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1.
Plast Reconstr Surg ; 145(2): 316e-323e, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985627

RESUMO

BACKGROUND: Perioperative use of opioids is common in surgical practice and frequently results in troublesome opioid-related side effects that often lead to suboptimal postsurgical outcomes. As such, multiple studies have sought to identify alternatives that may reduce reliance on opioid-based perioperative pain management. Recently, it has been shown that patient education and patient involvement in care positively impact surgical outcomes. This study evaluates how patient education regarding the role of endogenous beta-endorphins in reducing pain and the opposing effect of opioid analgesics impacts opioid consumption and mood after surgery. METHODS: Patients scheduled for breast augmentation were divided into two groups, A and B. Both groups received identical multimodal anesthesia regimens; however, only patients in group B were educated on the role of endogenous beta-endorphins in pain control and mood enhancement, and how opioids block their action. RESULTS: Patients in the group receiving preoperative education on the analgesic and mood-enhancing role of endogenous beta-endorphins and how opioids block their action consumed significantly less opioids and had better postsurgical outcomes as determined by self-reported measures of pain level and mood/sense of well-being. CONCLUSIONS: The findings of this study suggest that opioid use was significantly reduced and patients' mood/sense of well-being was significantly enhanced when patients received preoperative education on the oppositional relationship between beta-endorphins and opioids. Such patient education may be linked to a significant reduction in opioid use and improved patient mood/sense of well-being, especially when combined with opioid-free multimodal anesthesia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Assuntos
Afeto/efeitos dos fármacos , Analgésicos Opioides/efeitos adversos , Mamoplastia , Manejo da Dor/métodos , Educação de Pacientes como Assunto/métodos , Adulto , Feminino , Humanos , Estudos Prospectivos , Adulto Jovem
3.
Forensic Sci Int ; 306: 110093, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31816483

RESUMO

Studies on the mortalities of drug abusers in China are scarce. This study explores the deaths of methamphetamine, opioid, and ketamine abusers in Shanghai (2004-2017) and Wuhan (2005-2017). Chi-square/Fisher's exact tests were used to compare the differences in terms of region, gender, age, cause of death, and the method used in the last drug abuse. Poisson regression models were used to estimate the rate ratios ("RRs") and annual percentage changes ("APCs"). 314 heroin, 43 methamphetamine, and 4 ketamine abusers were included. Furthermore, simultaneously, 6 abusers used heroin and methamphetamine, and 7 abusers used methamphetamine and ketamine. Heroin-related deaths have declined in Shanghai (APC, -16.1; 95 % CI, -18.4 to -11.3) and Wuhan (APC, -16.0; 95 % CI, -18.9 to -10.6), whereas methamphetamine-related deaths have increased in Wuhan (APC, 12.8; 95 % CI, 0.0 to 29.2). On the whole, in the two cities, males were more frequently observed than females in heroin-related deaths (4.4, 230/52). However, the gender ratios for methamphetamine- (1.8, 34/19) and ketamine-related deaths (1.2, 6/5) were close to one. In view of the mortality rates of the drug abusers in most Chinese cities were still unclear, it is thus important to improve mortality surveillance of the drug abusers at the national level.


Assuntos
Analgésicos Opioides/envenenamento , Ketamina/envenenamento , Metanfetamina/envenenamento , Transtornos Relacionados ao Uso de Substâncias/mortalidade , Adolescente , Adulto , Distribuição por Idade , Analgésicos Opioides/efeitos adversos , Intoxicação por Monóxido de Carbono/mortalidade , China/epidemiologia , Feminino , Heroína/efeitos adversos , Heroína/envenenamento , Humanos , /envenenamento , Ketamina/efeitos adversos , Masculino , Metanfetamina/efeitos adversos , Pessoa de Meia-Idade , Distribuição por Sexo , Suicídio/estatística & dados numéricos , Adulto Jovem
4.
Br J Anaesth ; 124(1): 44-62, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31653394

RESUMO

Most cases of serotonin toxicity are provoked by therapeutic doses of a combination of two or more serotonergic drugs, defined as drugs affecting the serotonin neurotransmitter system. Common serotonergic drugs include many antidepressants, antipsychotics, and opioid analgesics, particularly fentanyl, tramadol, meperidine (pethidine), and methadone, but rarely morphine and other related phenanthrenes. Symptoms of serotonin toxicity are attributable to an effect on monoaminergic transmission caused by an increased synaptic concentration of serotonin. The serotonin transporter (SERT) maintains low serotonin concentrations and is important for the reuptake of the neurotransmitter into the presynaptic nerve terminals. Some opioids inhibit the reuptake of serotonin by inhibiting SERT, thus increasing the plasma and synaptic cleft serotonin concentrations that activate the serotonin receptors. Opioids that are good inhibitors of SERT (tramadol, dextromethorphan, methadone, and meperidine) are most frequently associated with serotonin toxicity. Tramadol also has a direct serotonin-releasing action. Fentanyl produces an efflux of serotonin, and binds to 5-hydroxytryptamine (5-HT)1A and 5-HT2A receptors, whilst methadone, meperidine, and more weakly tapentadol, bind to 5-HT2A but not 5-HT1A receptors. The perioperative period is a time where opioids and other serotonergic drugs are frequently administered in rapid succession, sometimes to patients with other serotonergic drugs in their system. This makes the perioperative period a relatively risky time for serotonin toxicity to occur. The intraoperative recognition of serotonin toxicity is challenging as it can mimic other serious syndromes, such as malignant hyperthermia, sepsis, thyroid storm, and neuroleptic malignant syndrome. Anaesthetists must maintain a heightened awareness of its possible occurrence and a readiness to engage in early treatment to avoid poor outcomes.


Assuntos
Analgésicos Opioides/efeitos adversos , Anestesiologistas , Serotoninérgicos/efeitos adversos , Síndrome da Serotonina/terapia , Febre/induzido quimicamente , Humanos , Complicações Intraoperatórias/induzido quimicamente , Síndrome da Serotonina/diagnóstico
5.
Toxicol Lett ; 319: 237-241, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31738974

RESUMO

The RSDL® (Reactive Skin Decontamination Lotion) Kit contains a lotion-impregnated sponge extensively studied for the removal or neutralization of chemical warfare agents from skin. Pilot investigation of efficacy with industrial threat compounds noted that synthetic opioid fentanyl citrate was removed by the RSDL Kit but not chemically inactivated by the lotion. This implies that after use the RSDL Kit will contain intact fentanyl, which may pose a dermal health hazard if the fentanyl is then transferred to skin after use without proper handling. This in vitro investigation studied the contaminated RSDL Kit using three different concentrations of fentanyl with a skin contact time of 15 min under direct interaction from passive contact, light touch, and leaning with one hand. It was demonstrated that the expected transfer of fentanyl from contaminated RSDL depends on 1) the concentration of fentanyl and 2) the area of the exposed surface. From a toxicological perspective, the contact risk of fentanyl under the conditions tested can be considered low but not absent. The present study determined that a contaminated RSDL Kit, used for removal of fentanyl, should be handled with proper care. Use of protective gloves in operational use and washing skin afterwards is advised to prevent undesired contamination.


Assuntos
Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/análise , Contaminação de Medicamentos , Fentanila/efeitos adversos , Fentanila/análise , Creme para a Pele/efeitos adversos , Creme para a Pele/análise , Animais , Substâncias para a Guerra Química/química , Técnicas In Vitro , Projetos Piloto , Medição de Risco , Absorção Cutânea , Suínos
6.
J Forensic Sci ; 65(1): 112-116, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31483504

RESUMO

Given the common occurrence of both opioid and cardiovascular deaths, and the concomitant use of opioids in those with cardiac disease, the present study was undertaken to see whether the old adage of using the triad of cerebral and pulmonary edema and bladder fullness to suggest an opioid death could be used to differentiate deaths due to opioid toxicity from deaths due to cardiac disease. Brain weight, lung weight, and bladder fullness were compared among opioid-related deaths, cardiac deaths, and a control population. It was found that opioid-related deaths were more likely to have heavy lungs, a heavy brain, and a full bladder, while cardiac-related deaths had smaller volumes of urine in the bladder and heavier hearts. In conjunction with a thorough investigation, these findings may be useful to forensic pathologists when determining whether a death is opioid-related, especially in the setting of concomitant cardiac disease.


Assuntos
Analgésicos Opioides/envenenamento , Doenças Cardiovasculares/diagnóstico , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Adolescente , Adulto , Distribuição por Idade , Idoso , Analgésicos Opioides/efeitos adversos , Autopsia , Encéfalo/patologia , Edema Encefálico/patologia , Estudos de Casos e Controles , Overdose de Drogas , Feminino , Patologia Legal , Humanos , Pulmão/patologia , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Tamanho do Órgão , Edema Pulmonar/patologia , Estudos Retrospectivos , Distribuição por Sexo , Bexiga Urinária/patologia , Adulto Jovem
7.
Toxicol Lett ; 321: 90-94, 2020 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-31881244

RESUMO

Potent opioids are increasingly responsible for morbidity and mortality in the Western world. Fentanyl and fentanyl derivatives are increasingly prevalent as adulterants or substitutes for opioid drugs of abuse in Europe and in North America. Trafficking and distribution of these chemicals evolve continuously and are poorly characterized at this time. Rescue and emergency personnel are increasingly concerned with the possibility of unintentional environmental exposures that might occur in the course of their operational duties. There is evidence that opioid agonists have been broadcast or applied directly in an offensive manner as incapacitating agents. Defending against toxicity from such agents requires a thoughtful plan for protection, decontamination, and treatment.


Assuntos
Analgésicos Opioides/efeitos adversos , Substâncias para a Guerra Química/efeitos adversos , Tráfico de Drogas , Socorristas , Fentanila/efeitos adversos , Exposição Ocupacional/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Trabalho de Resgate , Descontaminação , Fentanila/análogos & derivados , Humanos , Exposição Ocupacional/prevenção & controle , Medição de Risco , Fatores de Risco
8.
Biochem Med (Zagreb) ; 30(1): 010802, 2020 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-31839727

RESUMO

Introduction: Hypoglycaemia has been reported as an unusual complication of tramadol use and in a few cases of tramadol poisoning, but the exact mechanism is not known. Case description: An ambulance crew was dispatched to an unconscious 46-year old man. A glucometer point-of-care measurement revealed a profound hypoglycaemia (1.9 mmol/L). Treatment with intravenous glucose was started and the patient was transported to the hospital. The patient had several episodes of pulseless electrical activity requiring cardiopulmonary resuscitation in the ambulance and upon arrival in the hospital. Despite continuous glucose infusion the hypoglycaemia was difficult to correct during the next few hours and the patient developed hypokalaemia. Further investigation to identify the cause of hypoglycaemia revealed that insulin and C-peptide were inappropriately raised. A toxicological investigation revealed the presence of tramadol and its metabolites in lethal concentrations. Also acetaminophen, ibuprofen and lormetazepam were present. Ethanol screening was negative (< 0.1 g/L) and no sulfonylurea were detected. The patient developed multiple organ failure, but eventually recovered. What happened: The hypoglycaemia was caused by inappropriate stimulation of insulin secretion in a patient intoxicated with tramadol. The sudden hypokalaemia was caused by a massive intracellular shift of potassium in response to the hyperinsulinemia, triggered by the intravenous administration of glucose. Main lesson: To our knowledge, we are the first to document a significant rise in endogenous insulin production in a hypoglycaemic patient presenting with tramadol intoxication. Our observation suggests that hyperinsulinemia could be the cause of the hypoglycaemia associated with tramadol use.


Assuntos
Analgésicos Opioides/efeitos adversos , Hipoglicemia/diagnóstico , Tramadol/efeitos adversos , Analgésicos Opioides/uso terapêutico , Glicemia/análise , Peptídeo C/sangue , Glucose/administração & dosagem , Humanos , Hipoglicemia/induzido quimicamente , Hipoglicemia/etiologia , Insulina/sangue , Masculino , Pessoa de Meia-Idade , Dor/tratamento farmacológico , Tramadol/uso terapêutico
9.
J Opioid Manag ; 15(5): 375-387, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31849029

RESUMO

OBJECTIVES: Assessment of opioid-induced constipation (OIC) prevalence and relationship with demographic, clinical, and drug predictors in our daily practice. DESIGN: Observational and retrospective study. SETTING: Chronic pain (CP) center of Bologna's Teaching Hospital, Italy. SUBJECTS: Mixed consecutive CP opioid-user outpatients (n = 128). MAIN OUTCOME MEASURE(S): OIC was assessed with the Bowel Function Index (BFI) in three consecutive visits. Absolute difference and Student's t-test were used to compare BFI scores. Predictors (opioid compound and type, morphine-equivalent daily-dose [MEDD], and laxatives) were retrieved from the patients' charts. BFI and predictors relationships were checked by multinomial logistic regression (MLR); independent predictors of BFI scores were assessed with χ2 analysis. RESULTS: Of the 384 evaluations, 85 percent were on strong opioids with a MEDD range of 11-50 mg per day in the majority (60 percent) and 64 percent showed moderate constipation; 42 percent did not use laxatives while 24 percent used macrogol with significant decrease in the BFI. MLR showed that oxycodone was associated with a risk for moderate constipation. Lactulose and glycerin suppositories were associated with severe constipation. Non-opioid users and cancer patients were associated with normal bowel function and severe constipation, respectively. CONCLUSIONS: OIC was found in almost all evaluations of weak or strong opioidusers (97 percent); moderate to severe OIC was found in 72 percent of the evaluations. Cancer patients were associated with severe constipation. Macrogol was superior to other laxatives. In our experience, macrogol relieved constipation in those on the combination of oxycodone and naloxone and in those on fentanyl patches. Lactulose and glycerol suppositories were associated with severe constipation.


Assuntos
Dor Crônica , Constipação Intestinal/induzido quimicamente , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Constipação Intestinal/epidemiologia , Preparações de Ação Retardada , Combinação de Medicamentos , Humanos , Naloxona , Oxicodona , Prevalência , Estudos Retrospectivos
10.
J Opioid Manag ; 15(5): 407-415, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31849031

RESUMO

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.


Assuntos
Analgésicos Opioides , Morfina , Resultado da Gravidez , Adulto , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Morfina/administração & dosagem , Morfina/efeitos adversos , Dor , Manejo da Dor , Gravidez , Estudos Retrospectivos , Adulto Jovem
11.
J Opioid Manag ; 15(6): 479-485, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31850509

RESUMO

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.


Assuntos
Analgésicos Opioides , Comunicação , Registros Eletrônicos de Saúde , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Padrões de Prática Médica , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Tomada de Decisões , Humanos , Naloxona , Médicos , Pesquisa Qualitativa
12.
Nurs Clin North Am ; 54(4): 495-501, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31703775

RESUMO

This article offers a brief review geared toward primary care providers of the most critical aspects of the management of opiate use disorder, including screening, brief intervention, and referral to treatment as well as medication-assisted treatment and the alarming trends and dangers of illicitly produced fentanyl.


Assuntos
Analgésicos Opioides/efeitos adversos , Overdose de Drogas/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Atenção Primária à Saúde , Overdose de Drogas/tratamento farmacológico , Fentanila/efeitos adversos , Humanos , Transtornos Relacionados ao Uso de Opioides/terapia
13.
J Opioid Manag ; 15(4): 285-293, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637681

RESUMO

OBJECTIVE: To compare dependence characteristics between patients with chronic pain treated within an addiction medicine setting with those attending specialist pain clinics. SETTING AND PATIENTS: Forty patients with chronic non-cancer pain taking opioid analgesics for >1 year were recruited from university-affiliated, tertiary teaching hospital clinics; 20 from an addiction medicine clinic (addiction clinic group) and 20 from specialist pain clinics (pain clinic group). DESIGN AND MAIN OUTCOME MEASURES: Data regarding demographics, past and current substance use, pain history and current daily opioid intake were collected. Patients completed three questionnaires: the Severity of Opioid Dependence Questionnaire, Leeds Dependence Questionnaire, and Pain Disability Index. A novel "Opioid Problem Checklist score" assessing drug-related problems was also determined for each patient. RESULTS: The addiction clinic group were younger, more likely to have experienced drug overdose and had a shorter duration of chronic pain. No significant differences in dependence questionnaire scores were found between groups. However, higher Pain Disability Index scores and higher Opioid Problem Checklist scores (indicating more drug-related problems) were found for the addiction clinic group. CONCLUSIONS: Some degree of dependence was present across both addiction and pain clinic groups, supporting the notion a state of dependence can be identified among chronic pain patients taking opioids long term. Aberrant behaviors were not common in the pain clinic sample, suggesting these patients are unlikely to meet Diagnostic and Statistical Manual of Mental Disorders-V criteria for Substance Use Disorder. However, opioid dependence carries significant risks for relapse, chronicity, morbidity and mortality, warranting specific medical management. Management of such risks should be considered routine care in chronic pain patients taking opioids long term.


Assuntos
Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Comportamento Aditivo , Dor Crônica , Transtornos Relacionados ao Uso de Opioides , Dor Crônica/tratamento farmacológico , Humanos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Clínicas de Dor , Avaliação de Sintomas
14.
J Opioid Manag ; 15(4): 323-331, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637684

RESUMO

OBJECTIVE: To develop a survey instrument to identify adult sickle cell disease (SCD) patients on chronic opioid therapy who are at-risk for opioid abuse. DESIGN: Prospective survey and interview. SETTING: Adult SCD clinic in a large urban teaching facility. PATIENTS/PARTICIPANTS: Convenience sampling of adult patients presenting to the sickle cell clinic. INTERVENTIONS: None. MAIN OUTCOME: Primary outcome was "at-risk for opioid misuse," defined as at least 3/8 "yes" answers (a positive composite score) on the Prescription Opioid Misuse Index (POMI) questionnaire. Secondary outcome was DSM-IV criteria for substance abuse using the DSM IV Diagnostic Interview Schedule. RESULTS: Of the 99 patients who completed the POMI, the mean age was 36 years; 58.6 percent were female, 48 percent were hemoglobin SS (47/99), and 26 percent were SC (26/99). Twenty-four percent (24/99) were identified as at-risk for opioid misuse using the POMI. There were no differences in demographic, SCD genotype, or socioeconomic variables for at-risk versus not-at-risk patients. CONCLUSION: Twenty-four percent of unselected adult SCD patients on opioids were identified as at-risk for opioid misuse using a quick survey. This may represent as much as 2.5-7 times the national misuse rate. This group of patients may benefit from additional diagnostic and therapeutic interventions to help understand and manage their opioid usage.


Assuntos
Analgésicos Opioides/efeitos adversos , Anemia Falciforme , Transtornos Relacionados ao Uso de Opioides , Inquéritos e Questionários/normas , Adulto , Analgésicos Opioides/uso terapêutico , Anemia Falciforme/tratamento farmacológico , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Estudos Prospectivos , Medição de Risco
15.
J Opioid Manag ; 15(4): 333-341, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637685

RESUMO

BACKGROUND: The use of opioid analgesics in the United States has increased nearly fourfold since 1999 resulting in a similar increase in opioid-related overdose deaths. Although the Centers for Disease Control published guidelines for prescribing chronic opioids, there is a lack of guidance for prescribing postoperative opioids. OBJECTIVE: To offer an evidence-based approach to prescribing opioids for post-operative pain management in the orthopedic setting. METHODS: A narrative review was performed of studies evaluating and quantifying opioid use in orthopedic patients in the postoperative setting, as well as studies analyzing patient satisfaction and perception with regards to opioid use. RESULTS: Studies show that postoperative pain may not be the largest contributing factor to developing an opioid use disorder, but rather patient factors such as tobacco and substance use disorder, mental health disorders, anxiety, mood disorders, pre-existing chronic pain, and recent opioid use may play a role. The review also found that most patients do not utilize significant portions of prescribed opioids and most do not require a refill. This trend leaves patients with thousands of unused pills, which are either retained, shared, or diverted. Although there is no guideline for prescribing opioids postoperatively, data suggest that clinicians can prescribe smaller dosages and fewer quantities of opioids initially. There are also non-opioid strategies that can be employed to reduce opioid consumption. CONCLUSION: There is a need for more high quality research to be conducted to standardize postoperative opioid prescribing patterns and create best practice guidelines to guide clinicians. Orthopedic practices should consider creating institutional guidelines to reduce the amount of opioids prescribed.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Humanos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Procedimentos Ortopédicos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos
16.
J Opioid Manag ; 15(4): 345-348, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637687

RESUMO

Opioid tapering may be necessary for patients on long-term opioids. Here, the authors presented a patient who had uncontrolled chronic musculoskeletal pain while on chronic methadone. Upon methadone tapering, the patient had been taking methadone for longer than six years and had severe methadone-related adverse effects. Using multidisciplinary interventions of patient education and counseling, physical interventions, and nonopioid medications, patient's methadone was discontinued after longer than one year tapering with relatively good pain control. The tapering process highlights the importance of pain management during opioid tapering using multidisciplinary interventions to prevent and treat opioid withdrawal and pain relapses.


Assuntos
Analgésicos Opioides/efeitos adversos , Metadona , Manejo da Dor/métodos , Síndrome de Abstinência a Substâncias , Humanos , Metadona/uso terapêutico , Entorpecentes , Síndrome de Abstinência a Substâncias/prevenção & controle
17.
Lancet ; 394(10211): 1807-1815, 2019 11 16.
Artigo em Inglês | MEDLINE | ID: mdl-31645288

RESUMO

BACKGROUND: Three perioperative factors impair host defence against recurrence during cancer surgery: the surgical stress response, use of volatile anaesthetic, and opioids for analgesia. All factors are ameliorated by regional anaesthesia-analgesia. We tested the primary hypothesis that breast cancer recurrence after potentially curative surgery is lower with regional anaesthesia-analgesia using paravertebral blocks and the anaesthetic propofol than with general anaesthesia with the volatile anaesthetic sevoflurane and opioid analgesia. A second hypothesis was that regional anaesthesia-analgesia reduces persistent incisional pain. METHODS: We did a randomised controlled trial at 13 hospitals in Argentina, Austria, China, Germany, Ireland, New Zealand, Singapore, and the USA. Women (age <85 years) having potentially curative primary breast cancer resections were randomised by computer to either regional anaesthesia-analgesia (paravertebral blocks and propofol) or general anaesthesia (sevoflurane) and opioid analgesia. The primary outcome was local or metastatic breast cancer recurrence. The secondary outcome was incisional pain at 6 months and 12 months. Primary analyses were done under intention-to-treat principles. This trial is registered with ClinicalTrials.gov, NCT00418457. The study was stopped after a preplanned futility boundary was crossed. FINDINGS: Between Jan 30, 2007, and Jan 18, 2018, 2132 women were enrolled to the study, of whom 24 were excluded before surgery. 1043 were assigned to regional anaesthesia-analgesia and 1065 were allocated to general anaesthesia. Baseline characteristics were well balanced between study groups. Median follow-up was 36 (IQR 24-49) months. Among women assigned regional anaesthesia-analgesia, 102 (10%) recurrences were reported, compared with 111 (10%) recurrences among those allocated general anaesthesia (hazard ratio 0·97, 95% CI 0·74-1·28; p=0·84). Incisional pain was reported by 442 (52%) of 856 patients assigned to regional anaesthesia-analgesia and 456 (52%) of 872 patients allocated to general anaesthesia at 6 months, and by 239 (28%) of 854 patients and 232 (27%) of 852 patients, respectively, at 12 months (overall interim-adjusted odds ratio 1·00, 95% CI 0·85-1·17; p=0·99). Neuropathic breast pain did not differ by anaesthetic technique and was reported by 87 (10%) of 859 patients assigned to regional anaesthesia-analgesia and 89 (10%) of 870 patients allocated to general anaesthesia at 6 months, and by 57 (7%) of 857 patients and 57 (7%) of 854 patients, respectively, at 12 months. INTERPRETATION: In our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain. FUNDING: Sisk Healthcare Foundation (Ireland), Eccles Breast Cancer Research Fund, British Journal of Anaesthesia International, College of Anaesthetists of Ireland, Peking Union Medical College Hospital, Science Fund for Junior Faculty 2016, Central Bank of Austria, and National Healthcare Group.


Assuntos
Anestesia por Condução/métodos , Anestesia Geral/métodos , Neoplasias da Mama/cirurgia , Recidiva Local de Neoplasia/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Anestesia por Condução/efeitos adversos , Anestesia Geral/efeitos adversos , Anestésicos Inalatórios/efeitos adversos , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Mastectomia/métodos , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia/etiologia , Estadiamento de Neoplasias , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Sevoflurano/efeitos adversos
18.
Forensic Sci Int ; 305: 109970, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31629200

RESUMO

Our aim was to investigate the reason for relatively low detection rates for opioids and fentanyl in particular in post-mortem cases in the State of Hamburg. We re-analysed 822 blood samples from two different time periods, 2011/12 and 2016. These samples had been previously analysed in accordance with post-mortem routine by a case selected strategy. All samples were re-analysed with an LC-MS/MS method specific for prescription opioids. The main point in the evaluation was to determine whether the previous analysis strategy had led to underreporting of drug-related deaths (DRD), especially with regard to fentanyl. Another aim was to evaluate changes in prescribing prevalence of opiates and opioids. We compared pharmacy claims data in Hamburg with Germany. The analyses showed that the number of DRD remained unaffected by the new analytical strategy. Detection rates in DRD, however, increased for fentanyl 3.4-fold from 1.2% to 4.1%, buprenorphine from 5.9% to 7.6%, oxycodone from 0% to 1.8%, tilidine from 1.8% to 2.4%. The most frequently detected opioids in DRD cases were methadone (39.4%) and heroin (20%). Prescription rates between 2011-2017 decreased in Hamburg for nearly all opioids, morphine by - 43.5%, buprenorphine - 43%, codeine - 57%, fentanyl - 25%, tilidine -17%, tramadol - 31%, and hydromorphone -6%. Oxycodone, tapentadol, and piritramide prescription rates increased. For Germany, a decrease in the prescription rates for fentanyl was also found during this period (-12.9 %), although not as pronounced as in Hamburg. Prescription rates for methadone were three to greater than five times higher in Hamburg as compared to the German average due to the higher number of substituted persons per inhabitant. Conclusion: Despite the global problem of opioid abuse, there are significant regional differences in the nature and extent of opioid abuse. It is necessary to collect data at the national level to develop appropriate prevention strategies.


Assuntos
Analgésicos Opioides/análise , Fentanila/análise , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adulto , Idoso de 80 Anos ou mais , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/envenenamento , Cromatografia Líquida , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Fentanila/efeitos adversos , Fentanila/envenenamento , Toxicologia Forense , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Mudanças Depois da Morte , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Espectrometria de Massas em Tandem , Adulto Jovem
19.
West Afr J Med ; 36(3): 232-238, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31622485

RESUMO

BACKGROUND: Pain is a public health problem requiring serious attention. One major barrier to the provision of quality pain treatment in many countries is lack of training for healthcare workers. The aim of this study was to evaluate the impact of pain education on the knowledge and attitude of healthcare workers, and opioid utilization in a university teaching hospital. METHODS: Pain management workshops were conducted for healthcare workers over a 12-month period. The modified "Knowledge and Attitudes Survey Regarding Pain" questionnaire was administered to participants pre- and post- training for each of the workshops. The total mark by each participant was entered into the Statistical Package for Social Sciences (SPSS) software version 16 software for windows (SPSS Inc., Chicago, Illinois, USA) for comparison of means for pre- and post-test. Changes in opioid utilization were evaluated. RESULTS: The pre-test and post-test questionnaires were filled by 715 and 700 participants respectively. The mean post-test score was significantly higher than the pre-test score (68% versus 49% respectively, p = 0.00001). The doctors scored significantly higher than the other groups (p < 0.0001) in the pre-test. The mean post-test scores were significantly higher than the corresponding mean pre-test scores for the various groups (p < 0.0001). Sustained increase (up to 60.4%) in total morphine utilization was observed during the training. CONCLUSION: There is a wide knowledge gap requiring regular training and re-training to achieve improved pain management and opioid utilization among healthcare workers. Inclusion of robust pain curricula in medical training programs will significantly improve pain management.


Assuntos
Analgésicos Opioides/efeitos adversos , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/educação , Manejo da Dor/métodos , Dor/tratamento farmacológico , Competência Profissional , Adulto , Avaliação Educacional , Feminino , Hospitais de Ensino , Humanos , Capacitação em Serviço , Masculino , Pessoa de Meia-Idade , Nigéria , Avaliação de Programas e Projetos de Saúde , Inquéritos e Questionários
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