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Otolaryngologic Clinics of North America Oct 2020In the last 30 years, pain control in the United States has undergone several evolutions impacting the care of surgical patients. More recently, safe pain control has... (Review)
Review
In the last 30 years, pain control in the United States has undergone several evolutions impacting the care of surgical patients. More recently, safe pain control has been a subject of quality improvement efforts by otolaryngologists focusing on minimizing opioid consumption. This article discusses the rising overprescription of opioids, influenced by legislation and governmental agencies, and the steps taken to correct and reform policies to decrease the amount of opioids prescribed. Lastly, specific institutional examples of quality improvement protocols implemented to help decrease opioid consumption and prescription are discussed.
Topics: Analgesics, Opioid; Humans; Opioid Epidemic; Opioid-Related Disorders; Pain Management; Pain, Postoperative; Policy; Practice Patterns, Physicians'; Prescription Drug Overuse; Quality Improvement; United States
PubMed: 32684287
DOI: 10.1016/j.otc.2020.05.020 -
Annals of Palliative Medicine Mar 2020Opioids are complex drugs that produce profit (most importantly analgesia) as well as a myriad of adverse effects including gastrointestinal motility disturbances, abuse... (Review)
Review
Opioids are complex drugs that produce profit (most importantly analgesia) as well as a myriad of adverse effects including gastrointestinal motility disturbances, abuse and addiction, sedation and potentially lethal respiratory depression (RD). Consequently, opioid treatment requires careful evaluation in terms of benefit on the one hand and harm on the other. Considering benefit and harm from an economic perspective, opioid treatment should lead to profit maximization with decision theory defining utility as (profit - loss). We here focus on the most devastating opioid adverse effect, RD and define opioid utility U = P(benefit) - P(harm), where P(benefit) is the probability of opioid-induced analgesia and P(harm) the probability of opioid-induced RD. Other utility functions are also discussed including the utility U = P(benefit AND NOT harm), the most wanted opioid effect, i.e., analgesia without RD, and utility surfaces, which depict the continuum of probabilities of presence or absence of analgesia in combination with the presence or absence of RD. Utility functions are constructed from pharmacokinetic and pharmacodynamic data sets, although pragmatic utility functions may be constructed when pharmacokinetic data are not available. We here discuss utilities of several opioids including the partial mu-opioid-receptor agonist buprenorphine, the full opioid receptor agonists fentanyl and alfentanil, and the bifunctional opioid cebranopadol, which acts at mu-opioid and nociception/orphanin FQ-receptors. We argue that utility functions give clinicians the opportunity to make an informed decision when opioid analgesics are needed for pain relief, in which opioids with a positive utility function are preferred over opioids with negative functions. Furthermore, utility functions of subpopulations will give an extra insight as a utility functions measured in one subgroup (e.g., patients with postoperative pain, good opioid responders) may not be mirrored in other patient subgroups (e.g., neuropathic pain patients, poor opioid responders).
Topics: Analgesics, Opioid; Attitude of Health Personnel; Clinical Decision-Making; Disease Management; Humans; Pain; Pain Management; Pain Measurement
PubMed: 31865743
DOI: 10.21037/apm.2019.10.09 -
British Journal of Hospital Medicine... Jan 2024Adverse effects of perioperative opioids have led to the pursuit of 'opioid-free anaesthesia'. While early studies have shown that effective analgesia can be achieved...
Adverse effects of perioperative opioids have led to the pursuit of 'opioid-free anaesthesia'. While early studies have shown that effective analgesia can be achieved without using opioids, with some reduction in unwanted effects, further research is needed to elucidate which patients may benefit most and how.
Topics: Humans; Anesthesia; Anesthesiology; Analgesia; Analgesics, Opioid; Drug-Related Side Effects and Adverse Reactions
PubMed: 38300677
DOI: 10.12968/hmed.2023.0344 -
Annals of Palliative Medicine Sep 2023Moral challenges with addiction and overdosing have resulted from the abundance of opioids, but the coronavirus disease of 2019 has prompted reflection on ethical issues...
Moral challenges with addiction and overdosing have resulted from the abundance of opioids, but the coronavirus disease of 2019 has prompted reflection on ethical issues that could arise from a shortage. Driven by a duty to plan, some jurisdictions have formed committees to see if standard allocation considerations extend to cover a shortage of opioid pain medication. The problem, we argue, is that the standard allocation protocols do not apply to a shortage of opioids because prognosis only has limited relevance and the moral disvalue of pain is not dependent upon a patient's status as a frontline worker, age, or residence in a disadvantaged community. While the use of lotteries in allocation schemes has been deemphasized in standard allocation schema, we argue for and outline the details of a tiered lottery that first prioritizes opioids needed for emergent procedures and then moves on to allocate opioids based on the severity of a patient's pain. Additionally, we argue that some deception, in the form of withholding information from patients about the implementation and details of a pain lottery, is ethically permissible to address the unique moral tension between transparency and beneficence that arises for the treatment of pain in conditions of opioid scarcity.
Topics: Humans; Analgesics, Opioid; Pain; Morals
PubMed: 37164967
DOI: 10.21037/apm-22-1278 -
Journal of Palliative Medicine Nov 2019
Topics: Analgesics, Opioid; Humans; Nalbuphine
PubMed: 31661394
DOI: 10.1089/jpm.2019.0482 -
BMJ Supportive & Palliative Care Jul 2022Pain control is an essential component of high-quality palliative care. Unfortunately, many low-income and middle-income countries lack an appropriate infrastructure to... (Review)
Review
BACKGROUND
Pain control is an essential component of high-quality palliative care. Unfortunately, many low-income and middle-income countries lack an appropriate infrastructure to provide palliative care and suffer from a severe lack of access to opioid analgesics to alleviate pain from various conditions such as cancer.
OBJECTIVES
We aimed to review the history and current status of cancer pain management in Mexico, a middle-income Latin American country. Our objective was to identify existing barriers to proper, effective opioid use, as well as provide practical recommendations for improvement.
METHODS
Using a search of EBSCOhost database, PubMed and Google, we found official documents and peer-reviewed articles related to health legislation, opioid consumption, palliative care infrastructure and palliative care training in Mexico.
RESULTS
Despite advances in palliative care and access to opioids in Mexico, there are still several barriers that undermine effective pain management, showing a major gap between policy and practice. Although Mexican legislation and guidelines include adequate palliative care and pain control as a right for all patients with cancer, the lack of adequate infrastructure and trained personnel severely hampers the implementation of these policies. Additionally, there are important barriers to prescribing opioids, many of which are related to attempts at reducing the consumption of recreational drugs.
CONCLUSIONS
Although Mexico has made significant improvements in pain control and palliative care, much needs to be done. Expansion of drug availability, improvement of palliative care training, and constant oversight of regulations and guidelines will help to strengthen Mexico's palliative care services.
Topics: Analgesics, Opioid; Humans; Mexico; Neoplasms; Pain; Pain Management; Palliative Care
PubMed: 31666230
DOI: 10.1136/bmjspcare-2019-001871 -
Pharmacology Research & Perspectives May 2021Opioids are a commonly prescribed and efficacious medication for the treatment of chronic pain but major side effects such as addiction, respiratory depression,... (Review)
Review
Opioids are a commonly prescribed and efficacious medication for the treatment of chronic pain but major side effects such as addiction, respiratory depression, analgesic tolerance, and paradoxical pain hypersensitivity make them inadequate and unsafe for patients requiring long-term pain management. This review summarizes recent advances in our understanding of the outcomes of chronic opioid administration to lay the foundation for the development of novel pharmacological strategies that attenuate opioid tolerance and hypersensitivity; the two main physiological mechanisms underlying the inadequacies of current therapeutic strategies. We also explore mechanistic similarities between the development of neuropathic pain states, opioid tolerance, and hypersensitivity which may explain opioids' lack of efficacy in certain patients. The findings challenge the current direction of analgesic research in developing non-opioid alternatives and we suggest that improving opioids, rather than replacing them, will be a fruitful avenue for future research.
Topics: Analgesia; Analgesics, Opioid; Animals; Drug Hypersensitivity; Drug Tolerance; Humans; Pain; Receptors, Opioid; Signal Transduction
PubMed: 34096178
DOI: 10.1002/prp2.789 -
Molecules (Basel, Switzerland) May 2022A few neurotransmitter systems have fascinated the research community, as muchas the opioid system (i.e., opioid ligands and their receptors) [...].
A few neurotransmitter systems have fascinated the research community, as muchas the opioid system (i.e., opioid ligands and their receptors) [...].
Topics: Analgesics, Opioid; Drug Discovery; Ligands; Receptors, Opioid
PubMed: 35630616
DOI: 10.3390/molecules27103140 -
The American Journal of Psychiatry Apr 2022
Topics: Analgesics, Opioid; Drug Prescriptions; Humans; Opioid-Related Disorders; Practice Patterns, Physicians'
PubMed: 35360920
DOI: 10.1176/appi.ajp.20220182 -
Cancer Jan 2021
Topics: Analgesics, Opioid; Epidemics; Humans; Opioid Epidemic; Practice Patterns, Physicians'; Surgeons
PubMed: 33002194
DOI: 10.1002/cncr.33199