2.46 pp to 2.51 pp) and reduced, but did not eliminate, disparities in MOUD use between individuals with and without criminal justice system-referred treatment. In 2021, only 33.6% of individuals in criminal justice system-referred treatment received MOUD, 15.6 pp lower than for individuals referred to treatment by other sources. Trends in the probability of MOUD use varied substantially for individuals in criminal justice system-referred treatment across states, but very few experienced enough growth to eliminate this disparity. Conclusions and Relevance: The results of this cross-sectional study suggest that targeted efforts to address persistent disparities in MOUD use among those with OUD and criminal justice system involvement are needed to address the poor health outcomes experienced by this population.

Knowledge of medications for opioid use disorder and associated stigma among primary care professionals.

BACKGROUND: Medications for opioid use disorder (MOUD) are the gold standard. However, significant barriers limit their use in the primary care setting, including limited knowledge of the medications and stigmatizing attitudes. In this study, we assess knowledge levels among primary care-aligned professionals (PCPs) currently in practice, and whether knowledge of MOUD is associated with stigma and treatment attitudes. PARTICIPANTS AND METHODS: Using rosters from the state of Ohio licensing boards, we surveyed 403 physicians, nurse practitioners, and physician associates in 2022, on the mechanism of different MOUD, as well as stigma and treatment attitudes. To assess MOUD knowledge, we employed descriptive and bivariate statistics. We fit four linear regression models, which controlled for empathy towards patients with OUD and provider demographics to assess the relationship between MOUD knowledge and four endpoints: stigma, perceived controllability of opioid use, perceived vulnerability to opioid use disorder, and support for abstinence-only treatment. RESULTS: 43% of participants correctly identified the mechanism of all 3 medications whereas 13% of participants did not identify the mechanism of any MOUD correctly. MOUD knowledge was higher among physicians as compared to nurse practitioners and physician associates. Lower MOUD knowledge was associated with more negative attitudes towards patients with OUD and MOUD treatment. CONCLUSION: Expanding access to MOUD treatment requires a trained and willing health-care professional (HCP) workforce. Our findings highlight considerable variation in clinician knowledge of MOUD and suggest that knowledge levels are also related to negative attitudes towards patients with OUD and MOUD. Training interventions that increase knowledge, as well as focus on stigma reduction, are critical for reducing the longstanding treatment gap for opioid use disorder.

Differences in toxicology reports and hospital emergency care for patients suspected of experiencing drug-facilitated crimes: an analysis according to gender. / Atención de pacientes con sospecha de sumisión química en un servicio de urgencias hospitalario y resultados del análisis toxicológico: diferencias según el sexo.

OBJECTIVE: To analyze gender-related differences in patient and care characteristics and in toxicology findings in suspected cases of drug facilitated crime (DFC). METHODS: Observational cross-sectional study of all patients in suspected DFC cases attended in the emergency department of Hospital Clínico San Carlos and of their blood or urine samples analyzed by the National institute of Toxicology and Forensics in Madrid between March 1, 2015, and March 1, 2023. We analyzed variables from patient records and the toxicology reports according to gender. RESULTS: A total of 514 suspected DFC episodes were studied; 101 (19.6%) were proactive crimes, 61 (11.9%) opportunistic, and 352 (68.5%) mixed. The median (interquartile range) age was 25 years (21-34 years), and 370 (72%) were women. Eighty-three percent of the patients had amnesia, and 48% of the cases involved sexual assault or robbery. Toxicology identified substances in 78% of the patients (alcohol, 53%; street drugs, 37%; and/or psychopharmaceuticals or opioids, 23%). Independent variables associated with female gender in the multivariate analysis, according to adjusted odds ratio (aORs) were age less than 25 years (aOR, 2.73; 95% CI, 1.75 4.24; P < .001); physician-referred emergency (aOR, 1.77; 95% CI, 1.12-2.80; P = .03); robbery (aOR, 0.25; 95% CI, 0.15-0.41; P < .001); alcohol-positive test result (aOR, 1.91; 95% CI, 1.21-3.00; P = .01); and a drug-positive result (aOR, 0.43; 95% CI, 0.28-0.64; P < .001). Police and a forensic physician intervened in 13% of the cases, and in such cases the victim was more likely to be female (aOR, 3.97; 95% CI, 1.41-11.13; P < .001). Toxicology identified the presence of an unknown substance in 39%, and a woman was less likely to be involved in such cases (aOR, 0.43; 95% CI, 0.28-0.67; P < .001). CONCLUSIONS: The majority of victims of DFCs were female, and the crimes were mixed, involving involve alcohol, psychopharmaceuticals or street drugs. Female victims were more likely to be under the age of 25 years, be referred to the emergency service by a physician, be attended by a forensic physician for sexual assault, and have an alcoholpositive toxicology report. Women were also less likely to report a robbery or have a toxicology report identifying drugs or an unknown substance.

OBJETIVO: Analizar las diferencias en las características de los pacientes atendidos por sospecha de sumisión química (SQ) y en los resultados del análisis toxicológico (AT) en función del sexo. METODO: Estudio observacional transversal retrospectivo que incluyó a todos los casos con SQ atendidos en el servicio de urgencias del Hospital Clínico San Carlos y las muestras (sangre o orina) para el AT en el Instituto Nacional de Toxicología y Ciencias Forenses de Madrid entre el 1 de marzo de 2015 y el 1 de marzo de 2023. Se analizan variables de la historia clínica y del AT según el sexo. RESULTADOS: Se incluyeron 514 episodios con sospecha de SQ [101 (19,6%) proactiva, 61 (11,9%) oportunista y 352 (68,5%) mixta] en pacientes con una mediana de 25 años (RIC: 21-34), 370 (72%) de sexo femenino. El 83% presentó amnesia y el 48% asoció agresión sexual o robo. En el 78% se identificó alguna sustancia en el AT (53% alcohol etílico, 37% drogas y/o 23% psicofármaco u opiáceos). En el análisis multivariado las variables que se asociaron de manera independiente con el sexo femenino fueron la edad menor de 25 años con ORa de 2,73 (IC 95%: 1,75-4,24; p < 0,001), con médico deriva a urgencias con ORa de 1,77 (IC 95%: 1,12-2,80; p = 0,03), delito de robo con de ORa 0,25 (IC 95%: 0,15-0,41; p < 0,001), alcohol etílico en el AT con ORa 1,91 (IC 95%: 1,21-3,00; p = 0,01) y alguna droga en el AT con ORa 0,43 (IC 95%: 0,28-0,64; p < 0,001). En el 13% de casos hubo intervención policial y médico-forense y fue más probable que fuera a una mujer, con ORa 3,97 (IC 95%: 1,41-11,13; p < 0,001). En el 39% de AT se identificó alguna sustancia desconocida y fue menos probable que fuera mujer, con ORa de 0,43 (IC 95%: 0,28-0,67; p < 0,001). CONCLUSIONES: La mayoría de casos registrados fueron mujeres con sospecha de SQ mixta por alcohol, psicofármacos o drogas de abuso. Las mujeres presentaron mayor probabilidad de tener menos de 25 años, ser derivada a urgencias por un médico, de intervención médico-forense por agresión sexual y encontrar alcohol etílico en el AT.

Drug Decriminalization, Fentanyl, and Fatal Overdoses in Oregon.

Importance: With the implementation of Measure 110 (M110) in 2021, Oregon became the first US state to decriminalize small amounts of any drug for personal use. To date, no analysis of the association of this law with overdose mortality has fully accounted for the introduction of fentanyl-a substance that is known to drive fatal overdose-to Oregon's unregulated drug market. Objective: To evaluate whether the decriminalization of drug possession in Oregon was associated with changes in fatal drug overdose rates after accounting for the rapid spread of fentanyl in Oregon's unregulated drug market. Design, Setting, and Participants: In this cohort study, the association between fatal overdose and enactment of M110 was analyzed using a matrix completion synthetic control method. The control group consisted of the 48 US states and Washington, DC, all of which did not decriminalize drugs. The rapid spread of fentanyl in unregulated drug markets was determined using the state-level percentage of all samples reported to the National Forensic Laboratory Information System that were identified as fentanyl or its analogues. Mortality data were obtained from the Centers for Disease Control and Prevention for January 1, 2008, to December 31, 2022. Data analysis was performed from fall 2023 through spring 2024. Exposures: Measure 110 took effect in Oregon on February 1, 2021. Main Outcomes and Measures: The primary outcome assessed was fatal drug overdose rates per half-year. A changepoint analysis also determined when each state experienced a rapid escalation of fentanyl in its unregulated drug market. Results: In this analysis, rapid spread of fentanyl in Oregon's unregulated drug supply occurred in the first half of 2021, contemporaneous with enactment of M110. A positive crude association was found between drug decriminalization and fatal overdose rate per 100 000 per half year (estimate [SE], 1.83 [0.47]; P < .001). After adjusting for the spread of fentanyl as a confounder, the effect size changed signs (estimate [SE], -0.51 [0.61]; P = .41) and there was no longer an association between decriminalization and overdose mortality in Oregon. Sensitivity analyses were consistent with this result. Conclusions and Relevance: In this cohort study of fatal drug overdose and the spread of fentanyl through Oregon's unregulated drug market, no association between M110 and fatal overdose rates was observed. Future evaluations of the health effects of drug policies should account for changes in the composition of unregulated drug markets.

Effect of oxycodone versus fentanyl for patient-controlled intravenous analgesia after laparoscopic hysteromyomectomy: a single-blind, randomized controlled trial.

A single-blind, randomized controlled trial comparing oxycodone and fentanyl for patient-controlled intravenous analgesia (PCIA) after laparoscopic hysteromyomectomy found comparable pain relief between the two groups. The study included 60 participants, with NRS scores for pain at rest and when moving showing no significant differences between oxycodone and fentanyl groups at various time points postoperatively. Self-rating depression scale scores were also similar between the groups at 48 h. However, patients' satisfaction with PCIA was higher in the oxycodone group, with 73.3% reporting being very satisfied compared to 36.7% in the fentanyl group. Additionally, the oxycodone group had fewer incidences of headaches within 48 h postoperatively compared to the fentanyl group. These findings suggest that oxycodone may offer comparable pain relief, higher patient satisfaction, and fewer headaches for patients undergoing laparoscopic hysteromyomectomy compared to fentanyl, making it a suitable option for postoperative pain management in this population.Clinical trial registration number The study was registered with CHICTR.org, ChiCTR2100051924.

Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol.

BACKGROUND: Opioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study. METHODS: This is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement. DISCUSSION: Most ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality. TRIAL REGISTRATION: ClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 - Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991 .

Association of Postnatal Opioid Exposure and 2-Year Neurodevelopmental Outcomes in Infants Undergoing Cardiac Surgery.

BACKGROUND: Opioids are commonly used to provide analgesia during and after congenital heart surgery. The effects of exposure to opioids on neurodevelopment in neonates and infants are not well understood. OBJECTIVES: This study sought to evaluate the associations between cumulative opioid exposure (measured in morphine mg equivalent) over the first year of life and 2-year neurodevelopmental outcomes (Bayley Scales of Infant and Toddler Development-Third/Fourth Edition [Bayley-III/IV] cognitive, language, and motor scores). METHODS: A single-center retrospective cohort study of infants undergoing congenital heart surgery was performed. Adjustment for measurable confounders was performed through multivariable linear regression. RESULTS: A total of 526 subjects were studied, of whom 32% underwent Society for Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 or 5 operations. In unadjusted analyses, higher total exposure to opioids was associated with worse scores across all 3 Bayley-III/IV domain scores (all P < 0.05). After adjustment for measured confounders, greater opioid exposure was associated with lower Bayley-III/IV scores (cognitive: ß = -1.0 per log-transformed morphine mg equivalents, P = 0.04; language: ß = -1.2, P = 0.04; and motor: ß = -1.1, P = 0.02). Total hospital length of stay, prematurity, genetic syndromes, and worse neighborhood socioeconomic status (represented either by Social Vulnerability Index or Childhood Opportunity Index) were all associated with worse Bayley-III/IV scores across all domains (all P < 0.05). CONCLUSIONS: Greater postnatal exposure to opioids was associated with worse neurodevelopmental outcomes across cognitive, language, and motor domains, independent of other less modifiable factors. This finding should motivate research and efforts to explore reduction in opioid exposure while preserving quality cardiac intensive care.

Evaluating fentanyl test strips as a harm reduction strategy in rural and urban counties: study protocol for a randomized controlled trial.

BACKGROUND: Opioid-related fatalities are a leading cause of death in Ohio and nationally, with an increasing number of overdoses attributable to fentanyl. Rapid fentanyl test strips can identify fentanyl and some fentanyl analogs in urine samples and are increasingly being used to check illicit drugs for fentanyl before they are used. Fentanyl test strips are a promising harm reduction strategy; however, little is known about the real-world acceptability and impact of fentanyl test strip use. This study investigates fentanyl test strip distribution and education as a harm reduction strategy to prevent overdoses among people who use drugs. METHODS: The research team will recruit 2400 individuals ≥ 18 years with self-reported use of illicit drugs or drugs purchased on the street within the past 6 months. Recruitment will occur at opioid overdose education and naloxone distribution programs in 16 urban and 12 rural Ohio counties. Participating sites will be randomized at the county level to the intervention or non-intervention study arm. A brief fentanyl test strip educational intervention and fentanyl test strips will be provided to participants recruited from sites in the intervention arm. These participants will be eligible to receive additional fentanyl test strips for 2 years post-enrollment. Participants recruited from sites in the non-intervention arm will not receive fentanyl test strip education or fentanyl test strips. All participants will be followed for 2 years post-enrollment using biweekly, quarterly, and 6-month surveys. Primary outcomes include (1) identification of perceived barriers and facilitating factors associated with incorporating fentanyl test strip education and distribution into opioid overdose education and naloxone distribution programs; (2) differences in knowledge and self-efficacy regarding how to test drugs for fentanyl and strategies for reducing overdose risk between the intervention and non-intervention groups; and (3) differences in non-fatal and fatal overdose rates between the intervention and non-intervention groups. DISCUSSION: Findings from this cluster randomized controlled trial will contribute valuable information about the feasibility, acceptability, and impact of integrating fentanyl test strip drug checking in rural and urban communities in Ohio and help guide future overdose prevention interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT05463341. Registered on July 19, 2022. https://clinicaltrials.gov/study/NCT05463341.

[Efficacy of transdermal lidocaine 5% patches in postoperative analgesia following knee arthroscopy]. / Efectividad del parche transdérmico de lidocaína 5% en la analgesia postoperatoria después de la artroscopía de rodilla.

INTRODUCTION: knee arthroscopy is a common orthopedic procedure associated with postoperative pain, so optimizing pain management is essential for patient recovery and satisfaction. Lidocaine, a local anesthetic with well-established safety profiles, offers a potential alternative to traditional analgesic methods. Research regarding lidocaine patches has been conducted in several types of surgeries (laparoscopy, gynecological surgery, prostatectomy, etc.) showing promising results for some. This study investigates the effectiveness of transdermal lidocaine 5% patches as a novel approach to postoperative analgesia after knee arthroscopy. MATERIAL AND METHODS: a randomized, single-blind, placebo-controlled trial was conducted with participants undergoing knee arthroscopy. Patients were divided into two groups: one receiving transdermal lidocaine 5% patches and the other a placebo, both along traditional postoperative pain management, and using opioid only in cases with moderate-severe pain. Pain scores, opioid consumption, and patient-reported outcomes were assessed at various postoperative intervals. RESULTS: there was a significant reduction in pain scores and opioid consumption in the lidocaine patch group compared to the placebo group. CONCLUSIONS: transdermal lidocaine 5% patches emerge as a promising adjunct to postoperative pain management in knee arthroscopy patients. Their ease of application, minimal side effects, and opioid-sparing effects contribute to a multifaceted analgesic approach. This study underscores the potential of transdermal lidocaine patches in enhancing the overall postoperative experience for knee arthroscopy patients, advocating for their consideration in clinical practice.

INTRODUCCIÓN: la artroscopía de rodilla es un procedimiento ortopédico común asociado con dolor postoperatorio, por lo que optimizar el manejo del dolor es esencial para la recuperación y la satisfacción del paciente. La lidocaína, un anestésico local con perfiles de seguridad bien establecidos, ofrece una alternativa potencial a los métodos analgésicos tradicionales. Se ha llevado a cabo investigación sobre los parches de lidocaína en diversos tipos de cirugías (laparoscopía, cirugía ginecológica, prostatectomía, etcétera), mostrando resultados prometedores en algunos casos. MATERIAL Y MÉTODOS: se realizó un ensayo clínico aleatorizado, ciego simple y controlado con placebo que incluyó participantes sometidos a artroscopía de rodilla. Los pacientes fueron divididos en dos grupos: uno recibió parches transdérmicos de lidocaína al 5% y otro un placebo, ambos junto con el manejo tradicional del dolor postoperatorio y utilizando opioides sólo en casos de dolor moderado a severo. Se evaluaron las puntuaciones de dolor, el consumo de opioides y los resultados informados por los pacientes en varios intervalos postoperatorios. RESULTADOS: se registró una reducción significativa en las puntuaciones de dolor y el consumo de opioides en el grupo de parches de lidocaína en comparación con el grupo de placebo. CONCLUSIONES: los parches transdérmicos de lidocaína al 5% emergen como un complemento prometedor para el manejo del dolor postoperatorio en pacientes sometidos a artroscopía de rodilla. Su facilidad de aplicación, mínimos efectos secundarios y efectos ahorradores de opioides contribuyen a un enfoque analgésico multifacético. Este estudio destaca el potencial de los parches de lidocaína transdérmica para mejorar la experiencia postoperatoria general de los pacientes con artroscopía de rodilla, abogando por su consideración en la práctica clínica.

Loss of Consciousness After Naltrexone Implantation: A Case Report. / Naltrekson Implant Uygulamasi Sonrasinda Gelisen Bilinç Kaybi: Olgu Sunumu.

Naltrexone is an µ opioid receptor antagonist that is used in alcohol and opiate use disorder. Naltrexone does not constitute tolerance and dependence, and cessation of the drug does not cause withdrawal symptoms. Sustained release form of naltrexone has been developed due to patient compliance issues. There is currently only one sustainedrelease form available in Turkey, which is inserted subcutaneously. In this case report, we present, a probable serious side effect of sustained release naltrexone implant. A 36 years old male with alcohol use disorder, developed a sudden clouding of consciousness one hour after the naltrexone implant application followed by anterograde amnesia in the next 8-10 hours. We were not able to detect any medical or neurological reasons for the altered mental status but after the removal of the naltrexone implant, the symptoms improved. To the best of our knowledge, this is the first case to report clouding of consciousness and anterograde amnesia after naltrexone implantation. Keywords: Naltrexone Implant, Side Effect, Alcohol Use Disorder, Lethargy, Consciousness.

Reliability and Validity of Turkish version of DSM-5 Substance Use Scale. / DSM-5 Madde Kullanimi Ölçegi'nin Türkçe Formunun Geçerligi ve Güvenilirligi.

OBJECTIVE: This study aims to evaluate the severity of substance use disorders according to the DSM-5 criteria and to show the reliability and validity of the Turkish version of the DSM-5 Substance Use Scale that improved to learn what kind of substances are used. METHODS: In this study,54 in or out-patients who met the criteria for any substance use disorder according to DSM-5 and who are receiving treatment in Psychiatry Department of Celal Bayar University Faculty of Medicine and AMATEM department of Bakirköy Prof. Dr. Mahzar Osman Mental Health and Neurology Training and Research Hospital, were included. One hundred volunteers without any mental or physical disease were also recruited as the control group. Beside the DSM-5 Level 2 substance use scale, Addiction Profile Index was used for concurrent validity. Internal consistency coefficient and item-total correlation analysis were performed for reliability analysis. ROC Analysis was used in the validity analysis. RESULTS: Mean age was 26.97±10.20 years in the study group and 39% of the sample (n=60) were female. 5.6% (n=3) of the patient group were female and 94.4% (n=51) were male. In the control group, 57% (n=57) were female and 43% (n=43) were male. Of the patients diagnosed with substance use disorder (n=54), 88.7% had opiate use disorder, 5.6% had polysubstance use disorder, 5.6% had other (unknown) substance (synthetic cannabinoid) use disorder and 1.8% of patients have cannabis use disorder. The internal consistency of the substance use scale was 0.80 and itemtotal correlation coefficients were between 0,196- 0,643 (p<0.0001). Coefficient of correlation analysis with API was calculated as r=0.806 (p<0.0001). CONCLUSION: The results showed that DSM-5 Substance Use Scale is a valid and reliable questionnaire that can be used to measure the progress of different dimensions of alcohol and substance use.

The effectiveness and outcomes of epidural analgesia in patients undergoing open liver resection: a propensity score matching analysis.

BACKGROUND: Open liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection. METHODS: A retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects. RESULTS: A total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). However, there was no significant difference in pain scores (p = 0.422). Additionally, perioperative hypotension requiring treatment, as well as nausea and vomiting, were significantly higher in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). CONCLUSIONS: Epidural analgesia is superior to intravenous morphine in terms of reducing postoperative opioid consumption within the initial 72 h after open liver resection. Nevertheless, perioperative hypotension, which necessitates management, should be approached with consideration and vigilance. TRIAL REGISTRATION: The study was registered in the Clinical Trials Registry at www. CLINICALTRIALS: gov/ , NCT number: NCT06301932.

State Mandates On Naloxone Coprescribing Associated With Short-Term Increase In Naloxone Codispensing.

In the midst of the opioid crisis in the US, efforts to mitigate overdose risks have become paramount, leading some states to introduce mandates for coprescribing the life-saving overdose reversal drug naloxone. These mandates were designed to specifically address people receiving opioid analgesics who had an elevated risk for overdose. This included people receiving high opioid dosages, those concurrently using benzodiazepines, or those with a history of substance use disorder or overdose. Using a nationally representative, multipayer cohort of patients receiving prescription opioids, we investigated how naloxone codispensing rates changed at the state level from 2016 to 2021 among patients with an elevated risk for overdose. Then we used controlled interrupted time series analyses to assess mandates' longitudinal impact on naloxone codispensing in ten states that implemented mandates. We observed an immediate and significant increase in the naloxone codispensing rates in eight states after the implementation of mandates. Nevertheless, in five of these states, the codispensing rates exhibited a subsequent downward trend after the initial increase. State mandates show potential for improving naloxone codispensing; however, mandates alone might not be adequate for sustained change. Further research is needed to identify strategies complementing and enhancing the impact of mandates in combating the overdose crisis.