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1.
Curr Opin Anaesthesiol ; 35(4): 514-520, 2022 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-35788122

RESUMO

PURPOSE OF REVIEW: The increasing prevalence of opioid tolerant individuals, in combination with the expanding scope and utilization of nonoperating room anesthesia (NORA) necessitates ongoing investigation into best clinical practice for managing surgical/procedural pain in this population. The purpose of this article is to review recent guidelines, identify specific challenges, and offer considerations for managing pain in patients who are opioid tolerant secondary to opioid use disorder (OUD), with or without medications for the treatment of OUD. RECENT FINDINGS: A comprehensive preoperative evaluation in conjunction with a multidisciplinary, multimodal pain approach is optimal. NORA adds unique situational and environmental challenges for optimizing acute on chronic pain control in tolerant individuals while maintaining safety. Direct and partial/mixed mu-agonists should typically be continued throughout the perioperative period, while mu-antagonists (naltrexone) should be held 72 h. Postprocedural discharge instructions and follow-up must be carefully arranged and ensured. SUMMARY: Clinical recommendations continue to evolve as new consensus guidelines are published, although institution-specific guidelines are most often followed. This review focuses on most recent best practices, within NORA and operating room settings, for managing opioid tolerant patients, patients with OUD and those on medications for the treatment of OUD.


Assuntos
Anestésicos , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/efeitos adversos , Humanos , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor/tratamento farmacológico , Manejo da Dor/efeitos adversos
2.
Pain Physician ; 25(5): E739-E748, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35901485

RESUMO

BACKGROUND: Spinal cord stimulation (SCS) is an effective treatment for failed back surgery syndrome (FBSS). In patients with FBSS, opioids have often been initiated, even before SCS is trialed. OBJECTIVE: We studied the effect of retirement on opioid use in patients with chronic pain after failed back surgery. STUDY DESIGN: A retrospective study design. SETTING: The study was conducted at Kuopio University Hospital. METHODS: The study group consisted of all 230 patients with SCS trialed or implanted for FBSS at Kuopio University Hospital Neurosurgery from January 1, 1996 through December 31, 2014. All purchases of prescribed opioids and their daily defined doses, as well as data on working ability, were obtained from the Social Insurance Institution. Patients were divided into 3 groups: SCS trial only, SCS implanted permanently, and SCS implanted but later explanted. We analyzed the differences in opioid use among these groups 2 years before and 2 years after the start of their disability pension (DP). RESULTS: During the follow-up period, a total of 60 patients received a DP. One year before DP, the majority of patients used opioids (n = 43, 72%), and throughout the one-year follow-up after retirement, the number of users increased slightly (n = 46, 77%). In the permanently implanted SCS group, the number of strong opioid users decreased after retirement. Most patients used a moderate dose (0.1-10.5 morphine milligram equivalent/d). Retirement appeared to interrupt dose escalation in all groups, but doses increased further as the follow-up continued. LIMITATIONS: No structured questionnaires were used in this study. Also, many underlying factors contributing to chronic pain were missing. CONCLUSIONS: DP did not reduce the use of opioids in patients with FBSS. Opioid doses were lower and dose escalation less steep with continuous SCS therapy.


Assuntos
Dor Crônica , Síndrome Pós-Laminectomia , Transtornos Relacionados ao Uso de Opioides , Estimulação da Medula Espinal , Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Dor Crônica/etiologia , Síndrome Pós-Laminectomia/tratamento farmacológico , Síndrome Pós-Laminectomia/etiologia , Humanos , Transtornos Relacionados ao Uso de Opioides/etiologia , Pensões , Estudos Retrospectivos , Medula Espinal , Estimulação da Medula Espinal/efeitos adversos , Resultado do Tratamento
3.
J Am Coll Surg ; 234(6): 1033-1043, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35703794

RESUMO

BACKGROUND: State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score. STUDY DESIGN: Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as >75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis. RESULTS: A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p < 0.001), depression (p = 0.003), anxiety (p < 0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p < 0.001), and 31 Clinical Classifications Software Refined classifications (p < 0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p < 0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p < 0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use. CONCLUSIONS: Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Assistência ao Convalescente , Analgésicos Opioides/uso terapêutico , Cesárea/efeitos adversos , Feminino , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Alta do Paciente , Padrões de Prática Médica , Gravidez , Prescrições , Estudos Retrospectivos
4.
Anaesthesia ; 77(8): 882-891, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35762026

RESUMO

Persistent pain following knee arthroplasty occurs in up to 20% of patients and may require ongoing analgesia, including extended opioid administration. A comprehensive secondary analysis was performed from results of a study that considered persistent postoperative pain in 242 patients who underwent unilateral knee arthroplasty using a standardised enhanced recovery programme. Opioid prescribing for 12 months before and 12 months after surgery was evaluated and converted to oral morphine equivalents. Demographic, functional, psychological and pain questionnaires were completed along with quantitative sensory testing and genetic analysis. Forty-nine percent of patients had at least one opioid prescription in the 12 months before surgery. Opioid prescriptions were filled in 93% of patients from discharge to 3 months and in 27% of patients ≥6 months after surgery. Persistent opioid use ≥6 months after surgery was strongly associated with pre-operative opioid use (RR 3.2, p < 0.001 (95%CI 1.9-5.4)). The median (IQR [range]) oral morphine equivalent daily dose was 3.6 (0.9-10.5 [0-100.0]) mg pre-operatively, 35.0 (22.5-52.5 [4.6-180.0]) mg in hospital, 12.8 (5.1-24.8 [0-57.9]) mg from discharge to 3 months and 5.9 (4.5-12.0 [0-44.5]) mg at ≥6 months following surgery. Predictors of increased daily oral morphine equivalent ≥6 months after surgery included increased average daily oral morphine equivalent dose compared with previous values (lag), increased body mass index and three or more comorbid pain sites. Persistent opioid use was not associated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (RR 1.003, p = 0.655, 95%CI 0.65-1.002) or WOMAC function (RR 1.001, p = 0.99, 95%CI 0.99-1.03) outcomes 6 months after surgery. There was no association between persistent opioid use and pre-operative quantitative sensory testing results or psychological distress. Pre-operatively, patients with a higher body mass index, more comorbid pain sites and those who had filled an opioid prescription in the last 12 months, were at increased risk of persistent opioid use and a higher oral morphine equivalent daily dose ≥ 6 months after surgery. Strategies need to be developed to limit dose and duration of persistent opioid use in patients following knee arthroplasty surgery.


Assuntos
Artroplastia do Joelho , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides , Artroplastia do Joelho/efeitos adversos , Humanos , Morfina , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor Pós-Operatória/etiologia , Padrões de Prática Médica , Estudos Retrospectivos
5.
Surgery ; 172(2): 602-611, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35387745

RESUMO

BACKGROUND: Opioid overprescribing after surgery is a significant public health issue in most developed countries, including New Zealand. However, there is a lack of literature on the patterns and risk factors for postoperative opioid use among general surgical patients in New Zealand. This study aimed to examine opioid use in patients undergoing general surgery at Auckland District Health Board between January and December 2019 and to identify factors associated with opioid use after surgery and persistent opioid use (defined as having filled ≥1 opioid prescription in the 91 to 180 days after surgery). METHODS AND MATERIALS: This is a retrospective cohort study. Data from patients' electronic clinical records and community pharmacy dispensing records were extracted to obtain data on sociodemographics, surgical characteristics, comorbidities, co-prescribed medications, and opioid use. RESULTS: A total of 1,110 patients were included in the study, with 42.4% dispensed an opioid following discharge after surgery. Of opioid-naïve patients who filled opioids after surgery (n = 401), 9.5% became persistent opioid users. Preoperative use of nonopioid analgesics, longer hospital stays, higher operation severity, procedure type, and higher pain scores were positively associated with opioid use, whereas older age was a negative predictor. Longer hospital stays, an initial discharge prescription with high opioid load, and female sex increased the risk of persistent opioid use. Conversely, a higher severity of surgery was associated with lower risk of persistent opioid use. CONCLUSION: The findings suggest that a considerable proportion of patients become persistent opioid users after surgery. The risk factors identified can guide clinicians to prescribe in a manner that reduces opioid-related adverse outcomes and help guide future interventions.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Assistência ao Convalescente , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Alta do Paciente , Padrões de Prática Médica , Estudos Retrospectivos
6.
Arthroscopy ; 38(4): 1086-1088, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-35369913

RESUMO

In 2020, approximately 94,000 people died in the United States due to drug overdose, a grim 78% increase since release of the American Academy of Orthopaedic Surgeons (AAOS) information statement on opioid abuse nearly 5 years ago. Annual opioid-related mortality rates now far surpass those stemming from either car crashes or gun violence. Multiple risk factors exist for opioid misuse and abuse, including a major risk factor under the orthopaedic surgeon's control-exposure to opioid medication. Prescription protocols that decrease a patient's access to narcotic medication could lead to a decrease in overall opioid abuse, while also avoiding second-order effects, such as drug diversion. Multimodal, nonopioid pain protocols often employ peripheral nerve blocks, acetaminophen, nonsteroidal anti-inflammatory medication (NSAIDs), gabapentinoids, and antispasmodic muscle relaxants, and this has yielded promising results after arthroscopic rotator cuff surgery. As good stewards of the musculoskeletal community, we should proactively employ evidence-based practices for establishing realistic postoperative patient expectations, common analgesic care pathways, and standardized pill counts stratified by procedure type.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/efeitos adversos , Artroplastia/efeitos adversos , Humanos , Transtornos Relacionados ao Uso de Opioides/etiologia , Manejo da Dor/métodos , Manguito Rotador , Estados Unidos
7.
Curr Treat Options Oncol ; 23(7): 921-935, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35435616

RESUMO

OPINION STATEMENT: Long-term opioid therapy (LTOT) for chronic cancer and non-cancer pain is commonly ineffective in providing its stated goal of improving function through good control of pain. Opioid tapering (slow dose reduction and/or discontinuation), the logical solution, also appears to be ineffective among many patients on LTOT as it often leads to even worse pain control and function, leaving the patients and providers managing LTOT in a clinical conundrum with little treatment choices. Complex persistent opioid dependence (CPOD) was recently offered as a heuristic to explain this clinical conundrum exemplified by the ineffectiveness of both LTOT and opioid tapering. This manuscript provides a detailed description of the neurobehavioral underpinnings of CPOD, explaining how long-term opioid use can lead to more pain even while experiencing relief with each opioid dose. CPOD is characterized by the allostatic opponent mechanisms of neuroadaptations related to the progression of opioid dependence and tolerance involving nociceptive/anti-nociceptive brain systems causing opioid-induced hyperalgesia and reward/anti-reward systems causing hyperkatefia or suffering that induces pain experience through the cognitive/emotional component of pain mechanisms. "Opioid Induced Chronic Pain syndrome" (OICP) is offered as an alternate clinical diagnostic term instead of CPOD that has several limitations as a diagnosis term including poor patient acceptance due to stigma towards addiction and clinical confounding with opioid use disorder, a related but separate clinical entity. OICP with LTOT is conceptualized as a recoverable iatrogenic problem that can be managed by pain providers. Broad guidance on management of OICP is also provided.


Assuntos
Dor Crônica , Neoplasias , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/efeitos adversos , Dor Crônica/diagnóstico , Dor Crônica/tratamento farmacológico , Dor Crônica/etiologia , Humanos , Neoplasias/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etiologia , Manejo da Dor
8.
Am J Otolaryngol ; 43(3): 103436, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35429845

RESUMO

BACKGROUND: Based on a 2018 American Academy of Otolaryngology - Head and Neck Surgery survey, an average of 37 tablets of opioid medication, or about a week's worth of medication, were prescribed after adult tonsillectomy. Nearly 15% of patients will still be taking opioids one year after an initial weeklong prescription, according to data from the Centers for Disease Control and Prevention. Non-steroidal anti-inflammatory medications have traditionally been avoided in adult tonsillectomy patients due to concern for increased bleeding risk from platelet dysfunction, despite little evidence supporting this claim. This study sought to demonstrate that ibuprofen prescriptions after tonsillectomy could be a safe and effective way to reduce postoperative opioid use. METHODS: This study was a retrospective chart review of patients undergoing tonsillectomy with one surgeon over three years. Half of the patients received a prescription for postoperative opioid medications and were counseled against taking ibuprofen. The other half of patients were prescribed ibuprofen following surgery and only provided with opioid analgesia as a rescue medication. The New Mexico Prescription Monitoring System was used to verify opioid prescriptions. Descriptive statistics and logistic regression were used to analyze the data. RESULTS: Ninety-nine patients were included in analysis, with 53 in the first group that did not receive ibuprofen and 46 in the second group that did receive ibuprofen. There was no difference in the bleeding rate between the two groups. Significantly fewer patients in the ibuprofen group filled postoperative opioid prescriptions when compared to the group that did not receive ibuprofen (40% vs. 96.2%, p < 0.0001, OR = 0.02). CONCLUSION: Ibuprofen is a safe and effective analgesic following adult tonsillectomy and significantly reduces the proportion of patients who must fill a postoperative opioid prescription.


Assuntos
Analgésicos não Narcóticos , Transtornos Relacionados ao Uso de Opioides , Tonsilectomia , Acetaminofen , Adulto , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Humanos , Ibuprofeno/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Prescrições , Estudos Retrospectivos , Tonsilectomia/efeitos adversos
9.
J Arthroplasty ; 37(6S): S147-S154, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35346549

RESUMO

BACKGROUND: Duloxetine, a serotonin-norepinephrine dual reuptake inhibitor, may improve analgesia after total knee arthroplasty (TKA). Previous studies had one primary outcome, did not consistently use multimodal analgesia, and used patient-controlled analgesia devices, potentially delaying discharge. We investigated whether duloxetine would reduce opioid consumption or pain with ambulation. METHODS: A total of 160 patients received 60 mg duloxetine or placebo daily, starting from the day of surgery and continuing 14 days postoperatively. Patients received neuraxial anesthesia, peripheral nerve blocks, acetaminophen, nonsteroidal anti-inflammatory drugs, and oral opioids as needed. The dual primary outcomes were Numeric Rating Scale (NRS) scores with movement on postoperative days 1, 2, and 14, and cumulative opioid consumption surgery through postoperative day 14. RESULTS: Duloxetine was noninferior to placebo for both primary outcomes and was superior to placebo for opioid consumption. Opioid consumption (mean ± SD) was 288 ± 226 mg OME [94, 385] vs 432 ± 374 [210, 540] (duloxetine vs placebo) P = .0039. Pain scores on POD14 were 4.2 ± 2.0 vs 4.8 ± 2.2 (duloxetine vs placebo) P = .018. Median satisfaction with pain management was 10 (8, 10) and 8 (7, 10) (duloxetine vs placebo) P = .046. Duloxetine reduced interference by pain with walking, normal work, and sleep. CONCLUSION: The 29% reduction in opioid use corresponds to 17 fewer pills of oxycodone, 5 mg, and was achieved without increasing pain scores. Considering the ongoing opioid epidemic, duloxetine can be used to reduce opioid usage after knee arthroplasty in selected patients that can be appropriately monitored for potential side effects of the medication.


Assuntos
Artroplastia do Joelho , Transtornos Relacionados ao Uso de Opioides , Analgesia Controlada pelo Paciente , Analgésicos Opioides , Artroplastia do Joelho/efeitos adversos , Método Duplo-Cego , Cloridrato de Duloxetina/uso terapêutico , Humanos , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia
10.
Curr Opin Anaesthesiol ; 35(3): 401-408, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35283458

RESUMO

PURPOSE OF REVIEW: This review article aims to describe the perioperative clinical implications of opioid use or opioid use disorder (OUD) and to provide recommendations related to analgesia, anesthesia, and postoperative care for patients with this 'new medical disease'. RECENT FINDINGS: Evidence suggest that 1 in 4 surgical patients will be using opioids preoperatively. Management of these patients, or those with OUD, can be challenging given their opioid tolerance, hyperalgesia, decreased pain tolerance, and increased pain sensitivity. Therefore, an individualized plan that considers how to manage OUD treatment medications, the risk of relapse, multimodal analgesia, and postoperative monitoring requirements is highly important. Fortunately, recent publications provide both insight and guidance on these topics. Postoperatively, persistent opioid utilization appears higher in patients currently using opioids and even for those with a prior history. Although numerous other adverse outcomes are also associated with opioid use or abuse, some may be modifiable with cessation. SUMMARY: A coordinated, evidence-based, multidisciplinary team approach is critical when caring for patients with OUD to ensure safety, provide adequate analgesia, and reduce the risk of relapse. Enhanced postoperative monitoring, multimodal analgesia, and a plan for preoperative opioid management may help to modify the risks of adverse postoperative outcomes.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Tolerância a Medicamentos , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Assistência Perioperatória , Recidiva
11.
J Surg Res ; 275: 208-217, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35306256

RESUMO

INTRODUCTION: To justify a practice change, it is critical to determine if opioids prescribed after surgery, surgery prescription (Rx) opioids, are in fact associated with opioid misuse and diversion. Currently, there is only limited data to support this assumption. METHODS: We administered a 40-question survey to US adults (18+) who had received a surgery Rx opioid within the last 5 y on Amazon Mechanical Turk, an online crowdsourcing worksite. Incidence and risk factors for surgery Rx opioid misuse, self-reported taking of surgery Rx opioids in a way other than instructed by a provider, and diversion, self-reported having one's surgery Rx opioids shared, sold, or stolen, were analyzed. The government validated Opioid Risk Tool (ORT) was used. RESULTS: A total of 966 participants from all 50 states met inclusion: 52% were male, 43% were aged 30-39 y, and 79% self-identified as white. Overall, 34% (n = 333) of respondents reported misusing their surgery Rx opioids and risk factors included working in healthcare, scoring high on the ORT, experiencing an elevated mood with opioids, refilling a Rx, and keeping leftover pills. A total of 22% (n = 212) reported diverting their surgery Rx opioids, and risk factors included working in healthcare, scoring high on the ORT, undergoing plastic surgery, refilling a Rx, and keeping leftover pills. CONCLUSIONS: Rates of surgery Rx opioid misuse and diversion in the US may be as high as one in three and one in five adults, respectively. Efforts to improve leftover pill disposal and risk stratification for prescribing patterns may help to mitigate risk.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Adulto , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Padrões de Prática Médica , Fatores de Risco , Inquéritos e Questionários
12.
J Arthroplasty ; 37(7S): S530-S535, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35219575

RESUMO

BACKGROUND: While interest has focused on opioid use after total hip arthroplasty, little research has investigated opioid use in elderly patients after hip fracture. We hypothesize that a substantial number of opioid-naïve elderly patients go on to chronic opioid use after hip fracture surgery. METHODS: We reviewed a consecutive series of 219 patients 65 years and older who underwent surgical fixation between January 1, 2016 and February 28, 2019 for a native hip fracture. Patients were excluded for polytrauma, periprosthetic or pathologic fractures, recent major surgery, or death within 90 days of their hip surgery. The state prescription monitoring database was used to determine opioid use. RESULTS: Overall, 58 patients (26%) were postoperative chronic opioid users. Of the initial 188 opioid-naïve patients, 43 (23%) became chronic users. Of the 31 preoperative opioid users, 15 (48%) continued as chronic users. Chronic postoperative users were more likely to be White (76% vs 91%, P = .04), younger (78 vs 82 years, P = .003), and preoperative opioid users (odds ratio 3.3, P = .007). Arthroplasty vs fixation did not affect the rate of chronic opioid use (P = .22). CONCLUSION: Chronic opioid use is surprisingly common after hip fracture repair in the elderly. Twenty-three percent of opioid-naïve hip fracture patients became chronic users after surgery. Continued vigilance is needed by orthopedic surgeons to limit the amount and duration of postoperative narcotic prescriptions and to monitor for continued use.


Assuntos
Artroplastia de Quadril , Fraturas do Quadril , Transtornos Relacionados ao Uso de Opioides , Idoso , Analgésicos Opioides/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/cirurgia , Humanos , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Prevalência , Estudos Retrospectivos
13.
Surgery ; 172(1): 241-248, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35181126

RESUMO

BACKGROUND: More than 100 million surgeries take place annually in the United States, and more than 90% of surgical patients receive an opioid prescription. A sizable minority of these patients will go on to use opioids long-term, contributing to the national opioid epidemic. METHODS: The objective of this study was to develop and validate a model to predict persistent opioid use after surgery. Participants included surgical patients (≥18 years old) enrolled in a cohort study at an academic medical center between 2015 and 2018. Persistent opioid use was defined as filling opioid prescriptions in postdischarge days 4 to 90 and 91 to 180. Predictors included electronic health record data, state prescription drug monitoring data, and patient-reported measures. Three models were developed: a full, a restricted, and a minimal model using a derivation and validation cohort. RESULTS: Of 24,040 patients, 4,879 (20%) experienced persistent opioid use. In the validation cohort, the full, restricted, and minimal model had C-statistics of 0.87 (95% CI 0.86-0.88), 0.86 (0.85-0.88), and 0.85 (0.84-0.87), respectively. All models performed better among patients with preoperative opioid use compared to opioid-naive patients (P < .001). The models slightly overpredicted risk in the validation cohort. The net benefit of using the restricted model to refer patients for preoperative counseling was 0.072 to 0.092, which is superior to evaluating no patients (net benefit of 0) or all patients (net benefit of -0.22 to -0.63). CONCLUSION: This study developed and validated a prediction model for persistent opioid use using accessible data resources. The models achieved strong performance, outperforming prior published models.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Adolescente , Assistência ao Convalescente , Analgésicos Opioides/uso terapêutico , Estudos de Coortes , Registros Eletrônicos de Saúde , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Alta do Paciente , Medidas de Resultados Relatados pelo Paciente , Estados Unidos/epidemiologia
14.
Am J Obstet Gynecol MFM ; 4(3): 100576, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-35114423

RESUMO

BACKGROUND: Anxiety disorders are the most common mental health condition. They are associated with negative pain experiences and can hinder rehabilitation in the hospital setting. Anxiety has been shown to be predictive of increased postoperative pain in patients undergoing nonobstetrical surgery. OBJECTIVE: To evaluate the impact of preexisting maternal anxiety disorders on average self-reported pain scores and opioid use in the first 24 hours following cesarean delivery STUDY DESIGN: This was a single-center retrospective cohort study of cesarean deliveries between January 1, 2016 and December 31, 2017. The primary outcome was average pain, calculated by averaging all documented self-reported pain scores (0-10 scale) during the first 24 hours postdelivery. The secondary outcome included the oral morphine milligram equivalents used in the first 24 hours postdelivery. Analysis of the impact of anxiety disorders on these outcomes was performed using multivariable linear regression to control for confounding variables. RESULTS: A total of 2228 cesarean deliveries were analyzed, of which 578 (25.9%) had an anxiety disorder documented. Women with a diagnosis of anxiety had higher average pain scores (3.9 vs 3.5; P<.001) and morphine milligram equivalents use (110.4 mg vs 102.2 mg; P<.001) than women without anxiety. CONCLUSION: Patients with preexisting anxiety diagnoses reported higher average pain scores and opioid pain medication use in the first 24 hours following cesarean delivery.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/efeitos adversos , Ansiedade/diagnóstico , Ansiedade/tratamento farmacológico , Ansiedade/epidemiologia , Feminino , Humanos , Derivados da Morfina/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Gravidez , Estudos Retrospectivos
15.
Am J Clin Oncol ; 45(4): 161-167, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35131971

RESUMO

PURPOSE: We sought to characterize the incidence of chronic opioid dependence among head and neck cancer survivors treated by radiation, as well as to identify patient and treatment factors associated with persistent use. MATERIALS AND METHODS: The medical records of patients with head and neck cancer who received radiation therapy from January 2012 to July 2016 were reviewed. All patients received 60 to 70 Gy with curative intent. Patients who progressed or died within 1 year were intentionally excluded. Opioid doses were calculated in morphine equivalent daily doses in milligrams (mg). Univariate and multivariate regression models were used to identify associations between demographic, medical, disease, and persistent opioid use. RESULTS: Two hundred and sixty-one patients were included. The median follow-up was 39 months (range: 12 to 83 mo). Two hundred and eleven patients (80%) received opioids for pain control during radiation. The median morphine equivalent daily dose during treatment was 73.8 mg (range: 5 to 561 mg). Rates of persistent opioid use at 6 months, 1 year, and 2 years from completion of radiation were 41.8%, 30.1%, and 26.0%, respectively. On multivariate analysis, only preradiation opioid use correlated with persistent opioid use at all 3 time points (P<0.05). Smoking history and a Charlson comorbidity index ≥2 predicted for persistent opioid use at some time points, but not all. CONCLUSIONS: High rates of persistent opioid use exist in patients with head and neck cancer after radiation therapy. Early interventions to appropriately wean patients should be further investigated.


Assuntos
Neoplasias de Cabeça e Pescoço , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Neoplasias de Cabeça e Pescoço/radioterapia , Humanos , Incidência , Derivados da Morfina , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Estudos Retrospectivos , Sobreviventes
16.
J Arthroplasty ; 37(5): 824-830, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-35114319

RESUMO

BACKGROUND: Preoperative opioid use strongly correlates with greater postoperative opioid use and complications following total joint arthroplasty (TJA). However, there is a lack of information regarding the effect of opioid consumption during the hospital stay and within the operating room on postoperative opioid use. METHODS: We retrospectively reviewed 369 consecutive patients undergoing primary TJA at an academic center over a 9-month period. Ninety-day preoperative and postoperative opioid prescriptions were obtained from the state's drug monitoring database. In-hospital opioid consumption data was obtained from the preoperative unit, operating room, postanesthesia care unit (PACU), and hospital floor. Multivariate analysis was utilized to compare patients' total in-hospital opioid consumption with their preoperative and postoperative use, along with opioid use throughout the hospitalization. RESULTS: Total in-hospital opioid consumption was independently associated with postoperative opioid use (rs = 0.17, P = .0010). Opioids consumed on the hospital floor correlated with opioid use in the preoperative unit (rs = 0.11, P = .0338) and PACU (rs = 0.15, P = .0032). Increased preoperative opioid consumption was the greatest risk factor for excessive postoperative use (rs = 0.44, P < .0001). A greater proportion of patients <65 years of age were high posthospital opioid consumers (P = .0146) and significantly more TKA patients were in the higher use groups (P = .0006). CONCLUSION: In-hospital opioid use is independently associated with preoperative and postoperative consumption. Preoperative opioid use remains the greatest risk factor for increased opioid consumption after TJA. Multimodal approaches to decrease reliance on opioids for pain control during hospitalization may offer hope to further decrease postoperative usage. LEVEL OF EVIDENCE: III.


Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Hospitais , Humanos , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Estudos Retrospectivos
17.
Drug Des Devel Ther ; 16: 251-264, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35082488

RESUMO

BACKGROUND: The adverse effects of short-term opioid analgesics are well known and acknowledged; however, the spectrum of the sequelae of long-term use seems less clear. Some effects may remain undetected but still have the potential to cause harm and reduce patients' quality of life. OBJECTIVE: To review the literature on the adverse effects of long-term opioid therapy. METHODS: We performed a quasi-systematic search, analyzing articles published in the MEDLINE database between January 2000 and March 2021 that identified adverse effects of opioids used for chronic pain treatment. RESULTS: Growing evidence indicates that there are multiple serious adverse effects of opioid treatment. Long-term opioid use may have significant effects on the endocrine, immune, cardiovascular, respiratory, gastrointestinal, and neural systems. Studies show that long-term opioid treatment increases the risk of fractures, infections, cardiovascular complications, sleep-disordered breathing, bowel dysfunction, overdose, and mortality. Opioids may potentially affect cancer development. Most consequences of the long-term use of opioids have been identified in studies of patients with non-malignant pain. CONCLUSION: Studies indicate that long-term use of opioids increases the risk of drug-related events in a significant number of patients. Clinicians should be aware of these complications associated with prescribing opioids, discuss them with patients, prevent complications, if possible, and diagnose them early and manage adequately. More human studies are needed to assess the risk, including trials with individual opioids, because they have different adverse effect profiles.


Assuntos
Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Dor Crônica/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etiologia , Animais , Contraindicações , Humanos , Qualidade de Vida
18.
JAMA Surg ; 157(2): 158-166, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-34878527

RESUMO

Importance: Uncontrolled and indiscriminate prescribing of opioids has led to an opioid crisis that started in North America and spread throughout high-income countries. The aim of this narrative review was to explore some of the current issues surrounding the use of opioids in the perioperative period, focusing on drivers that led to escalation of use, patient harms, the move away from using self-reported pain scores alone to assess adequacy of analgesia, concerns about the routine use of controlled-release opioids for the management of acute pain, opioid-free anesthesia and analgesia, and prescription of opioids on discharge from hospital. Observations: The origins of the opioid crisis are multifactorial and may include good intentions to keep patients pain free in the postoperative period. Assessment of patient function may be better than unidimensional numerical pain scores to help guide postoperative analgesia. Immediate-release opioids can be titrated more easily to match analgesic requirements. There is currently no good evidence to show that opioid-free anesthesia and analgesia affects opioid prescribing practices or the risk of persistent postoperative opioid use. Attention should be paid to discharge opioid prescribing as repeat and refill prescriptions are risk-factors for persistent postoperative opioid use. Opioid stewardship is paramount, and many governments are passing legislation, while statutory bodies and professional societies are providing advice and guidance to help mitigate the harm caused by opioids. Conclusions and Relevance: Opioids remain a crucial part of many patients' journey from surgery to full recovery. The last few decades have shown that unfettered opioid use puts patients and societies at risk, so caution is needed to mitigate those dangers. Opioid stewardship provides a multilayered structure to allow continued safe use of opioids as part of broad pain management strategies for those patients who benefit from them most.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Humanos , Transtornos Relacionados ao Uso de Opioides/etiologia , Manejo da Dor/métodos , Medição da Dor
19.
Surg Endosc ; 36(1): 701-710, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-33569727

RESUMO

BACKGROUND: Opioid dependence is a public health crisis and surgery is a risk factor for long-term opioid use. Though minimally invasive surgery (MIS) is associated with less perioperative pain, demonstrating an association with less long-term opioid use would be another reason to justify adoption of minimally invasive techniques. We compared the rates for long-term opioid prescriptions among patients in a large national database who underwent minimally invasive and open colectomy. METHODS: Using the MarketScan Database, we retrospectively analyzed patients undergoing colon resection for benign and malignant diseases between 2013 and 2017. Among opioid-naïve patients who had ≥ 1 opioid prescriptions filled perioperatively (30 days before surgery to 14 days after discharge), propensity score matching was applied for group comparisons [open (OS) versus MIS, and laparoscopic (LS) versus robotic-assisted surgery (RS)]. The primary outcome was long-term opioid use defined as the proportion of patients with ≥ 1 long-term opioid prescriptions filled 90-180 days after discharge. Risks factors for long-term opioid use were assessed using logistic regression. RESULTS: Among the 5413 matched pairs in the MIS versus OS cohorts, MIS significantly reduced long-term opioid use of 'any opioids' (13.3% vs. 20.9%), schedule II/III opioids (11.7% vs. 19.2%), and high-dose opioids (4.3% vs. 7.7%; all p < 0.001). Among the 1195 matched pairs in the RS versus LS cohorts, RS was associated with less high-dose opioids (2.1% vs. 3.8%, p = 0.015) 90-180 days after discharge. Other risk factors for long-term opioid use included younger age, benign indications, tobacco use, mental health conditions, and > 6 Charlson comorbidities. CONCLUSION: Minimally invasive colectomy is associated with a significant reduction in long-term opioid use when compared to OS. Robotic-assisted colectomy was associated with less high-dose opioids compared to LS. Increasing adoption of minimally invasive surgery for colectomy and including RS, where appropriate, may decrease long-term opioid use.


Assuntos
Laparoscopia , Transtornos Relacionados ao Uso de Opioides , Procedimentos Cirúrgicos Robóticos , Analgésicos Opioides/uso terapêutico , Colectomia/métodos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Pontuação de Propensão , Estudos Retrospectivos
20.
J Pharmacol Exp Ther ; 380(1): 1-14, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34625464

RESUMO

Opioid use disorder reflects a major public health crisis of morbidity and mortality in which opioid withdrawal often contributes to continued use. However, current medications that treat opioid withdrawal symptoms are limited by their abuse liability or lack of efficacy. Although cannabinoid 1 (CB1) receptor agonists, including Δ9-tetrahydrocannabinol, ameliorate opioid withdrawal in both clinical and preclinical studies of opioid dependence, this strategy elicits cannabimimetic side effects as well as tolerance and dependence after repeated administration. Alternatively, CB1 receptor positive allosteric modulators (PAMs) enhance CB1 receptor signaling and show efficacy in rodent models of pain and cannabinoid dependence but lack cannabimimetic side effects. We hypothesize that the CB1 receptor PAM ZCZ011 attenuates naloxone-precipitated withdrawal signs in opioid-dependent mice. Accordingly, male and female mice given an escalating dosing regimen of oxycodone, a widely prescribed opioid, and challenged with naloxone displayed withdrawal signs that included diarrhea, weight loss, jumping, paw flutters, and head shakes. ZCZ011 fully attenuated naloxone-precipitated withdrawal-induced diarrhea and weight loss and reduced paw flutters by approximately half, but its effects on head shakes were unreliable, and it did not affect jumping behavior. The antidiarrheal and anti-weight loss effects of ZCZ0111 were reversed by a CB1 not a cannabinoid receptor type 2 receptor antagonist and were absent in CB1 (-/-) mice, suggesting a necessary role of CB1 receptors. Collectively, these results indicate that ZCZ011 completely blocked naloxone-precipitated diarrhea and weight loss in oxycodone-dependent mice and suggest that CB1 receptor PAMs may offer a novel strategy to treat opioid dependence. SIGNIFICANCE STATEMENT: Opioid use disorder represents a serious public health crisis in which current medications used to treat withdrawal symptoms are limited by abuse liability and side effects. The CB1 receptor positive allosteric modulator (PAM) ZCZ011, which lacks overt cannabimimetic behavioral effects, ameliorated naloxone-precipitated withdrawal signs through a CB1 receptor mechanism of action in a mouse model of oxycodone dependence. These results suggest that CB1 receptor PAMs may represent a viable strategy to treat opioid withdrawal.


Assuntos
Antidiarreicos/uso terapêutico , Agonistas de Receptores de Canabinoides/uso terapêutico , Diarreia/tratamento farmacológico , Indóis/uso terapêutico , Síndrome de Abstinência a Substâncias/tratamento farmacológico , Tiofenos/uso terapêutico , Regulação Alostérica , Animais , Diarreia/etiologia , Feminino , Masculino , Camundongos , Camundongos Endogâmicos ICR , Naloxona/efeitos adversos , Antagonistas de Entorpecentes/efeitos adversos , Entorpecentes/toxicidade , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etiologia , Oxicodona/toxicidade , Receptor CB1 de Canabinoide/metabolismo , Síndrome de Abstinência a Substâncias/etiologia
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