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Neurosurgical Review Apr 2024In recent years, nonsteroidal anti-inflammatory drug (NSAIDs), which are considered to affect the prognosis of spinal surgery, have been widely used in perioperative... (Meta-Analysis)
Meta-Analysis
In recent years, nonsteroidal anti-inflammatory drug (NSAIDs), which are considered to affect the prognosis of spinal surgery, have been widely used in perioperative analgesia in spinal surgery, but the relationship between these two factors remains unclear. The purpose of this study was to explore the effect of perioperative use of NSAIDs on the prognosis of patients treated with spinal surgery. We systematically searched PubMed, Embase, and Cochrane Library for relevant articles published on or before July 14, 2023. We used a random-effect model for the meta-analysis to calculate the standardized mean difference (SMD) with a 95% confidence interval (CI). Sensitivity analyses were conducted to analyze stability. A total of 23 randomized clinical trials including 1457 participants met the inclusion criteria. Meta-analysis showed that NSAIDs were significantly associated with postoperative morphine use (mg) (SMD = -0.90, 95% CI -1.12 to -0.68) and postoperative pain (SMD = -0.71, 95% CI -0.85 to -0.58). These results were further confirmed by the trim-and-fill procedure and leave-one-out sensitivity analyses. The current study shows that perioperative use of NSAIDs appears to be an important factor in reducing postoperative pain and morphine use in patients undergoing spinal surgery. However, well-designed, high-quality randomized controlled trials (RCTs) are still required.
Topics: Humans; Anti-Inflammatory Agents, Non-Steroidal; Morphine Derivatives; Pain, Postoperative; Randomized Controlled Trials as Topic; Spine
PubMed: 38578529
DOI: 10.1007/s10143-024-02371-7 -
The International Journal on Drug Policy May 2024Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD)... (Review)
Review
BACKGROUND
Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap.
METHODS
This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented.
RESULTS
A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD.
CONCLUSIONS
This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted.
Topics: Humans; Canada; Opiate Substitution Treatment; Opioid-Related Disorders; Health Services Accessibility; Analgesics, Opioid; Practice Guidelines as Topic; Healthcare Disparities
PubMed: 38554565
DOI: 10.1016/j.drugpo.2024.104343 -
Journal of Comparative Effectiveness... May 2024In the absence of head-to-head comparative data from randomized controlled trials, indirect treatment comparisons (ITCs) may be used to compare the relative effects of... (Comparative Study)
Comparative Study Review
Gastrointestinal adverse effects associated with the use of intravenous oliceridine compared with intravenous hydromorphone or fentanyl in acute pain management utilizing adjusted indirect treatment comparison methods.
In the absence of head-to-head comparative data from randomized controlled trials, indirect treatment comparisons (ITCs) may be used to compare the relative effects of treatments versus a common comparator (either placebo or active treatment). For acute pain management, the effects of oliceridine have been compared in clinical trials to morphine but not to fentanyl or hydromorphone. To assess the comparative safety (specifically differences in the incidence of nausea, vomiting and opioid-induced respiratory depression [OIRD]) between oliceridine and relevant comparators (fentanyl and hydromorphone) through ITC analysis. A systematic literature review identified randomized clinical trials with oliceridine versus morphine and morphine versus fentanyl or hydromorphone. The ITC utilized the common active comparator, morphine, for the analysis. A total of six randomized controlled trials (oliceridine - 2; hydromorphone - 3; fentanyl - 1) were identified for data to be used in the ITC analyses. The oliceridine data were reported in two studies (plastic surgery and orthopedic surgery) and were also reported in a pooled analysis. The ITC focused on nausea and vomiting due to limited data for OIRD. When oliceridine was compared with hydromorphone in the ITC analysis, oliceridine significantly reduced the incidence of nausea and/or vomiting requiring antiemetics compared with hydromorphone (both orthopedic surgery and pooled data), while results in plastic surgery were not statistically significant. When oliceridine was compared with hydromorphone utilizing data from Hong, the ITC only showed a trend toward reduced risk of nausea and vomiting with oliceridine that was not statistically significant across all three comparisons (orthopedic surgery, plastic surgery and combined). An ITC comparing oliceridine with a study of fentanyl utilizing the oliceridine orthopedic surgery data and combined orthopedic and plastic surgery data showed a trend toward reduced risk that was not statistically significant. In ITC analyses, oliceridine significantly reduced the incidence of nausea and/or vomiting or the need for antiemetics in orthopedic surgery compared with hydromorphone and a non-significant trend toward reduced risk versus fentanyl.
Topics: Humans; Hydromorphone; Fentanyl; Analgesics, Opioid; Acute Pain; Randomized Controlled Trials as Topic; Vomiting; Nausea; Administration, Intravenous; Respiratory Insufficiency; Pain Management; Quinuclidines; Spiro Compounds; Thiophenes
PubMed: 38497192
DOI: 10.57264/cer-2023-0041 -
BMC Health Services Research Mar 2024Opioid Maintenance Treatment (OMT) is the gold standard for people with opioid dependence. However, drop-out rates are high, and many patients do not reach desired...
BACKGROUND
Opioid Maintenance Treatment (OMT) is the gold standard for people with opioid dependence. However, drop-out rates are high, and many patients do not reach desired outcomes. Understanding patients' and healthcare providers' experiences with the treatment can provide valuable information to improve the quality of OMT and to increase acceptability and accessibility of services. The aim of this systematic review is to explore and synthesise the experiences of OMT among persons with opioid dependence and health care providers, to inform policy makers and practitioners on how to improve OMT outcomes.
METHODS
We conducted a qualitative evidence synthesis. We systematically searched in electronic databases (CINAHL, Embase, MEDLINE, and nordic databases) and searched for grey literature. As we identified many studies that met our inclusion criteria, we purposively sampled a manageable number of studies to include in this review. Two researchers independently extracted and coded data from the included studies and used the Andersen's healthcare utilization model to organize and develop codes. We assessed the methodological limitations of the studies, and our confidence in the findings using GRADE CERQual.
RESULTS
We retrieved 56 relevant studies and purposively sampled 24 qualitative studies of patients' and healthcare providers' experiences with OMT. Our analyses resulted in six main themes: (1) External stigma prevents engagement and retention in treatment, (2) Being identified as in OMT contributed to an increased experience of stigma (3) Inadequate knowledge and expertise among healthcare providers affected patients' treatment experiences, (4) Quality of communication between personnel and patients impacts patients' engagement with treatment and treatment outcomes, (5) Patients wanted help with many aspects of their lives not just medication, and (6) Balancing positive expectations of OMT with treatment stigma. We found that stigma was an overarching theme across these themes.
CONCLUSION
Our findings suggest that OMT could be more beneficial for patients if treatment programs prioritize efforts to diminish societal and OMT provider stigma and find strategies to better address patient needs. Initiatives should focus on improving treatment knowledge among providers, encouraging the use of client perspectives, considering the context of family members, and establishing a more holistic and flexible treatment environment.
Topics: Humans; Opiate Substitution Treatment; Delivery of Health Care; Family; Health Personnel; Qualitative Research; Opioid-Related Disorders
PubMed: 38481254
DOI: 10.1186/s12913-024-10778-7 -
Cancer Treatment Reviews Apr 2024Cancer-related pain often requires opioid treatment with opioid-induced constipation (OIC) as its most frequent gastrointestinal side-effect. Both for prevention and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cancer-related pain often requires opioid treatment with opioid-induced constipation (OIC) as its most frequent gastrointestinal side-effect. Both for prevention and treatment of OIC osmotic (e.g. polyethylene glycol) and stimulant (e.g. bisacodyl) laxatives are widely used. Newer drugs such as the peripherally acting µ-opioid receptor antagonists (PAMORAs) and naloxone in a fixed combination with oxycodone have become available for the management of OIC. This systematic review and meta-analysis aims to give an overview of the scientific evidence on pharmacological strategies for the prevention and treatment of OIC in cancer patients.
METHODS
A systematic search in PubMed, Embase, Web of Science and the Cochrane Library was completed from inception up to 22 October 2022. Randomized and non-randomized studies were systematically selected. Bowel function and adverse drug events were assessed.
RESULTS
Twenty trials (prevention: five RCTs and three cohort studies; treatment: ten RCTs and two comparative cohort studies) were included in the review. Regarding the prevention of OIC, three RCTs compared laxatives with other laxatives, finding no clear differences in effectivity of the laxatives used. One cohort study showed a significant benefit of magnesium oxide compared with no laxative. One RCT found a significant benefit for the PAMORA naldemedine compared with magnesium oxide. Preventive use of oxycodone/naloxone did not show a significant difference in two out of three other studies compared to oxycodone or fentanyl. A meta-analysis was not possible. Regarding the treatment of OIC, two RCTs compared laxatives, of which one RCT found that polyethylene glycol was significantly more effective than sennosides. Seven studies compared an opioid antagonist (naloxone, methylnaltrexone or naldemedine) with placebo and three studies compared different dosages of opioid antagonists. These studies with opioid antagonists were used for the meta-analysis. Oxycodone/naloxone showed a significant improvement in Bowel Function Index compared to oxycodone with laxatives (MD -13.68; 95 % CI -18.38 to -8.98; I = 58 %). Adverse drug event rates were similar amongst both groups, except for nausea in favour of oxycodone/naloxone (RR 0.51; 95 % CI 0.31-0.83; I = 0 %). Naldemedine (NAL) and methylnaltrexone (MNTX) demonstrated significantly higher response rates compared to placebo (NAL: RR 2.07, 95 % CI 1.64-2.61, I = 0 %; MNTX: RR 3.83, 95 % CI 2.81-5.22, I = 0 %). With regard to adverse events, abdominal pain was more present in treatment with methylnaltrexone and diarrhea was significantly more present in treatment with naldemedine. Different dosages of methylnaltrexone were not significantly different with regard to both efficacy and adverse drug event rates.
CONCLUSIONS
Magnesium oxide and naldemedine are most likely effective for prevention of OIC in cancer patients. Naloxone in a fixed combination with oxycodone, naldemedine and methylnaltrexone effectively treat OIC in cancer patients with acceptable adverse events. However, their effect has not been compared to standard (osmotic and stimulant) laxatives. More studies comparing standard laxatives with each other and with opioid antagonists are necessary before recommendations for clinical practice can be made.
Topics: Humans; Laxatives; Analgesics, Opioid; Narcotic Antagonists; Constipation; Oxycodone; Opioid-Induced Constipation; Magnesium Oxide; Cohort Studies; Naloxone; Polyethylene Glycols; Neoplasms; Drug-Related Side Effects and Adverse Reactions; Quaternary Ammonium Compounds; Naltrexone
PubMed: 38452708
DOI: 10.1016/j.ctrv.2024.102704 -
Drugs Mar 2024To evaluate the efficacy of opioids for people with acute musculoskeletal pain against placebo. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To evaluate the efficacy of opioids for people with acute musculoskeletal pain against placebo.
STUDY DESIGN
Systematic review and meta-analyses of randomised, placebo-controlled trials of opioid analgesics for acute musculoskeletal pain in any setting. The primary outcomes were pain and disability at the immediate timepoint (< 24 h).
DATA SOURCES
Multiple databases were searched from their inception to February 22nd, 2023.
DATA SYNTHESIS
Continuous outcomes were converted to a 0-100 scale. Dichotomous outcomes were presented as risk differences. Risk of bias and certainty of evidence was assessed.
RESULTS
We located 17 trials (1 intravenous and 16 oral route of administration). For adults, high certainty evidence from 11 comparisons shows that oral opioids provide small benefits relative to placebo in the immediate term for pain (mean difference [MD] - 8.8 95% confidence interval [CI] - 12.0 to - 5.6). For disability, the difference is uncertain (MD - 6.2, 95% CI - 17.8 to 5.4). Opioid groups were at higher risk of adverse events (MD 14.3%, 95% CI 8.3-20.4%, very low certainty). There was moderate certainty evidence of a large effect of IV morphine on sciatica pain (MD -42.5, 95% CI - 49.9 to - 35.1, n = 197, 1 study). In paediatric populations, moderate certainty evidence from 3 trials shows that oral opioids probably do not provide benefit beyond that of placebo for pain (MD 6.1, 95% CI - 1.7 to 12.8) and there was no evidence for disability. There was low certainty evidence that there may be no difference in adverse events (MD 10.4%, 95% CI - 0.6 to 21.4%).
DISCUSSION
Intravenous morphine likely offers benefits, but oral opioids may not provide clinically meaningful benefits.
PROSPERO REGISTRATION
CRD42021249346.
Topics: Adult; Child; Humans; Analgesics, Opioid; Musculoskeletal Pain; Acute Pain; Morphine
PubMed: 38451443
DOI: 10.1007/s40265-024-01999-5 -
Value in Health : the Journal of the... May 2024Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be... (Review)
Review
OBJECTIVES
Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions.
METHODS
We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs.
RESULTS
We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC.
CONCLUSIONS
OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs.
Topics: Humans; Cost-Benefit Analysis; Opiate Overdose; North America; Quality-Adjusted Life Years; Canada
PubMed: 38401795
DOI: 10.1016/j.jval.2024.02.004 -
Substance Use & Addiction Journal Apr 2024Buprenorphine is among the most effective treatments for opioid use disorder. Even though the federal government recently eliminated the waiver requirement and patient...
BACKGROUND
Buprenorphine is among the most effective treatments for opioid use disorder. Even though the federal government recently eliminated the waiver requirement and patient limits applicable to office-based buprenorphine treatment (OBBT), among other settings, some states may still have policies imposing requirements on OBBT providers not required by federal law.
METHODS
We collected statutes and regulations from 50 US states and the District of Columbia (ie, 51 jurisdictions) between August 11 and November 30, 2022 using the Nexis Uni legal database and search terms related to OBBT counseling, dosage, and/or frequency of visits. We then used template analysis, a mixed deductive-inductive qualitative method, to analyze legal content.
RESULTS
Ten jurisdictions (20%) in 2022 had an OBBT counseling, dosage, and/or visit frequency requirement. Four jurisdictions had at least one law in each OBBT policy category examined. One-fifth of jurisdictions have OBBT policies not required under federal law. Five of these jurisdictions are among those with the highest overdose death rates per capita, according to publicly available data from 2021. Some OBBT requirements could potentially limit clinician interest in offering buprenorphine treatment or result in inadequate care (eg, if dosage limitations are too low.).
CONCLUSIONS
Even though a federal waiver is no longer required for OBBT, our results suggests that at least some jurisdictions have other OBBT requirements, such as counseling, dosage, and/or frequency requirements. Given the severity of the ongoing opioid overdose crisis, policymakers should carefully consider the extent to which OBBT requirements are evidence based.
Topics: Humans; Buprenorphine; Opioid-Related Disorders; Opiate Substitution Treatment; Counseling; Drug Overdose
PubMed: 38288697
DOI: 10.1177/29767342231223721 -
Journal of Clinical Orthopaedics and... Jan 2024Despite the fact that preoperative corticosteroid injections within three to six months of surgery increase the risk of postoperative infection, there is a growing trend... (Review)
Review
BACKGROUND
Despite the fact that preoperative corticosteroid injections within three to six months of surgery increase the risk of postoperative infection, there is a growing trend of using corticosteroid injections intraoperatively as an effort to decrease postoperative pain and opiate use. Our aim with this review was to answer the question "Do intraoperative corticosteroid injections increase the risk of infections in arthroscopic surgery?"
METHODS
A systematic search of MEDLINE, Cochrane, and PMC databases was conducted adhering to PRISMA 2020 guidelines after registration with PROSPERO (ID: CRD42023459138). We included studies comparing infection rates in patients who received intraoperative corticosteroid injections (IOCSI) to those who received no injection. The MINORS risk of bias tool was used to assess the quality of included studies.
RESULTS
305 individual records were screened and a total of 8 studies met the criteria for inclusion in the study, containing data from over 700,000 patient records. All 7 retrospective studies showed an increase in infection rates and the single small randomized controlled trial had no infections in either the control or intervention group. The combined weighted odds ratio of infection rates in comparable studies was 2.23 95% CI (1.66-3.11).
CONCLUSIONS
Current data shows that IOCSIs more than double the risk of postoperative infection during arthroscopic surgery. Surgeons should consider and weigh the impact of infection to the minor clinical benefit corticosteroid injections add over other multimodal injections. We expect similar increases in infection rates in other surgeries where IOCSIs are used due to the inherent immunosuppressive mechanisms of corticosteroids.
PubMed: 38282804
DOI: 10.1016/j.jcot.2024.102332 -
The Indian Journal of Medical Research Nov 2023This systematic review evaluates the human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) burden among people who inject drugs (PWIDs)...
BACKGROUND OBJECTIVES
This systematic review evaluates the human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) burden among people who inject drugs (PWIDs) in India. In addition, we selectively examined research on opioid substitution treatment (OST)-related services due to their role in antiviral treatment uptake and adherence.
METHODS
Data were sourced from peer-reviewed and government publications between 1991 and September 20, 2023, searched in MEDLINE, Scopus and EBSCOhost. English language studies reporting weighted prevalence or raw numbers and recruitment sites were included for review. Quality was assessed using the Joanna Briggs Institute tool. Data synthesis was done in graphs and tables.
RESULTS
We included 50 reports, yielding 150 HIV, 68 HCV and 24 HBV prevalence estimates across India, revealing significant regional heterogeneity. Notably, 16 States had a single community-based HIV estimate, and 19 States had limited or no HCV data. The highest HIV and HCV prevalence was in Manipur (74.7% and 97.5%, respectively) in 1996. Recent spikes included 50.2 per cent HIV prevalence in Punjab (2010) and 73 per cent HCV in Uttar Pradesh (2021). Nationally, OST coverage in 2020 was under five per cent, with some northeast, north and central States exceeding this, but most others were falling below two per cent. No studies on the cost-effectiveness of directly observed treatment models for OST were identified.
INTERPRETATION CONCLUSIONS
There is a lack of sufficiently granular and generalizable estimates for HIV prevalence and any estimates for HCV and HBV among PWIDs in large parts of the country. Community-based representative studies are required to quantify the prevalence and severity of these diseases and allocate resources.
Topics: Humans; Drug Users; India; Opiate Substitution Treatment; Hepatitis B; Hepatitis C; Hepatitis B virus; Hepacivirus; HIV Infections
PubMed: 38265946
DOI: 10.4103/ijmr.ijmr_1930_23