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1.
Medicine (Baltimore) ; 99(9): e19306, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32118751

RESUMEN

The study aimed to explore whether cancer-related pain and opioids use are associated with the survival of cancer patients, and perform a cohort study and a meta-analysis to quantify the magnitude of any association.A retrospective cohort study was performed to analyze the impact of pain level, and opioids use on cancer-specific survival (CSS) in advanced cancer patients. Patients and relevant medical records were selected from the registry of the Radiation and chemotherapy division of Ningbo First Hospital between June 2013 and October 2017. Hazard ratios (HRs) and 95% confidential intervals (CIs) for CSS by opioids use were calculated by univariate and multivariate Cox regression analyses. The systematic review included relevant studies published before October 2018. The combined HRs and 95% CIs for overall survival (OS) and progression-free survival (PFS) were calculated using random-effect models.A total of consecutive 203 cancer patients were included in the cohort study. Kaplan-Meier curves indicate a negative association between CSS and cancer-related pain or opioids requirement, but less evidence of an association with the dose of opioids use. Multivariate models revealed that the pain level and opioids requirement were associated with shorter CSS, after adjusting for significant covariates. The results of the meta-analysis indicated that postoperative opioids use had a poor effect on PFS, and opioids use for cancer-related pain was associated with poor OS in cancer patients, while intraoperative opioids use was not associated with cancer survival.We concluded that cancer-related pain and opioids requirements are associated with poor survival in advanced cancer patients, and postoperative opioids use and opioids use for cancer-related pain may have an adverse effect on the survival of cancer patients.


Asunto(s)
Analgésicos Opioides/normas , Neoplasias/tratamiento farmacológico , Neoplasias/mortalidad , Dolor/tratamiento farmacológico , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Análisis de Varianza , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/complicaciones , Dolor/etiología , Manejo del Dolor/métodos , Manejo del Dolor/normas , Manejo del Dolor/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Análisis de Supervivencia
3.
R I Med J (2013) ; 103(2): 45-48, 2020 Mar 02.
Artículo en Inglés | MEDLINE | ID: mdl-32122101

RESUMEN

Pain is universal, yet the prevalence of overdose and treatment of pain varies significantly between the United States (US) and Western Europe. Overdose deaths are seven times more common in the US compared to Western Europe. Cultural perceptions of pain, perception and treatment of opioid use disorder, pharmaceutical advertising, and rates and regulation of prescribing of opioids represent examples of factors that may be related to such differences between the US and Western Europe. As Rhode Island continues to battle the devastating and well-documented national opioid overdose epidemic, we should consider how cultural, regulatory differences, and economic factors may influence pain and its treatment.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Sobredosis de Droga/mortalidad , Prescripciones de Medicamentos/estadística & datos numéricos , Trastornos Relacionados con Opioides/epidemiología , Oxicodona/administración & dosificación , Pautas de la Práctica en Medicina/estadística & datos numéricos , Dolor Agudo/tratamiento farmacológico , Analgésicos Opioides/envenenamiento , Comparación Transcultural , Sobredosis de Droga/epidemiología , Europa (Continente)/epidemiología , Humanos , Oxicodona/envenenamiento , Manejo del Dolor/métodos , Rhode Island/epidemiología
5.
MMWR Morb Mortal Wkly Rep ; 69(11): 298-302, 2020 Mar 20.
Artículo en Inglés | MEDLINE | ID: mdl-32191686

RESUMEN

In 2017, prescription opioids were involved in 36% of opioid-involved overdose deaths in the United States (1). Prescription opioids can be obtained by prescription or through diversion (the channeling of regulated drugs from legal to illegal sources) (2). Among new heroin users, 66%-83% reported that their opioid use began with the misuse of a prescription opioid (3). "Misuse" is generally defined as drugs taken for a purpose other than that directed by the prescribing physician, in greater amounts, more often, or for a longer duration than prescribed (2). Exposure to prescription opioids can be lessened by ensuring recommended prescribing, thereby potentially reducing the risk for misuse, opioid use disorder, and overdose (4). Sex and age groups with high exposure to prescription opioids are not well defined. Using a retail pharmaceutical database from IQVIA,* nationwide trends in opioid prescription fill rates for adult outpatients by age and sex were examined during 2008-2018. Opioid prescription fill rates were disproportionately higher among men and women aged ≥65 years and women of all ages. For reasons not well understood, these disparities persisted over 11 years even as the opioid fill rate declined for each age group and sex. Interventions to improve prescribing practices by following evidence-based guidelines that include weighing the benefits and risks for using prescription opioids for each patient and adopting a multimodal approach to pain management could improve patient safety while ameliorating pain. These efforts might need to consider the unique needs of women and older adults, who have the highest opioid prescription fill rates.


Asunto(s)
Atención Ambulatoria/estadística & datos numéricos , Analgésicos Opioides/uso terapéutico , Prescripciones de Medicamentos/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Adulto , Factores de Edad , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores Sexuales , Estados Unidos , Adulto Joven
6.
BMJ ; 368: m283, 2020 03 04.
Artículo en Inglés | MEDLINE | ID: mdl-32131996

RESUMEN

OBJECTIVE: To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. DESIGN: Observational evaluation. SETTING: Veterans Health Administration. PARTICIPANTS: 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). MAIN OUTCOME MEASURES: A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient's death. RESULTS: 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n=799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. CONCLUSIONS: Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient's perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Sobredosis de Droga/epidemiología , Suicidio/estadística & datos numéricos , Veteranos/estadística & datos numéricos , Privación de Tratamiento/estadística & datos numéricos , Adulto , Anciano , Prescripciones de Medicamentos , Humanos , Persona de Mediana Edad , Pautas de la Práctica en Medicina , Modelos de Riesgos Proporcionales , Estados Unidos/epidemiología
7.
Br J Anaesth ; 124(3): 281-291, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-32000975

RESUMEN

BACKGROUND: Many patients use opioids chronically before surgery; it is unclear if surgery alters the likelihood of ongoing opioid consumption in these patients. METHODS: We performed a population-based matched cohort study of adults in Ontario, Canada undergoing one of 16 non-orthopaedic surgical procedures and who were chronically using opioids, defined as (1) an opioid prescription that overlapped the index date and (2) either a total of 120 or more cumulative calendar days of filled opioid prescriptions, or 10 or more prescriptions filled in the prior year. Each surgical patient was matched based on age, sex, Charlson comorbidity index, and daily preoperative opioid dose to three non-surgical patients who were also chronic opioid users. The primary outcome was time to opioid discontinuation. RESULTS: The cohort included 4755 surgical and 14 265 matched non-surgical patients. After adjustment for sociodemographic characteristics and comorbidities, surgery was associated with an increased likelihood of opioid discontinuation (adjusted hazard ratio: 1.34, 95% confidence interval [CI]: 1.27, 1.42). Among surgical patients, factors associated with a reduced odds of discontinuation included a mean preoperative opioid dose above 90 morphine milligram equivalents (adjusted odds ratio [aOR]: 0.39; 95% CI: 0.32, 0.49) or filling a prescription for oxycodone (aOR: 0.73; 95% CI: 0.56, 0.98). Receipt of an in-patient Acute Pain Service consultation (aOR: 1.34; 95% CI: 1.06, 1.69) or residing in the highest neighbourhood income quintile (aOR: 1.35; 95% CI: 1.04, 1.79) were associated with a greater odds of opioid discontinuation. CONCLUSIONS: For chronic opioid users, surgery was associated with an increased likelihood of discontinuation of opioids in the following year compared with non-surgical chronic opioid users.


Asunto(s)
Analgésicos Opioides/administración & dosificación , Trastornos Relacionados con Opioides/epidemiología , Dolor Postoperatorio/tratamiento farmacológico , Procedimientos Quirúrgicos Operativos/métodos , Anciano , Analgésicos Opioides/uso terapéutico , Estudios de Casos y Controles , Enfermedad Crónica , Estudios de Cohortes , Esquema de Medicación , Prescripciones de Medicamentos/estadística & datos numéricos , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Ontario/epidemiología , Periodo Posoperatorio , Privación de Tratamiento/estadística & datos numéricos
8.
Medicine (Baltimore) ; 99(6): e19004, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32028411

RESUMEN

BACKGROUND: Endoscopic tonsillectomy is associated with postoperative pain. Postoperative pain management remains to be improved in children. We aimed to investigate oxycodone preemptive analgesia in children undergoing endoscopic plasma total adenotonsillectomy. METHODS: 166 children with adenotonsillar hypertrophy were recruited at Wuhan Children's Hospital between 08/2016 and 03/2017. They were randomly assigned to receive SPOA (postoperative sufentanil), SPEA+SPOA (preemptive sufentanil and postoperative sufentanil), and OPEA+SPOA (preemptive oxycodone and postoperative sufentanil). The primary endpoint was serum c-fos levels. The secondary endpoints were the response entropy (RE) value, Pediatric Anesthesia Emergence Delirium (PAED) score, FLACC score, and adverse events. RESULTS: c-fos mRNA levels were increased significantly after surgery in the SPOA and SPEA+SPOA groups (P < .05). Postoperatively, c-fos mRNA levels were higher in the SPOA group compared with the OPEA+SPOA group (P = .044). The RE values increased in all groups after surgery (P < .05). At extubation, RE values were higher in the SPOA group compared with the SPEA+SPOA and OPEA+SPOA groups (P < .05). The PAED scores were higher in the SPOA group compared with the OPEA+SPOA group (P = .045). In the SPOA group, the FLACC scores were decreased at 24 h after surgery vs 4 hours (P = .044). Prediction probability (Pk) values indicated that RE and c-fos mRNA levels were quantitative predictors for early postoperative stress reaction after surgery. CONCLUSIONS: The subanalgesic dose of oxycodone (0.1 mg/kg) as preemptive analgesia could improve pain after endoscopic plasma total adenotonsillectomy in children.


Asunto(s)
Adenoidectomía , Analgésicos Opioides/uso terapéutico , Oxicodona/uso terapéutico , Dolor Postoperatorio/prevención & control , Tonsilectomía , Actinas/sangre , Adenoidectomía/efectos adversos , Adenoidectomía/métodos , Niño , Endoscopía/efectos adversos , Endoscopía/métodos , Femenino , Humanos , Masculino , Proteínas Proto-Oncogénicas c-fos/sangre , Reacción en Cadena en Tiempo Real de la Polimerasa , Sufentanilo/uso terapéutico , Tonsilectomía/efectos adversos , Tonsilectomía/métodos
9.
Medicine (Baltimore) ; 99(5): e18924, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32000405

RESUMEN

Adiponectin is an adipose tissue-derived cytokine that exerts its antiinflammatory effects by binding to 2 adiponectin receptors, adiponectin receptor 1 (ADIPOR1) and adiponectin receptor 2 (ADIPOR2). However, the role of these adiponectin receptors on inflammatory pain remains unclear. We investigated the association between single nucleotide polymorphisms (SNPs) of these genes and inflammatory pain, such as postoperative pain and cancer pain.We analyzed 17 SNPs of the ADIPOR1 gene and 27 SNPs of the ADIPOR2 gene in 56 adult patients with postlaparotomy pain. We compared these genotypes with pain intensity and opioid consumption, adjusting for multiple testing. We analyzed the genotypes of 88 patients with cancer pain and examined the association of the relevant SNP(s) with pain intensity and opioid consumption.One variant of the ADIPOR1 gene (rs12045862) showed significant association with postoperative pain intensity; patients with minor allele homozygote (n = 7) demonstrated significantly worse pain intensity than that of combined patient group exhibiting major allele homozygote or the heterozygote (n = 49; Mann-Whitney test, P < .00002), although their opioid consumptions were comparable. Cancer pain intensity between minor allele homozygote patients (n = 7) and other 2 genotype patients (n = 81) were comparable.The rs12045862 SNP of the ADIPOR1 gene was associated with postoperative pain but not cancer pain. This might result from functional alteration of the ADIPOR1 signalling pathways, which influence the inflammatory process. ADIPOR1 may be a novel potential target for developing analgesics of postoperative pain.


Asunto(s)
Dolor en Cáncer/genética , Dolor Postoperatorio/genética , Polimorfismo de Nucleótido Simple , Receptores de Adiponectina/genética , Analgésicos Opioides/uso terapéutico , Dolor en Cáncer/tratamiento farmacológico , Neoplasias Colorrectales/genética , Neoplasias Colorrectales/cirugía , Femenino , Estudios de Asociación Genética , Humanos , Inflamación/genética , Laparotomía , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico
11.
JAMA ; 323(3): 237-247, 2020 01 21.
Artículo en Inglés | MEDLINE | ID: mdl-31961419

RESUMEN

Importance: For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. Objective: To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. Design, Setting, and Participants: The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018. Interventions: There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. Main Outcomes and Measures: The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality. Results: Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach. Conclusions and Relevance: Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings. Trial Registration: ISRCTN Identifier: ISRCTN45877994.


Asunto(s)
Cálculos/terapia , Drenaje , Endoscopía , Litotricia , Manejo del Dolor/métodos , Conductos Pancreáticos/cirugía , Pancreatitis Crónica/terapia , Adulto , Analgésicos Opioides/uso terapéutico , Área Bajo la Curva , Cálculos/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/etiología , Dimensión del Dolor , Pancreatitis Crónica/complicaciones , Pancreatitis Crónica/cirugía
12.
BMJ ; 368: l6968, 2020 01 29.
Artículo en Inglés | MEDLINE | ID: mdl-31996352

RESUMEN

OBJECTIVE: To examine the distribution and patterns of opioid prescribing in the United States. DESIGN: Retrospective, observational study. SETTING: National private insurer covering all 50 US states and Washington DC. PARTICIPANTS: An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017. MAIN OUTCOME MEASURES: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions. RESULTS: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years. CONCLUSIONS: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Prescripción Inadecuada/prevención & control , Manejo de Atención al Paciente/normas , Médicos , Pautas de la Práctica en Medicina , Adulto , Prescripciones de Medicamentos/normas , Prescripciones de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Revisión de Utilización de Seguros/estadística & datos numéricos , Masculino , Médicos/clasificación , Médicos/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendencias , Medicamentos bajo Prescripción/uso terapéutico , Mejoramiento de la Calidad , Estudios Retrospectivos , Estados Unidos/epidemiología
13.
Epidemiol Psychiatr Sci ; 29: e97, 2020 Jan 29.
Artículo en Inglés | MEDLINE | ID: mdl-31992376

RESUMEN

AIMS: Prescription opioid misuse (POM) contributes to a larger opioid crisis in the US and Canada, with over 17 000 US POM-related overdose deaths in 2017. Our aims were to (1) identify specific profiles of respondents based on POM motives using the US National Survey on Drug Use and Health (NSDUH) and (2) compare profile respondents on sociodemographics, substance use and mental and physical health outcomes. METHODS: Analyses included 2017-18 NSDUH respondents with data on POM motives (n = 4810). POM was defined as prescription opioid use in a way not intended by the prescriber, including use without a prescription, in larger amounts or more frequently. Nine POM motives for the most recent episode were assessed, including 'to relieve physical pain' and 'to get high'. Latent classes, based on POM motives, were estimated. Classes were compared on sociodemographics, substance use and physical and mental health outcomes. RESULTS: Eight latent classes were identified (in order of prevalence): pain relief only, relax-pain relief, sleep-pain relief, multi-motive, high, experimenter, emotional coping and dependent/hooked. Compared to the pain relief only group, the high and multi-motive classes had higher odds of all substance use outcomes, with the dependent/hooked class having higher odds on all but one outcome. Six of the eight classes had higher odds of past-year mental health treatment and suicidal ideation than the pain relief only class. CONCLUSIONS: Screening for pain, pain conditions, problematic substance use and psychopathology are recommended in those with any POM. While those in the dependent/hooked, multi-motive and emotional coping classes are most likely to have prescription opioid use disorder (OUD), screening for OUD symptoms in all individuals with POM is also warranted.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Mal Uso de Medicamentos de Venta con Receta/estadística & datos numéricos , Adolescente , Adulto , Anciano , Niño , Estudios Transversales , Femenino , Humanos , Análisis de Clases Latentes , Masculino , Persona de Mediana Edad , Motivación , Trastornos Relacionados con Opioides/epidemiología , Mal Uso de Medicamentos de Venta con Receta/psicología , Prevalencia , Factores Socioeconómicos , Estados Unidos/epidemiología , Adulto Joven
16.
Br J Anaesth ; 124(3): e117-e130, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31955857

RESUMEN

A systematic literature search was performed to identify studies that reported risk factors for persistent pain after childbirth. Many studies have sought to identify risk factors for post-delivery pain in different populations, using different methodologies and different outcome variables. Studies of several different but interrelated post-partum pain syndromes have been conducted. Factors strongly and specifically associated with persistent incisional scar pain after Caesarean delivery include a coexisting persistent pain problem in another part of the body and severe acute postoperative pain. For persistent vaginal and perineal pain, operative vaginal delivery and the magnitude of perineal trauma have been consistently linked. History of pregnancy-related and pre-pregnancy back pain and heavier body weight are robust risk factors for persistent back pain after pregnancy. Unfortunately, limitations, particularly small samples and lack of a priori sample size calculation designed to detect specific effect sizes for risk of persistent pain outcomes, preclude definitive conclusions about many other predictors and the strength of outcome associations. In future studies, assessments of specific phenotypes using a rigorous analysis with appropriate predetermined sample sizes and validated instruments are needed to allow elucidation of stronger and reliable associations. Interventional studies targeting the most robustly associated, modifiable risk factors, such as acute post-partum pain, may lead to solutions for the prevention and treatment of these common problems that impact a large population.


Asunto(s)
Cesárea/efectos adversos , Dolor Crónico/etiología , Parto Obstétrico/efectos adversos , Analgésicos Opioides/uso terapéutico , Catecol O-Metiltransferasa/genética , Dolor Crónico/prevención & control , Cicatriz/complicaciones , Femenino , Humanos , Perineo , Embarazo , Receptores Opioides mu/genética , Factores de Riesgo
17.
Postgrad Med ; 132(1): 56-61, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31711352

RESUMEN

Context: Chronic pain is highly prevalent in most of the industrialized nations around the world. Despite the documented adverse effects, opioids are widely used for pain management. Cannabinoids, and specifically Cannabidiol, is proposed as an opioid alternative, having comparable efficacy with better safety profile.Objectives: We aim to investigate the impact of full hemp extract cannabidiol (CBD) on opioid use and quality of life indicators among chronic pain patients.Methods: An initial sample of 131 patients was recruited from a private pain management center's investigative population. Ninety-seven patients completed the 8-week study. The primary inclusion criteria included patients between 30 and 65 years old with chronic pain who have been on opioids for at least 1 year. Data were collected at three different time points: baseline, 4, and 8 weeks. Opioid and other medication use were evaluated via the medication and psychiatric treatment receipt. Improvement was evaluated using four indices: Pain Disability Index (PDI-4); Pittsburgh Sleep Quality Index (PSQI), Pain Intensity and Interference (PEG); and Patient Health Questionnaire (PHQ-4).Results: Over half of chronic pain patients (53%) reduced or eliminated their opioids within 8 weeks after adding CBD-rich hemp extract to their regimens. Almost all CBD users (94%) reported quality of life improvements. The results indicated a significant relationship between CBD and PSQI (p = 0.003), and PEG (p = 0.006). There was a trend toward improvement but no significant relationship between CBD use and PHQ and PDI.Conclusion: CBD could significantly reduce opioid use and improve chronic pain and sleep quality among patients who are currently using opioids for pain management.Key Message: This is a prospective, single-arm cohort study for the potential role of cannabinoids as an alternative for opioids. The results indicate that using the CBD-rich extract enabled our patients to reduce or eliminate opioids with significant improvement in their quality of life indices.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Cannabidiol/uso terapéutico , Cannabis , Dolor Crónico/tratamiento farmacológico , Extractos Vegetales/uso terapéutico , Calidad de Vida , Adulto , Anciano , Dolor Crónico/psicología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fitoterapia/métodos , Calidad de Vida/psicología , Encuestas y Cuestionarios
18.
Postgrad Med ; 132(1): 44-51, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31721609

RESUMEN

Background: Among patients with chronic pain using long-term opioid therapy, the incidence of opioid abuse, addiction, overdose, and associated death are not well quantified. The range of estimates for these adverse outcomes varies drastically and may depend on how they are measured (i.e. study definitions of outcomes) and on patient characteristics and opioid-use factors (e.g. regimen, daily dose).Methods: Based on a review of the literature, the US Food and Drug Administration (FDA) required companies that manufacture and sell extended-release/long-acting (ER/LA) opioids conduct as a postmarketing requirement (PMR) a series of observational studies to estimate the rates of treatment-emergent misuse, abuse, addiction, overdose, and death using validated measures. The companies formed a consortium, the Opioid PMR Consortium (OPC), to conduct the studies.Results: The FDA initially requested four observational studies (a cohort study, a questionnaire validation study, a code validation study, and a doctor-shopping validation study), but in order to achieve the FDA's goals of the 4 studies, OPC and FDA agreed to 10 observational studies (a prospective cohort study, a retrospective database cohort study, three questionnaire validation studies, two code validation studies, and three doctor-shopping validation studies). The studies are continuing through 2020.Conclusions: A series of 10 observational studies was or are being conducted in response to the FDA's postmarketing requirement. All studies have been feasible to conduct, although a validated algorithm for measuring abuse and addiction in databases was not successful.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Preparaciones de Acción Retardada/uso terapéutico , Vigilancia de Productos Comercializados , Medición de Riesgo/métodos , Gestión de Riesgos/organización & administración , Sobredosis de Droga/epidemiología , Humanos , Estudios Observacionales como Asunto , Trastornos Relacionados con Opioides/epidemiología , Proyectos de Investigación , Estados Unidos/epidemiología , United States Food and Drug Administration
19.
Anaesthesia ; 75(3): 386-394, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31583679

RESUMEN

The posterior suprascapular nerve block has been proposed as an analgesic alternative for shoulder surgery based on the publication of several comparisons with interscalene block that failed to detect differences in analgesic outcomes. However, quantification of the absolute treatment effect of suprascapular nerve block on its own, in comparison with no block (control), to corroborate the aforementioned conclusions has been lacking. This study examines the absolute analgesic efficacy of suprascapular nerve block compared with control for shoulder surgery. We systematically sought electronic databases for studies comparing suprascapular nerve block with control. The primary outcomes included postoperative 24-h cumulative oral morphine consumption and the difference in area under the curve for 24-h pooled pain scores. Secondary outcomes included the incidence of opioid-related side-effects (postoperative nausea and vomiting) and patient satisfaction. Data were pooled using random-effects modelling. Ten studies (700 patients) were analysed; all studies examined landmark-guided posterior suprascapular nerve block performed in the suprascapular fossa. Suprascapular nerve block was statistically but not clinically superior to control for postoperative 24-h cumulative oral morphine consumption, with a weighted mean difference (99%CI) of 11.41 mg (-21.28 to -1.54; p = 0.003). Suprascapular nerve block was also statistically but not clinically superior to control for area under the curve of pain scores, with a mean difference of 1.01 cm.h. Nonetheless, suprascapular nerve block reduced the odds of postoperative nausea and vomiting and improved patient satisfaction. This review suggests that the landmark-guided posterior suprascapular nerve block does not provide clinically important analgesic benefits for shoulder surgery. Investigation of other interscalene block alternatives is warranted.


Asunto(s)
Bloqueo Nervioso/métodos , Hombro/cirugía , Analgesia , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Bloqueo del Plexo Braquial , Ensayos Clínicos como Asunto , Bases de Datos Factuales , Humanos , Morfina/administración & dosificación , Morfina/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/epidemiología , Satisfacción del Paciente , Náusea y Vómito Posoperatorios/epidemiología
20.
Postgrad Med ; 132(1): 37-43, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31549932

RESUMEN

Objective: Our institution implemented six multimodal, sliding scale protocols for managing pain in non-surgical inpatients. The purpose of this study was to compare the use of these acute pain protocols with traditional prescribing in regard to pain management efficacy and safety measures.Methods: This retrospective cohort study evaluated hospital in-patients who were prescribed one of the protocols during the first 6 months following implementation, admitted to the hospitalist service, and had received at least two doses of PRN analgesic medication within a 24-hour period. Data collected included baseline demographics, verbal pain rating scores to determine time to achieve analgesia, total opioid use in oral morphine equivalent doses (MEDs), and safety measures. A sample of patients admitted during the same time frame, meeting inclusion/exclusion criteria, but who received traditional analgesic prescribing served as controls.Results: Forty-six adult, non-surgical patients were included in the analysis, and 46 served as controls. The average baseline pain scores were similar between groups (7.26 in protocol, 7.43 in control, p = 0.684). Protocol patients required significantly less time to achieve meaningful analgesia (average 507.52 min) compared to the control group (894.33 min, p = 0.045). Patients in the protocol group used an average of 35.81 MEDs per day compared to 65.77 MEDs in controls (p = 0.019). Patients in the protocol group used significantly fewer PRN analgesic doses (12.70 vs. 24.02, p < 0.0001).Conclusion: Analysis of the implementation of acute pain management protocols indicates that using standardized pain management protocols of opioids, non-opioids, and medications to prevent opioid-related adverse events is more effective than traditional analgesic prescribing for our patient population.


Asunto(s)
Dolor Agudo/tratamiento farmacológico , Analgésicos/uso terapéutico , Prescripciones de Medicamentos , Dimensión del Dolor/métodos , Analgésicos Opioides/uso terapéutico , Protocolos Clínicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento
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