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1.
J Opioid Manag ; 15(5): 389-405, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31849030

RESUMEN

OBJECTIVE: Characterize changes in intraoperative opioid and non-opioid administration over time and to evaluate self-reported pain scores in the immediate postoperative period. DESIGN: Single-center retrospective longitudinal study. SETTING: Academic medical center. PATIENTS, PARTICIPANTS: All patients presenting for surgery between 2011 and 2017 in both an inpatient and outpatient setting. MAIN OUTCOME MEASURE(S): Determine total intraoperative opioid administration using intravenous oral morphine equivalents standardized to weight and intraoperative non-opioid use. Furthermore, postoperative self-reported pain scores within 2 hours of completion of surgery are reported. RESULTS: A total of 112,167 individual cases were identified from March 2011 to June 2017. There was a sustained and significant reduction in intraoperative mean and median opioid administration [2011: 0.16 ± 0.15 mg/kg and 0.13 (0-4.92) mg/kg vs 2017: 0.09 ± 0.09 mg/kg and 0.07 (0-4.17) mg/kg]. These effects are seen in emergent vs elective surgery, ambulatory vs inpatient, preoperative opioid use vs no preoperative opioid use, and those with and without intraoperative loco-regional procedures. Although median number of intraoperative non-opioid analgesic agents was unchanged over time, average difference in the number of intraoperative non-opioids increased over time. Finally, pain scores decreased over time [2011: mean (standard deviation) and median (range): 5.1 ± 2.62 and 5.4 (0-10) vs 2017: 3.29 ± 3.27 and 3 (0-10)]. CONCLUSION: This study confirms that intraoperative opioid use has decreased over time with increased utilization of non-opioid analgesic adjuncts and a commensurate decrease in immediate postoperative pain.


Asunto(s)
Analgésicos Opioides , Analgésicos , Dolor Postoperatorio , Analgésicos/administración & dosificación , Analgésicos Opioides/administración & dosificación , Femenino , Humanos , Estudios Longitudinales , Masculino , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Estudios Retrospectivos
2.
J Opioid Manag ; 15(5): 407-415, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31849031

RESUMEN

OBJECTIVES: To assess the effects of no, any, and acute and chronic prescription opioid exposure for pain during pregnancy on maternal and fetal outcomes. DESIGN: Retrospective cohort study. SETTING: Integrated healthcare delivery system. Information on pregnancies and their outcomes were obtained from administrative data and verified via manual chart review. PARTICIPANTS: Women ≥ 18 years of age who were pregnant between January 1, 2012 and May 31, 2015 and had chronic, acute, and no opioid exposure; defined as an ambulatory dispensing(s) of >30 (with a total of 225 morphine equivalents), 1-29, and 0 days supply of opioid, respectively, during pregnancy. MAIN OUTCOME MEASURE: Non-live birth. RESULTS: A total 13,809 pregnancies for 13,131 women were included. Pregnancies with opioid exposure had higher risk scores and more comorbid conditions. A total of 1,319 (9.6 percent) pregnancies had any documented opioid exposure during pregnancy with 125 (1.0 percent) and 1,194 (8.7 percent) pregnancies having had chronic and acute opioid exposure, respectively. Pregnancies with acute opioid exposure had a higher percentage of non-live births (3.1 percent) compared to pregnancies (1.0 percent) with no opioid exposure (adjusted odds ratio = 3.46, 95% confidence interval 2.33-5.14) but no difference compared to pregnancies with chronic (1.6 percent) opioid exposure (p > 0.05 with adjustment). CONCLUSIONS: While a dose response of opioid exposure was not identified, these results add to existing evidence that opioid exposure during pregnancy is correlated with negative outcomes. Practitioners may better serve pregnant women and their fetuses by encouraging alternate pain relief treatments.


Asunto(s)
Analgésicos Opioides , Morfina , Resultado del Embarazo , Adulto , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Femenino , Humanos , Morfina/administración & dosificación , Morfina/efectos adversos , Dolor , Manejo del Dolor , Embarazo , Estudios Retrospectivos , Adulto Joven
3.
J Opioid Manag ; 15(5): 417-427, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31849032

RESUMEN

OBJECTIVE: To evaluate the clinical effects of naltrexone following ALO-02 administration. DESIGN: Two phase three studies: an open-label, single-arm safety study, and a double-blind, placebo-controlled, randomized withdrawal, efficacy study (ClinicalTrials.gov identifiers: NCT01428583, NCT01571362). SETTING: Seventy US research centers. PATIENTS: Eight hundred and five patients with moderate-to-severe chronic noncancer pain (n = 395) or moderate-to-severe chronic low back pain (n = 410). INTERVENTIONS: Oral ALO-02 capsules (daily dose 20-160 mg oxycodone): openlabel titration followed by double-blind fixed dose ALO-02 or placebo (12 weeks) for the efficacy study; and open-label administration (≤12 months) for the safety study. MAIN OUTCOME MEASURES: Brief Pain Inventory-Short Form (BPI-sf), withdrawal-related adverse events, Clinical Opiate Withdrawal Scale (COWS), and naltrexone plasma concentrations. RESULTS: ALO-02 was received for = 30 days by 592 patients (73.5 percent), = 90 days by 348 patients (43.2 percent), and ≤361 days by 105 patients (13.0 percent). Maximum COWS scores were below the cutoff for mild withdrawal for the majority of patients: 86.6 percent of patients in the safety study, and for the efficacy study, 96.8 percent during titration and 95.0 percent during double-blind treatment. The frequency of quantifiable naltrexone plasma concentrations was similar between studies (18-23 percent of samples), and the levels were low, generally not exceeding 200 pg/mL. There was no apparent relationship between naltrexone plasma concentrations and COWS scores (total or change from baseline), or change from baseline in BPI-sf scores in the efficacy (R2 = 0.0184, 0.0224, and 0.0173, respectively) or safety studies (R2 = 0.0010, 0.0000, and 0.0122, respectively). CONCLUSIONS: Naltrexone plasma concentrations were low, not correlated with COWS or BPI-sf scores, and considered clinically insignificant.


Asunto(s)
Dolor Crónico , Naltrexona , Oxicodona , Analgésicos Opioides/administración & dosificación , Dolor Crónico/tratamiento farmacológico , Preparaciones de Acción Retardada , Método Doble Ciego , Esquema de Medicación , Combinación de Medicamentos , Femenino , Humanos , Masculino , Naltrexona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Oxicodona/administración & dosificación , Dimensión del Dolor , Resultado del Tratamiento
4.
J Opioid Manag ; 15(6): 445-453, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31850506

RESUMEN

OBJECTIVE: Guidelines for appropriate management of chronic opioid therapy are underutilized by primary care physicians (PCPs). The authors hypothesized that developing a multicomponent, team-based opioid management system with electronic health record (EHR) support would allow our clinicians to improve adherence to chronic opioid prescribing and monitoring guidelines. DESIGN: This was a retrospective pre-post study. SETTING: The authors performed this intervention at our large, urban, academic primary care practice. PATIENTS, PARTICIPANTS: All patients with the diagnosis of "chronic pain, opioid requiring (ICD-10 F11.20)" on their primary care EHR problem lists were included in this study. INTERVENTION: The authors implemented a five-pronged strategy to improve our system of opioid prescribing, including (1) a patient registry with regular dissemination of reports to PCPs; (2) standardization of policies regarding opioid prescribing and monitoring; (3) development of a risk-assessment algorithm and riskstratified monitoring guidelines; (4) a team-based approach to care with physician assistant care managers; and (5) an EHR innovation to facilitate communication and guideline adherence. MAIN OUTCOME MEASURES: The authors measured percent adherence to opioid prescribing guidelines, including annual patient-provider agreements, biannual urine drug screens (UDSs), and prescription monitoring program (PMP) verification. RESULTS: Between September 2015 and September 2016, the percentage of patients on chronic opioid therapy with a signed controlled substances agreement within the preceding year increased from 46 to 76 percent (p < 0.0001), while the percentage of patients with a UDS done within the past 6 months rose from 23 to 79 percent (p < 0.0001). The percentage of patients whose state PMPs profile had been checked by a primary care team member in the past year rose from 45 to 97 percent (p < 0.0001). CONCLUSION: A comprehensive strategy to standardize chronic opioid prescribing in our primary care practice coincided with an increase in adherence to opioid management guidelines.


Asunto(s)
Analgésicos Opioides , Dolor Crónico , Pautas de la Práctica en Medicina , Atención Primaria de Salud/normas , Analgésicos Opioides/administración & dosificación , Dolor Crónico/tratamiento farmacológico , Adhesión a Directriz , Humanos , Estudios Retrospectivos
5.
J Opioid Manag ; 15(6): 479-485, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31850509

RESUMEN

INTRODUCTION: In response to the US opioid epidemic, the Centers for Disease Control and Prevention issued a guideline (CDCG) for prescribing opioids for chronic pain. Successful implementation of the CDCG requires identification of the information, skills, and support physicians need to carry out its recommendations. However, such data are currently lacking. METHODS: The authors performed one-on-one interviews with nine practicing physicians regarding their needs and perspectives for successful CDCG implementation, including the perceived barriers, focusing on communication strategies. Interviews were audio recorded, transcribed, and a thematic qualitative analysis was performed. FINDINGS: Three major themes were identified: communication, knowledge, and information technology (IT). Physicians reported that open communication with patients about opioids was difficult and burdensome, but essential; they shared their communication strategies. Knowledge gaps included patient-specific topics (eg, availability of/insurance coverage for non-opioid treatments) and more general areas (eg, opioid dosing/equivalencies, prescribing naloxone). Finally, physicians discussed the importance of innovation in IT, focusing on the electronic medical record for decision support and to allow safer opioid prescribing within the time constraints of clinical practice. DISCUSSION: These qualitative data document practical issues that should be considered in the development of implementation plans for safer opioid prescribing practices. Specifically, healthcare systems may need to provide opioid-relevant communication strategies and training, education on key topics such as naloxone prescribing, resources for referrals to appropriate nonpharmacologic treatments, and innovative IT solutions. Future research is needed to establish that such measures will be effective in producing better outcomes for patients on opioids for chronic pain.


Asunto(s)
Analgésicos Opioides , Comunicación , Registros Electrónicos de Salud , Trastornos Relacionados con Opioides/prevención & control , Pautas de la Práctica en Medicina , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Toma de Decisiones , Humanos , Naloxona , Médicos , Investigación Cualitativa
6.
J Opioid Manag ; 15(6): 499-506, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31850512

RESUMEN

BACKGROUND: As determinants of the opioid epidemic are several, describing patterns of opioid prescription over time is of importance. OBJECTIVE: To characterize the prescribing patterns of opioids per US region and physician specialty from 2012 to 2015. METHODS: Truven Health Analytics MarketScan® Databases were used to obtain data on opioid prescription rates per US region and physician specialty for the years 2012-2015. Opioids included in the study are tramadol, hydrocodone, codeine, oxycodone, oxymorphone, methadone, and fentanyl. RESULTS: Starting sample consisted of 5,860,096 individuals. An increase in prescriptions was seen for codeine (22.3 percent), oxycodone (22.4 percent), and tramadol (22.4 percent), while other opioids had decreases between 6.5 and 20.2 percent during this period. Family medicine physicians were the most frequent prescriber for all opioids except for oxycodone; nonphysician prescribers' share of prescriptions nearly doubled for all opioids. The share of oxycodone and of tramadol among all opioids increased in all regions, while the opposite was seen for hydrocodone. Codeine prescription share increased substantially in the South but not in other regions. When comparing the period of 2012-2015, differences were significant for all regions (p < 0.0001 for all regions). In 2015, the rate of prescription of oxycodone was nearly twofold higher in the Northeast vs North Central (38 percent vs 18.5 percent, p < 0.0001), while tramadol was substantially more frequently prescribed in the South, where it responded to nearly 20 percent of all opioid prescriptions (p < 0.0001). CONCLUSION: Patterns of prescription per opioid vary considerably per physician specialty and per US region. Although an overall decrease in prescriptions was seen, certain opioids were more frequently prescribed in 2015 than in 2012.


Asunto(s)
Analgésicos Opioides , Prescripciones de Medicamentos/estadística & datos numéricos , Pautas de la Práctica en Medicina , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Humanos , Hidrocodona , Oxicodona , Pautas de la Práctica en Medicina/estadística & datos numéricos , Tramadol , Estados Unidos
7.
Medicine (Baltimore) ; 98(51): e18237, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31860970

RESUMEN

BACKGROUND: This review aims to evaluate the effectiveness and safety of acupuncture treatment for reducing opioid consumption in patients with chronic pain. METHODS: We will search the following electronic databases from their inception to November 2019: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, the Allied and Complementary Medicine Database, the China National Knowledge Infrastructure (a Chinese database), the Japan Science and Technology Information Aggregator (a Japanese database), and five Korean databases (KoreaMed, Research Information Service System, Korean Studies Information Service System, Database Periodical Information Academic, and Oriental Medicine Advanced Searching Integrated System). Randomized controlled trials comparing acupuncture to no treatment, sham acupuncture, and other active interventions for the reduction of opioid consumption in chronic pain patients will be included. The risk of bias will be assessed using the Cochrane risk of bias tool. The primary outcomes will include the prescribed or consumed dose of opioids and withdrawal symptoms related to opioid reduction. A meta-analysis will be performed to estimate a pooled effect, if possible. CONCLUSION: This study may provide important practical guidance for patients, practitioners, and health-policy makers regarding the use of acupuncture in opioid taper support programs. DISSEMINATION: The results will be disseminated through a peer-reviewed journal or conference presentations. TRIAL REGISTRATION NUMBER: PROSPERO 2019: CRD42019143486.


Asunto(s)
Analgesia por Acupuntura , Analgésicos Opioides/uso terapéutico , Dolor Crónico/terapia , Analgesia por Acupuntura/métodos , Analgésicos Opioides/administración & dosificación , Dolor Crónico/tratamiento farmacológico , Humanos , Dimensión del Dolor/métodos
8.
Orv Hetil ; 160(52): 2054-2060, 2019 Dec.
Artículo en Húngaro | MEDLINE | ID: mdl-31868008

RESUMEN

Introduction: Due to the increasing number of arthroplasties, the number of post-operative hospital days was reduced and the rate of rehabilitation accelerated. For this, proper postoperative analgesia is essential and the multimodal pain relief is an excellent tool. Aim: The aim of our study was to compare postoperative functional results, postoperative pain levels, and opioid analgesic needs of patients who received conventional and novel analgesic treatments. Method: In our prospective study, 81 patients were enrolled who underwent primary hip prosthesis surgery in our institution between February 2017 and January 2018. Of the randomized patients, 38 were in the control group and 43 in the multimodal pain group. We have tested their analgesic needs and the subjective pain levels of patients with the help of the visual analog scale (VAS). Results: Patients receiving multimodal pain relief had significantly lower opioid analgesic requirements and significantly lower VAS values assessed at 6 hours, and 3 and 4 days postoperatively. In addition, the patients in this group stayed in the hospital for a significantly shorter time after surgery. Conclusions: Based on our experience, multimodal pain relief in one-sided primary hip joint arthroplasty significantly reduced the patients' postoperative subjective pain sensation and pain killer consumptions. Orv Hetil. 2019; 160(52): 2054-2060.


Asunto(s)
Analgesia/métodos , Analgésicos Opioides/administración & dosificación , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Analgésicos Opioides/uso terapéutico , Humanos , Dolor Postoperatorio/etiología , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento
9.
J Surg Oncol ; 120(8): 1456-1461, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31680250

RESUMEN

BACKGROUND AND OBJECTIVES: Remifentanil infusion is used as an intraoperative anesthetic for thyroidectomy, but has been associated with acute opioid tolerance and hyperalgesia. A national shortage of remifentanil provided an opportunity to study postoperative pain in patients undergoing thyroidectomy. METHODS: Retrospective review of prospectively collected data from an outpatient surgery center. Primary analysis compared patients treated before and after remifentanil shortage. RESULTS: Median postoperative opioid consumption was 20 morphine milligram equivalents (MMEs) among those treated in the high-dose period and 15 MMEs in the low-dose period. Remifentanil/weight received was a significant predictor of requiring a postoperative narcotic (P = .006). Total non-remifentanil narcotics administered were equivalent but patients in the low dose period received higher amounts of intraoperative long-acting narcotics. CONCLUSIONS: Remifentanil infusion for thyroid surgery is associated with higher postoperative pain and postoperative narcotics requirement. While a hyperalgesia state is possible, shifting of longer-acting narcotics from intraoperative to postoperatively is also supported.


Asunto(s)
Analgésicos Opioides/administración & dosificación , Utilización de Medicamentos/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Remifentanilo/administración & dosificación , Tiroidectomía , Adulto , Procedimientos Quirúrgicos Ambulatorios , Femenino , Humanos , Infusiones Intravenosas , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Alta del Paciente , Periodo Posoperatorio , Estudios Retrospectivos
10.
Medicine (Baltimore) ; 98(41): e17503, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31593120

RESUMEN

BACKGROUND: The local injection of multimodal cocktail is currently commonly used in the treatment of postoperative pain after total knee arthroplasty (TKA). It is still inconclusive whether the morphine added to the intraoperative injection mixture could make some difference. This meta-analysis aimed to evaluate the efficacy and safety of additional morphine injection on postoperative analgesia in TKA, and provide some useful information on morphine usage in clinical practice. METHODS: The randomized controlled trials (RCTs) in databases including PubMed, Web of Science, Embase, Cochrane Library, Chinese biomedical literature database (CBM), and Chinese National Knowledge Infrastructure (CNKI) databases were systematically searched. Of 623 records identified, 8 RCTs involving 1093 knees were eligible for data extraction and meta-analysis according to criteria included. RESULTS: Meta-analysis showed that the use of local morphine injection was not associated with significant pain relief within 48 hours postoperatively at rest and on motion (P > .05, all). The use of morphine reduced postoperative total systemic opioids consumption (P < .05). This study found no significant differences in other outcomes including knee flexion range of motion (ROM) (P > .05), extension ROM (P > .05), The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (P > .05), Post-operative nausea and vomiting occurrence (P > .05) regardless of the presence of morphine or not in the injections. CONCLUSION: Additional morphine added to multimodal cocktail did not decrease the postoperative pain scores significantly based on our outcomes, but it reduced the systemic postoperative opioids consumption in total knee arthroplasty.


Asunto(s)
Analgesia/métodos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Morfina/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Analgesia/efectos adversos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Anestesia Local/métodos , Artroplastia de Reemplazo de Rodilla/métodos , Terapia Combinada/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Dimensión del Dolor/efectos de los fármacos , Dimensión del Dolor/métodos , Náusea y Vómito Posoperatorios/epidemiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Rango del Movimiento Articular/efectos de los fármacos
11.
Niger J Clin Pract ; 22(10): 1319-1323, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31607718

RESUMEN

Background: Morphine is a common analgesic often used to manage chronic pain, especially for patients with pain due to malignancies. Since UGT2B7 plays an important role in the metabolism of morphine, UGT2B7 gene mutation may influence the efficacy of morphine in patients with cancer being treated by this medication. Aims: The aim of this study is to investigate the relationship between the polymorphisms of UGT2B7 and the efficacy of morphine treatment on cancer pain among the Chinese Han population. Materials and Methods: A total of 120 patients with cancer pain were enrolled in this study. Morphine was administrated through patient-controlled analgesia infusion pump, and the visual analog score (VAS) was used for pain assessment at 0.5, 4, 6, 12, 24, 48, and 72-h post morphine treatment, respectively. The plasma concentration of morphine and genetic polymorphism of UGT2B7 C802T and G221T was analyzed, respectively. Results: The frequencies of UGT2B7 C802T were CC: 13.33%, CT: 45% and TT: 41.67%, and the frequencies of UGT2B7 G221T were GG: 76.67%, GT: 22.5% and TT: 0.83%. Moreover, the VAS score of patients with either C802T CT or TT was significantly higher than that in patients with C802T CC. However, no difference of VAS scores was observed between patients carrying G221T GG and patients carrying G221T GT. The plasma concentration of morphine for patients with the C802T CC was significantly lower than that in patients carrying C802T CT or TT, while there was no significant difference in the level of morphine between patients with G221T GG and G221T GT. Conclusion: The polymorphism of UGT2B7 C802T, but not UGT2B7 G221T, has been associated with the efficacy of morphine treatment on cancer pain among Chinese Han population.


Asunto(s)
Analgésicos Opioides/sangre , Grupo de Ascendencia Continental Asiática/estadística & datos numéricos , Dolor en Cáncer/tratamiento farmacológico , Glucuronosiltransferasa/genética , Morfina/sangre , Neoplasias/sangre , Polimorfismo Genético/genética , Adulto , Analgesia Controlada por el Paciente , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Grupo de Ascendencia Continental Asiática/genética , Dolor en Cáncer/genética , Femenino , Genotipo , Humanos , Bombas de Infusión , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Morfina/uso terapéutico , Neoplasias/complicaciones , Neoplasias/tratamiento farmacológico , Neoplasias/genética , Dimensión del Dolor , Escala Visual Analógica
14.
Life Sci ; 237: 116926, 2019 Nov 15.
Artículo en Inglés | MEDLINE | ID: mdl-31614148

RESUMEN

Sex-related differences in pain and opioids has been the focus of many researches. It is demonstrated that women experience greater clinical pain, lower pain threshold and tolerance, more sensitivity and distress to experimentally induced pain compared to men. Sex differences in response to opioid treatment revealed inconsistent results. However, the etiology of these disparities is not fully elucidated. It is, therefore, conceivable now that this literature merits to be revisited comprehensively. Possible multifaceted factors seem to be associated. These include neuroanatomical, hormonal, neuroimmunological, psychological, social and cultural aspects and comorbidities. This review aims at providing an overview of the substantial literature documenting the sex differences in pain and analgesic response to opioids from animal and human studies within the context of the modulatory effects of the aforementioned factors. A detailed and critical discussion of the cellular and molecular signaling pathways underlying the modulatory actions of gonadal hormones in the sexual dimorphism in pain processing and opioid analgesia is extensively presented. It is indicated that sexual dimorphic activation of certain brain regions contributes to differential pain sensitivity between females and males. Plausible crosstalk between sex hormones and neuroimmunological signaling pertinent to toll-like and purinergic receptors is uncovered as causal cues underlying sexually dimorphic pain and opioid analgesia. Conceivably, a thorough understanding of these factors may aid in sex-related advancement in pain therapeutic management.


Asunto(s)
Analgésicos Opioides/administración & dosificación , Hormonas Gonadales/metabolismo , Nocicepción/efectos de los fármacos , Dolor/tratamiento farmacológico , Animales , Femenino , Humanos , Masculino , Nocicepción/fisiología , Dolor/metabolismo , Caracteres Sexuales
15.
J Opioid Manag ; 15(4): 307-322, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31637683

RESUMEN

BACKGROUND: Increasing opioid-related deaths have heightened focus on combating the opioid epidemic. The impact of surgical trainees on opioid-related deaths is unclear, and there is little data examining the association between trainee pain management education and opioid prescribing practices. METHODS: An anonymous, online survey was distributed to members of the Resident and Associate Society of the American College of Surgeons. The survey covered five themes: education and knowledge, prescribing practices, clinical case scenarios, policy, and beliefs and attitudes. Linear mixed models were used to evaluate the influence of respondent characteristics on reported morphine milligram equivalents (MME) prescribed for common general surgery clinical scenarios. RESULTS: Of 427 respondents, 54 percent indicated receiving training in postoperative pain management during medical school and 66 percent during residency. Only 35 percent agreed that they had received adequate training in prescribing opioids. There was a significant association between undergoing formal pain management training in medical school and prescribing fewer MME for common outpatient general surgery scenarios (94 ± 15.2 vs 108 ± 15.0; p = 0.003). Similarly, formal pain management training in residency was associated with prescribing fewer MME in the survey scenarios (92.6 ± 15.2 vs 109 ± 15.2; p = 0.002). CONCLUSION: In this survey, nearly two-thirds of surgical residents felt that they were inadequately trained in opioid pre-scribing. Our findings additionally suggest that improving education may result in increased resident comfort with man-aging surgical pain, potentially leading to more responsible opioid prescribing. Further work will facilitate residency pro-grams' development of educational curricula for opioid prescribing best practices.


Asunto(s)
Analgésicos Opioides , Prescripciones de Medicamentos , Cuidados Posoperatorios/métodos , Pautas de la Práctica en Medicina , Analgésicos Opioides/administración & dosificación , Prescripciones de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Masculino , Encuestas y Cuestionarios
16.
Am Surg ; 85(10): 1155-1158, 2019 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-31657314

RESUMEN

The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015-March 2017) and after OSMMAP implementation (April 2017-March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Procedimientos Quirúrgicos del Sistema Digestivo , Tolerancia a Medicamentos , Morfina/uso terapéutico , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Adulto , Analgésicos no Narcóticos/administración & dosificación , Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/administración & dosificación , Estudios de Casos y Controles , Protocolos Clínicos , Procedimientos Quirúrgicos del Sistema Digestivo/estadística & datos numéricos , Femenino , Fentanilo/administración & dosificación , Fentanilo/uso terapéutico , Humanos , Laparoscopía/estadística & datos numéricos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Medicación Preanestésica/efectos adversos , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Resultado del Tratamiento
17.
Am Surg ; 85(10): 1194-1197, 2019 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-31657323

RESUMEN

Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73-225) minutes in the SL group versus 164 (range, 103-295) minutes in the HALS group (P = 0.09). Total 48-hour IV morphine use was 30 (range, 0-186) mg in the SL group compared with 56 (0-275) mg in the HALS group (P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients (P = 0.03). The postoperative length of stay was 3 (3-21) days in the SL group versus 5 (3-15) days in the HALS group (P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.


Asunto(s)
Colectomía/métodos , Colitis Ulcerosa/cirugía , Estética , Ileostomía , Laparoscopía/métodos , Adolescente , Adulto , Anciano , Analgésicos Opioides/administración & dosificación , Niño , Preescolar , Colectomía/efectos adversos , Colectomía/estadística & datos numéricos , Femenino , Laparoscópía Mano-Asistida/efectos adversos , Laparoscópía Mano-Asistida/métodos , Laparoscópía Mano-Asistida/estadística & datos numéricos , Humanos , Laparoscopía/efectos adversos , Laparoscopía/estadística & datos numéricos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Tempo Operativo , Complicaciones Posoperatorias , Estudios Prospectivos , Estomas Quirúrgicos , Resultado del Tratamiento , Adulto Joven
18.
Medicine (Baltimore) ; 98(43): e17647, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31651885

RESUMEN

BACKGROUND: Opioids are frequently prescribed for the management of patients with chronic non-cancer pain (CNCP). Previous meta-analyses of efficacy and harms have combined treatment effects across all opioids; however, specific opioids, pharmacokinetic properties (ie, long acting vs short acting), or the type of formulation (ie, immediate vs extended release) may be a source of heterogeneity for pooled effects. METHODS: We will conduct a network meta-analysis (NMA) of randomized controlled trials evaluating opioids for CNCP. We will acquire eligible studies through systematic searches of EMBASE, MEDLINE, CINAHL, AMED, PsycINFO, and the Cochrane Central Registry of Controlled Trials (CENTRAL). Eligible studies will have randomly allocated adult CNCP patients to an oral or transdermal opioid versus another type of opioid (or formulation) or placebo, and follow patients for ≥ 4 weeks. We will collect outcome data for pain intensity, physical function, nausea, vomiting, and constipation. Pairs of reviewers will, independently and in duplicate, abstract data from eligible trials and assess risk of bias using a modified Cochrane tool. We will assess coherence of our networks through both a global test, and by comparing direct and indirect evidence for each comparison with node-splitting. RESULTS: Using a frequentist approach, we will conduct random effects multiple treatment meta-analysis to establish treatment effects of individual opioids for each outcome. The certainty of evidence for pooled treatment effects will be assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. We will categorize interventions from most to least effective based on the effect estimates obtained from NMAs and their associated certainty of evidence, as follows: superior to both placebo and alternatives; superior to placebo, but inferior to alternatives; and no better than placebo. CONCLUSION: This NMA will determine the relative effectiveness and adverse effects of individual opioids among patients with CNCP. Our results will help inform the appropriateness of assuming similar beneficial and adverse effects of varying opioid formulations. SYSTEMATIC REVIEW REGISTRATION: This systematic review is registered with Prospective Register of Systematic Reviews, an international prospective register of systematic reviews (registration no.: CRD42018110331), available at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=110331.


Asunto(s)
Analgésicos Opioides/administración & dosificación , Dolor Crónico/tratamiento farmacológico , Preparaciones de Acción Retardada , Humanos , Metaanálisis en Red , Ensayos Clínicos Controlados Aleatorios como Asunto , Proyectos de Investigación
19.
Pharm Res ; 36(12): 171, 2019 Oct 25.
Artículo en Inglés | MEDLINE | ID: mdl-31654287

RESUMEN

PURPOSE: Physiologically-based pharmacokinetic (PBPK) modeling offers a unique modality to predict age-specific pharmacokinetics. The objective of this study was to assess the ability of PBPK model to predict plasma exposure of oxycodone, a widely used opioid for pain management, in adults and children. METHODS: A full PBPK model of oxycodone following intravenous and oral administration was developed using a 'bottom-up' and 'top-down' combined strategy. The model was then extrapolated to pediatrics through a reasonable scaling method. The adult and pediatric model was evaluated using data from 17 clinical PK studies by testing predicted/observed goodness of fit. The mean fold error for PK parameters was calculated. Finally, we used the validated PBPK model to visualize adult-children dose conversion for oxycodone. RESULTS: The developed PBPK model successfully predicted the oxycodone disposition in adults, wherein the predicted versus observed AUC, Cmax, and tmax were within 0.90 to 1.20-fold difference. After scaling anatomy/physiology, protein binding, and clearance, the model showed satisfactory prediction performance for pediatric populations as predicted AUC were within the 1.50-fold range of the observed values. According to the application of PBPK model, we found that different intravenous doses should be given in children of different ages compared to a standard 0.1 mg/kg in adults, while a progressive increasing dose with age growth following oral administration is recommended for children. CONCLUSIONS: The current example provides the opportunity for using the PBPK model to guide dose adjustment of oxycodone in the design of future pediatric clinical studies.


Asunto(s)
Analgésicos Opioides/farmacocinética , Oxicodona/farmacocinética , Administración Intravenosa , Administración Oral , Adolescente , Adulto , Analgésicos Opioides/administración & dosificación , Niño , Preescolar , Simulación por Computador , Relación Dosis-Respuesta a Droga , Humanos , Lactante , Recién Nacido , Tasa de Depuración Metabólica , Modelos Biológicos , Oxicodona/administración & dosificación , Pediatría
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