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The New Zealand Medical Journal Feb 2024Excessive opiate analgesia in relation to orthopaedic surgery is associated with morbidity and mortality. Pre-operative use of opiates is associated with higher...
AIMS
Excessive opiate analgesia in relation to orthopaedic surgery is associated with morbidity and mortality. Pre-operative use of opiates is associated with higher post-operative use. There is little information about opiate prescribing practices in relation to elective total joint arthroplasty (TJA) in New Zealand rural centres. The aims of this study were to describe opiate use before, immediately after and 1 year after TJA, and to compare prescribing practices with local guidelines.
METHODS
A retrospective cohort study of elective primary hip and knee arthroplasties was conducted between January 2018 and April 2019. Opiate use was evaluated from clinical records and from electronic prescribing records and described in morphine milligram equivalents (MME) with a particular focus on pre-operative and post-operative periods, and use after 1 year.
RESULTS
In the study period, 199 patients underwent 203 joint arthroplasties. Of these, data from 157 patients were analysed. Patient data were not analysed because of unavailable files (N=20), non-elective procedures (N=11), bilateral arthroplasties (N=4), deaths (N=4) and incomplete information (N=3). Pre-operative opiates were used by 92 (59%) patients, of whom 70 (76%) were not using opiates after 1 year. There were 126 (80%) patients who were discharged with opiate prescriptions and the vast majority, 121 (96%), did not receive discharge prescriptions that conformed to local guidelines.
CONCLUSION
Despite undergoing joint arthroplasty, about one quarter of patients who had been prescribed opiates before the operation were still receiving opiates after 1 year. There was poor compliance with local guidelines.
Topics: Humans; Arthroplasty, Replacement, Knee; Opiate Alkaloids; Retrospective Studies; Analgesics, Opioid; New Zealand; Prescriptions; Arthroplasty, Replacement, Hip; Pain, Postoperative; Practice Patterns, Physicians'
PubMed: 38301201
DOI: 10.26635/6965.6327 -
Drug and Therapeutics Bulletin Aug 2023Etminan M, Rezaeianzadeh R, Kezouh A, et al. Association between sublingual buprenorphine-naloxone exposure and dental disease. JAMA. 2022;328:2269-71. (Review)
Review
Etminan M, Rezaeianzadeh R, Kezouh A, et al. Association between sublingual buprenorphine-naloxone exposure and dental disease. JAMA. 2022;328:2269-71.
Topics: Humans; Administration, Sublingual; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Drug-Related Side Effects and Adverse Reactions; Naloxone; Narcotic Antagonists; Opioid-Related Disorders
PubMed: 37353308
DOI: 10.1136/dtb.2023.000034 -
Canadian Journal of Surgery. Journal... 2023Pancreaticoduodenectomy is the only curative option for patients with pancreatic cancer; however, pain remains a considerable problem postoperatively. With many centres...
BACKGROUND
Pancreaticoduodenectomy is the only curative option for patients with pancreatic cancer; however, pain remains a considerable problem postoperatively. With many centres moving away from using epidural analgesia, there is the need to evaluate alternative opiate sparing techniques for postoperative analgesia. We sought to determine if rectus sheath catheters (RSCs) had an opiate sparing and analgesic effect compared with standard care alone (opiate analgesia).
METHODS
We conducted a retrospective pre- and postintervention cohort study of patients undergoing pancreaticoduodenectomy at a single tertiary academic hospital in Toronto, Canada, between April 2018 and December 2019. All patients undergoing a pancreaticoduodenectomy were eligible for inclusion. Among the 101 patients identified, 84 (61 control, 23 RSCs) were analyzed after exclusion criteria were applied (epidural analgesia, admission to intensive care intubated or reintubated within the first 96 hours). The pre-intervention group received a semi-standardized course of analgesics, including intravenous hydromorphone, acetaminophen, ketamine, with or without nonsteroidal anti-inflammatory, and with or without intravenous lidocaine; the latter 2 drugs were at the individual anesthesiologist and surgeon's preference. For the postintervention group, the same course of analgesics were used, with the addition of RSCs. These were inserted at the end of the operation, with a loading dose of ropivacaine administered and followed by a programmed intermittent bolus regime for 72-96 hours. The primary outcome measure was total postoperative opiate consumption (oral morphine equivalents). Secondary outcomes included pain scores (numeric rating scale) and treatment-related adverse effects.
RESULTS
Opiate consumption (oral morphine equivalents) at 96 hours was significantly lower (median 188 mg, interquartile range [IQR] 112-228 v. 242.4 mg, IQR 166.8-352) with and without RSC, respectively ( = 0.01). The RSC group used significantly less opiates at each time point from 24 hours postoperatively, with no significant difference in pain scores between the groups and no significant catheter-related complications.
CONCLUSION
The use of RSCs was associated with significant reductions in postoperative opiate consumption. Given the ease of placement and management, with minimal complications, RSCs should be incorporated into a course of postoperative multimodal analgesia. A large scale randomized controlled trial should be conducted to further investigate these findings.
Topics: Humans; Opiate Alkaloids; Analgesics, Opioid; Retrospective Studies; Pain, Postoperative; Cohort Studies; Pancreaticoduodenectomy; Treatment Outcome; Analgesics; Morphine; Postoperative Complications; Catheters
PubMed: 37442583
DOI: 10.1503/cjs.006922 -
Blocking Palmitoylation of Apelin Receptor Alleviates Morphine Tolerance in Neuropathic Cancer Pain.International Journal of Biological... 2024Neuropathic cancer pain (NCP) is an important symptom in patients with cancer. However, significant analgesic tolerance and other side effects critically hamper the...
Neuropathic cancer pain (NCP) is an important symptom in patients with cancer. However, significant analgesic tolerance and other side effects critically hamper the administration of morphine. Protein palmitoylation mediated by the DHHC family may be involved in the glial activation and inflammatory responses underlying organ failure. In this study, we investigated the key role of protein palmitoylation in cancer pain and sought to target palmitoylation to suppress morphine tolerance. We found that long-term use of morphine led to the accumulation of the morphine metabolite, morphine-3-glucuronide, and activated ERK1/2 and microglia to release inflammatory factors through the apelin receptor APLNR. Palmitoyltransferase ZDHHC9 was upregulated in NCP, and APLNR was palmitylated to protect it from lysosomal degradation and to maintain its stability. We also designed competitive inhibitors of APLNR palmitoylation to inhibit the development of NCP, release of inflammatory factors, and attenuation of morphine tolerance. Therefore, targeting APLNR palmitoylation in combination with morphine is a potent method for cancer pain treatment. Our data provide a basis for the future clinical use of related drugs combined with morphine for the treatment of cancer-related pain.
Topics: Humans; Morphine; Apelin Receptors; Cancer Pain; Lipoylation; Neuralgia; Neoplasms
PubMed: 38164190
DOI: 10.7150/ijbs.86888 -
Missouri Medicine 2024
Topics: Naloxone; Humans; Narcotic Antagonists; Drug Overdose
PubMed: 38694597
DOI: No ID Found -
Journal of Addiction MedicineBuprenorphine is not reliably stocked in many pharmacies, and pharmacy-level barriers may deter patients from opioid use disorder care. We surveyed all outpatient...
OBJECTIVES
Buprenorphine is not reliably stocked in many pharmacies, and pharmacy-level barriers may deter patients from opioid use disorder care. We surveyed all outpatient pharmacies in Philadelphia to describe variation in buprenorphine access and developed a map application to aid in identifying pharmacies that stock the medication.
METHODS
Using a dataset from the Bureau of Professional and Occupational Affairs, we conducted a telephone survey of operating outpatient pharmacies (N = 422) about their buprenorphine stocking and dispensing practices. We used ArcGIS Pro 3.0.3 to join US Census Bureau ZIP code-level race and ethnicity data, conduct descriptive analyses, and create a map application.
RESULTS
We collected data from 351 pharmacies (83% response rate). Two hundred thirty-eight pharmacies (68%) indicated that they regularly stock buprenorphine; 6 (2%) would order it when a prescription is sent. Ninety-one (26%) said that they do not stock or order buprenorphine, and 16 (5%) were unsure. We identified 137 "easier access" pharmacies (39%), meaning they regularly stock buprenorphine, dispense to new patients, and have no dosage maximums. Zip codes with predominantly White residents had a median (interquartile range) of 3 (2-4) "easier access" pharmacies, and those with predominantly Black residents a median (interquartile range) of 2 (1-4.5). Nine zip codes had no "easier access" pharmacies, and 3 had only one; these 3 zip codes are areas with predominantly Black residents.
CONCLUSIONS
Buprenorphine access is not equitable across Philadelphia and a quarter of pharmacies choose not to carry the medication. Our map application may be used to identify pharmacies in Philadelphia that stock buprenorphine.
Topics: Buprenorphine; Humans; Philadelphia; Opioid-Related Disorders; Health Services Accessibility; Pharmacies; Opiate Substitution Treatment; Narcotic Antagonists
PubMed: 38345212
DOI: 10.1097/ADM.0000000000001284 -
Cleveland Clinic Journal of Medicine Sep 2023Buprenorphine is a safe and effective treatment for opioid use disorder but remains underutilized because a major challenge of conventional buprenorphine initiation... (Review)
Review
Buprenorphine is a safe and effective treatment for opioid use disorder but remains underutilized because a major challenge of conventional buprenorphine initiation (termed ) is that the patient must already be in opioid withdrawal. Previous legal barriers and clinician lack of familiarity with the unique pharmacology of buprenorphine have also limited its use. In this review, we outline changes regarding buprenorphine prescribing laws and physician perceptions of buprenorphine. We also review buprenorphine pharmacology and novel low-dose buprenorphine induction procedures that can be adopted in primary care settings to improve treatment acceptability, retention, and outcomes.
Topics: Humans; Buprenorphine; Opioid-Related Disorders; Physicians; Substance Withdrawal Syndrome; Primary Health Care
PubMed: 37657832
DOI: 10.3949/ccjm.90a.23022 -
BMJ Supportive & Palliative Care Jan 2024Although there is low-quality evidence, there has been an increase in publications on the experience of evaluating and managing cancer-related breathlessness using... (Review)
Review
INTRODUCTION
Although there is low-quality evidence, there has been an increase in publications on the experience of evaluating and managing cancer-related breathlessness using opioids other than morphine.
METHODS
The author conducted a non-systematic literature review in the PubMed/Medline and Embase until 4 October 2022. Eligible studies have evaluated the efficacy of opioids other than morphine for cancer-related breathlessness. Studies focused on sedation, anaesthesia, paediatric patients, opioid toxicity or basic research were excluded. Reviews/meta-analyses and non-English language publications were also excluded.
RESULTS
A total of 1556 records were identified, of which 23 studies including 469 patients who were treated with fentanyl (n=223), oxycodone (n=171) and hydromorphone (n=75) were considered eligible. Six phase II randomised clinical trials (RCTs), four observational studies and four case reports of fentanyl were found. For breathlessness on exertion, fentanyl yielded promising results, but no RCT showed significant superiority of fentanyl to placebo or morphine. For terminal breathlessness, three RCTs, five non-randomised or observational studies and one case report on oxycodone or hydromorphone were found. Although the results of the observational studies suggested that oxycodone and hydromorphone might be effective alternatives to morphine, the superiority over placebo or non-inferiority to morphine had not been demonstrated in the RCTs.
CONCLUSION
As an alternative to morphine, the author recommends fentanyl for breathless crisis or breathlessness on exertion, and oxycodone or hydromorphone for terminal breathlessness in advanced cancer. Larger and well-designed studies based on firm research policies are needed to confirm this current knowledge.
Topics: Child; Humans; Analgesics, Opioid; Dyspnea; Fentanyl; Hydromorphone; Morphine; Neoplasms; Oxycodone
PubMed: 37468224
DOI: 10.1136/spcare-2022-004115 -
Drug and Alcohol Dependence Nov 2023Buprenorphine reduces risk of opioid overdose mortality. However, its benefits are limited by low retention, particularly in early treatment. Optimizing initial dosage...
BACKGROUND
Buprenorphine reduces risk of opioid overdose mortality. However, its benefits are limited by low retention, particularly in early treatment. Optimizing initial dosage may impact retention. However, little is known about the prescription characteristics of new buprenorphine treatment episodes.
METHODS
In a US sample of commercial and employer-sponsored pharmacy claims, we identified new buprenorphine treatment episodes (days 1-30) from individuals ≥16 years following 90 days without buprenorphine from 2010 to 2019. Outcomes included first prescription average days supplied, first prescription average daily dosage, and average dosage on days 2, 8, 15 and 30.
RESULTS
We identified 117,793 new episodes among 96,451 unique individuals. Episodes per 10,000 person-years decreased slightly over time. Stratifying by age, sex and region demonstrated decreasing episodes among individuals ≤34 years and increasing episodes among individuals ≥35 years. From 2010-2019, first prescription average days supplied and daily dosage decreased from 17.1 to 15.3 days and 13.6mg to 11.6mg, respectively. Simultaneously, the proportion of episodes without possession and with dosages <16mg increased across all days and years. By day 30, episodes without buprenorphine possession grew from 27.9% to 30.8% and episodes involving dosages of <16mg grew from 26.4% to 33.4%.
CONCLUSIONS
We found that buprenorphine dosage and days supplied for new treatment episodes decreased from 2010 to 2019 while buprenorphine possession worsened. Further investigation examining the relationship between buprenorphine dosage and retention in the early treatment period is needed.
Topics: Humans; Adult; Buprenorphine; Opioid-Related Disorders; Opiate Substitution Treatment; Opiate Overdose; Analgesics, Opioid; Retrospective Studies
PubMed: 37839942
DOI: 10.1016/j.drugalcdep.2023.110981 -
The Western Journal of Emergency... Nov 2023Recent studies have demonstrated the promise of emergency department (ED)-initiated buprenorphine/naloxone (bup/nx) for improving 30-day retention in outpatient...
INTRODUCTION
Recent studies have demonstrated the promise of emergency department (ED)-initiated buprenorphine/naloxone (bup/nx) for improving 30-day retention in outpatient addiction care programs for patients with opioid use disorder (OUD). We investigated whether ED-initiated bup/nx for OUD also impacts repeat ED utilization.
METHODS
We performed a retrospective chart review of ED patients discharged with a primary diagnosis of OUD from July 2019-December 2020. Characteristics considered included age, gender, race, insurance status, domicile status, presence of comorbid Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, presenting chief complaint, and provision of a bup/nx prescription and/or naloxone kit. Primary outcomes included repeat ED visit (opioid or non-opioid related) within 30 days, 90 days, and one year. Statistical analyses included bivariate comparison and Poisson regression.
RESULTS
Of 169 participants, the majority were male (67.5%), White (82.8%), uninsured (72.2%), and in opioid withdrawal and/or requesting "detox" (75.7%). Ninety-one (53.8%) received ED-initiated bup/nx, which was independent of age, gender, race, insurance status, presence of comorbid DSM-5 diagnosis, or domicile status. Naloxone was more likely to be provided to patients who received bup/nx (97.8% vs 26.9%; < 0.001), and bup/nx was more likely to be given to patients who presented with opioid withdrawal and/or requested "detox" (63.3% vs 36.7%; < 0.001). Bup/nx provision was associated with decreased ED utilization for opioid-related visits at 30 days ( = 0.04). Homelessness and lack of insurance were associated with increased ED utilization for non-opioid-related visits at 90 days ( = 0.008 and = 0.005, respectively), and again at one year for homelessness ( < 0.001). When controlling for age and domicile status, the adjusted incidence rate ratio for overall ED visits was 0.56 (95% confidence interval [CI] 0.33-0.96) at 30 days, 0.43 (95% CI 0.27-0.69) at 90 days, and 0.60 (95% CI 0.39-0.92) at one year, favoring bup/nx provision.
CONCLUSION
Initiation of bup/nx in the ED setting was associated with decreased subsequent ED utilization. Socioeconomic factors, specifically health insurance and domicile status, significantly impacted non-opioid-related ED reuse. These findings demonstrate the ED's potential as an initiation point for bup/nx and highlight the importance of considering the social risk and social need for OUD patients.
Topics: Humans; Male; Female; Buprenorphine; Narcotic Antagonists; Analgesics, Opioid; Retrospective Studies; Opiate Substitution Treatment; Naloxone; Opioid-Related Disorders; Substance Withdrawal Syndrome
PubMed: 38165181
DOI: 10.5811/westjem.60511