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American Journal of Surgery Oct 2023
Topics: Humans; Opium; Opiate Alkaloids; Opioid-Related Disorders
PubMed: 37336710
DOI: 10.1016/j.amjsurg.2023.06.007 -
The Journal of Emergency Medicine Feb 2020Precipitated opioid withdrawal (POW) after opioid antagonist administration can be challenging to manage in the emergency department (ED), particularly if caused by a... (Review)
Review
BACKGROUND
Precipitated opioid withdrawal (POW) after opioid antagonist administration can be challenging to manage in the emergency department (ED), particularly if caused by a long-acting opioid antagonist such as naltrexone. There are no evidence-based guidelines to assist in safely and efficiently managing patients with this syndrome.
OBJECTIVE OF REVIEW
To review current practice on the treatment of long-acting antagonist POW and make recommendations on the treatment of this complex disease process.
METHODS
A literature search of opioid withdrawal cases precipitated by naltrexone was done using PubMed. One of the authors screened all the results of this search by title and abstract, leading to a final count of 27 articles that were reviewed in full by all authors. English language cases that involved precipitated opioid withdrawal from a long-acting opioid antagonist were included. Data were extracted, including the precipitant involved and dose, severity of opioid withdrawal, treatments rendered, and response to treatment. In all cases where symptoms and signs were described, a Clinical Opiate Withdrawal Scale score was calculated based on the information available.
RESULTS
Twenty-seven papers were included. Naltrexone alone was the primary antagonist reported in 19 of the papers, extended-release naltrexone in two, naltrexone-morphine combination in two, and nalmefene in four. Treatment most commonly included fluid replacement, benzodiazepines, antiemetics, and clonidine. Full opioid agonist treatment, although often suggested, was poorly described. Buprenorphine successfully reduced the severity and duration of withdrawal in several cases. No standardized response scale was used, and response to treatment ranged from 3 to 48 h prior to resolution of clinical effects.
CONCLUSIONS
Management of POW from long-acting antagonists is a complex problem with little formal evaluation of treatment options. There is not currently a sufficiently robust body of literature to support an evidence-based guideline. However, use of intravenous fluids, antiemetics, and benzodiazepines is commonly reported as successful and seems to be a reasonable approach until this process is better studied. A treatment strategy using partial agonists such as buprenorphine is emerging and may represent a safe and effective treatment pathway for these patients.
Topics: Drug Combinations; Emergency Service, Hospital; Humans; Morphine; Naltrexone; Narcotic Antagonists; Opioid-Related Disorders; Substance Withdrawal Syndrome
PubMed: 32005608
DOI: 10.1016/j.jemermed.2019.12.015 -
Cancer Epidemiology, Biomarkers &... Mar 2020There is little information on human exposure to carcinogens and other toxicants related to opiate use, alone or in combination with tobacco.
BACKGROUND
There is little information on human exposure to carcinogens and other toxicants related to opiate use, alone or in combination with tobacco.
METHODS
Among male participants of the Golestan Cohort Study in Northeast Iran, we studied 28 never users of either opiates or tobacco, 33 exclusive cigarette smokers, 23 exclusive users of smoked opiates, and 30 opiate users who also smoked cigarettes (dual users; 21 smoked opiates and 9 ingested them). We quantified urinary concentrations of 39 exposure biomarkers, including tobacco alkaloids, tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons (PAH), and volatile organic compounds (VOC), and used decomposition to parse out the share of the biomarker concentrations explained by opiate use and nicotine dose.
RESULTS
Dual users had the highest concentrations of all biomarkers, but exclusive cigarette smokers and exclusive opiate users had substantially higher concentrations of PAH and VOC biomarkers than never users of either product. Decomposition analysis showed that opiate use contributed a larger part of the PAH concentrations than nicotine dose, and the sum of 2- and 3-hydroxyphenanthrene (∑-phe) resulted almost completely from opiate use. Concentrations of most VOC biomarkers were explained by both nicotine dose and opiate use. Two acrylamide metabolites, a 1,3-butadiene metabolite and a dimethylformamide metabolite, were more strongly explained by opiate use. Acrylamide metabolites and ∑-phe were significantly higher in opiate smokers than opiate eaters; other biomarkers did not vary by the route of opiate intake.
CONCLUSIONS
Both cigarette smokers and opiate users (by smoking or ingestion) were exposed to many toxicants and carcinogens.
IMPACT
This high exposure, particularly among dual opiate and cigarette users, can have a substantial global public health impact.
Topics: Administration, Oral; Adult; Biomarkers; Carcinogens; Cigarette Smoking; Cohort Studies; Humans; Iran; Male; Middle Aged; Opiate Alkaloids; Smoking, Non-Tobacco Products; Tobacco Products
PubMed: 31915141
DOI: 10.1158/1055-9965.EPI-19-1212 -
Behavioural Brain Research Feb 2023Gender differences have been observed in the vulnerability to drug abuse and in the different stages of the addictive process. In opiate dependence, differences between...
Gender differences have been observed in the vulnerability to drug abuse and in the different stages of the addictive process. In opiate dependence, differences between sexes have been shown in humans and laboratory animals in various phases of opiate addiction, especially in withdrawal-associated negative affective states. Using a Y-maze conditioned place aversion paradigm, we investigated potential sex differences in the expression and extinction of the aversive memory of precipitated opiate withdrawal state in morphine-dependent rats. No significant difference between sexes was observed in the occurrence of withdrawal signs following naloxone injection during conditioning. Moreover, opiate withdrawal memory expression and extinction following repeated testing was demonstrated in both male and female rats, with no significant differences between sexes. Finally, we report spontaneous recovery following extinction of opiate withdrawal memory. Altogether these data provide further evidence that persistent withdrawal-related memories may be strong drivers of opiate dependence, and demonstrate that both males and females can be used in experimental rodent cohorts to better understand opiate-related effects, reward, aversive state of withdrawal, abstinence and relapse.
Topics: Humans; Rats; Animals; Female; Male; Opiate Alkaloids; Substance Withdrawal Syndrome; Avoidance Learning; Naloxone; Analgesics, Opioid; Morphine Dependence; Opioid-Related Disorders; Morphine; Narcotic Antagonists
PubMed: 36174840
DOI: 10.1016/j.bbr.2022.114122 -
The American Journal of Psychiatry Feb 2022
Topics: Analgesics, Opioid; Depression; Depressive Disorder, Major; Double-Blind Method; Humans; Opiate Alkaloids
PubMed: 35105159
DOI: 10.1176/appi.ajp.2021.21121204 -
Journal of Forensic Sciences Mar 2020
Topics: Amphetamines; Cocaine; Humans; Ketamine; Opiate Alkaloids; Substance-Related Disorders
PubMed: 31651993
DOI: 10.1111/1556-4029.14224 -
Journal of Forensic Sciences Mar 2020
Topics: Amphetamines; Cocaine; Humans; Ketamine; Opiate Alkaloids; Substance-Related Disorders
PubMed: 31995236
DOI: 10.1111/1556-4029.14273 -
American Journal of Respiratory and... Sep 2021
Topics: Analgesia; Delirium; Humans; Opiate Alkaloids; Pain; Pain Management
PubMed: 33956575
DOI: 10.1164/rccm.202104-0968ED -
American Journal of Rhinology & Allergy May 2022The literature on opiate use after endoscopic endonasal transsphenoidal surgery (EETS) is limited.
BACKGROUND
The literature on opiate use after endoscopic endonasal transsphenoidal surgery (EETS) is limited.
OBJECTIVE
To determine the risk factors for higher opiate use following EETS and the quantity of opiates used after discharge.
METHODS
A retrospective review of 144 patients undergoing EETS from July 2018 to July 2020 was conducted. Patient, tumor, and surgical factors were documented. Pain scores and medications used on postoperative days (POD) 0 and 1, and discharge prescriptions, were recorded. Opiate use was quantified using morphine milligram equivalents (MME) dose. Multiple linear regression determined risk factors independently associated with POD0 to 1 opiate use.
RESULTS
On POD 0 to 1, mean pain score was 4.9/10 (standard deviation [SD] ± 2.0). Mean acetaminophen use was 3.4 tablets (SD ± 1.6; 650 mg per tablet). Mean opiate use was 35.6 MME (SD ± 36.3), equivalent to 4.7 tablets (SD ± 4.8) of oxycodone 5 mg. Multiple linear regression showed that current smokers required an additional 37.1 MME ( = .011), and patients with grade 3 intraoperative cerebrospinal fluid leaks required an additional 36.7 MME ( = .046) on POD0 to 1. On discharge, mean opiate prescription was 117.7 MME (SD ± 102.1), equivalent to 15.7 tablets (SD ± 13.6) of oxycodone 5 mg. Thirty-nine patients (27.1%) did not require prescriptions. Only 10 patients (6.9%) required opiate refill(s) within 30 days after surgery.
CONCLUSION
Patients undergoing EETS have higher opiate needs compared to those undergoing endoscopic sinus surgery, although the overall requirements are still considered low. Independent risk factors associated with higher opiate use in the immediate postoperative period included current smokers and grade 3 intraoperative cerebrospinal fluid leaks.
Topics: Analgesics, Opioid; Cerebrospinal Fluid Leak; Endoscopy; Humans; Opiate Alkaloids; Pain, Postoperative; Retrospective Studies
PubMed: 34881667
DOI: 10.1177/19458924211061990 -
JAMA Network Open Apr 2023Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused.
IMPORTANCE
Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused.
OBJECTIVE
To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy.
DESIGN, SETTING, AND PARTICIPANTS
This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022.
EXPOSURE
A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback.
MAIN OUTCOMES AND MEASURES
The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed.
RESULTS
A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits).
CONCLUSIONS AND RELEVANCE
In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03023930.
Topics: Humans; Male; Adult; Female; Buprenorphine; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Naloxone; Emergency Service, Hospital
PubMed: 37017967
DOI: 10.1001/jamanetworkopen.2023.5439