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Background: Previously, we discovered that subjects co-prescribed both antibiotics and opioids on the same day in a hospital setting displayed an increased risk of developing an opioid use disorder (OUD) 12 months following hospital discharge. The goal of this study was to examine whether prescribing antibiotics in the inpatient or emergency department setting at various time points before or after an opioid prescription impacted the risk OUD.Methods: A propensity score matched cohort study was conducted to identify subjects (18–65 years old) with no previous history of OUD. Two cohorts were defined: subjects who were prescribed antibiotics 0–1, 2–4, 5–7, 8–10, 11–12 months before or after the date of an opioid prescription while in the emergency department or inpatient setting, from the years 2010–2019. The diagnosis of an Opioid Related Disorder (F11.10–F11.20) 12 months following discharge from the emergency department or inpatient unit was then observed.Results: Primary analysis showed that subjects prescribed an antibiotic 0–1 month or 8–10 months before an opioid prescription showed a modest risk of developing an OUD 12 months following an opioid prescription (0.04% and 0.20%, respectively). Similarly, subjects prescribed an antibiotic 0–1 month, 5–7 months, or 8–10 months after an opioid prescription displayed a modest risk of developing OUD 12 months after an opioid prescription (0.02% risk, 0.14% risk, and 0.16% risk, respectively).Conclusions: These findings suggest that there is little to no effect on the risk of developing OUD when antibiotics are prescribed at various time points before or after opioid prescription. [ABSTRACT FROM AUTHOR]

Purpose: Opioid use rates have dropped as North American patients gain access to medical cannabis, indicating a harm reduction role, yet health outcomes remain mostly unexplored. This study presents self-reported medical cannabis use, perceptions of health functioning, and changes in opioid pain medication use in Florida medical cannabis patients. Methods: Patients (n = 2,183) recruited from medical dispensaries across Florida completed a 66-item cross-sectional survey that included demographic, health, and medication usage items, along with items from the Medical Outcomes Survey (SF-36) to assess health functioning before and after cannabis initiation. Results: Most participants were between the ages of 20 and 70 years of age (95%), over 54% were female, 47% were employed, and most (85%) were white. Commonly reported ailment groups were Pain and Mental Health combined (47.92%), Mental Health (28.86%) or Pain (9.07%). Health domains of bodily pain, physical functioning, and social functioning improved while limitations due to physical and emotional problems were unchanged. Most patients rated medical cannabis as being important to their quality of life. Many (60.98%) reported using pain medications prior to medical cannabis, 93.36% of these reported a change in pain medication after medical cannabis. The majority of participants (79%) reported either cessation or reduction in pain medication use following initiation of medical cannabis and 11.47% described improved functioning. Conclusions: The findings suggest that some medical cannabis patients decreased opioid use without harming quality of life or health functioning, soon after the legalization of medical cannabis. The public health implications of medical cannabis as an alternative pain medication are discussed. [ABSTRACT FROM AUTHOR]

Appropriate use of opioid analgesics according to the World Health Organization pain relief ladder has provided pain relief to many patients with cancer pain. However, a proportion of patients fail to achieve sufficient pain relief and develop opioid resistance. Individual risk factors may relate to opioid resistance. Therefore, we conducted a historical cohort study to identify risk factors for opioid resistance and to construct an index to predict it. We investigated salient factors at the time of opioid initiation in the medical records of 233 patients. The outcome was the achievement of stable pain at 14 days after opioid introduction. We identified factors contributing to opioid resistance by multivariate analysis (p < 0.05). We created a resistance score from the regression equation of the identified factors to predict opioid resistance. Forty-nine (21.0%) patients were opioid resistant without achieving the outcome. Age, neuropathic pain, and alkaline phosphatase were extracted as significant factors for opioid resistance (p < 0.05). A resistance score was created from these factors and classified into binary values, the sensitivity was 80.6% and the negative predictive value was 91.6%. The findings suggest that the resistance score could be a sensitive predictor of opioid resistance before opioid initiation. [ABSTRACT FROM AUTHOR]

Background: In 2014, nearly 2.5 million Americans had a substance use disorder for opioids (e.g., prescription pain medication or heroin) with over half estimated to have had prior contact with the criminal justice system. Despite strong evidence that opioid agonist treatment (OAT) is effective in reducing overdose, increasing treatment retention, and improving physical health and well-being outcomes, the use of OAT among justice-involved individuals is relatively rare. Methods: The current study uses national data of publicly funded admissions to substance abuse treatment to assess the extent to which OAT is used for cases referred to treatment by the criminal justice system. We explore the relationship between demographics, substance use severity, and access to treatment and OAT receipt. Results: Findings indicate that fewer than 6% of criminal justice cases received OAT as part of the treatment plan. Those with daily substance use, comorbid psychiatric problems, prior treatment, females, Latinos, and those who were older and those who were living independently were more likely to receive OAT, as were those living in the Northeast and with government health insurance. Conclusions: Improving the integration of the criminal justice system with substance use treatment programs would improve access to care and potentially reduce multiple health disparities faced by those in the justice system. As criminal justice responses to substance use disorder move toward a public health approach, it is imperative that the criminal justice system consider mechanisms for improving access and referrals to OAT. [ABSTRACT FROM AUTHOR]

Concomitant with expanded legalization, cannabis is increasingly used to treat chronic pain among persons with HIV (PWH), despite equivocal benefit in research limited by small sample sizes and short duration of follow-up. To address these limitations, among a sample of PWH with pain interference enrolled in the Veterans Aging Cohort Study, we performed a target trial emulation study to compare the impact of four cannabis use strategies on pain interference. Among those receiving long-term opioid therapy (LTOT), we also explored impact of these strategies on ≥ 25% LTOT dose reduction. Among the analytic sample (N = 1284), the majority were men with a mean age of 50. Approximately 31% used cannabis and 12% received LTOT at baseline. Adjusting for demographic and clinical factors, cannabis use in any of 4 longitudinal patterns was not associated with resolved pain interference over 12- to 24-month follow-up. Among 153 participants receiving LTOT at baseline, cannabis use at both baseline and follow-up was negatively associated with LTOT dose reduction compared to no use at both baseline and follow-up. These findings support other observational studies finding no association between cannabis use and improved chronic pain or LTOT reduction among PWH. [ABSTRACT FROM AUTHOR]

Rates of opioid use disorder and associated deaths remain alarmingly high. Measures to address the epidemic have included reductions in opioid prescribing, in part guided by the Centers for Disease Control Opioid Prescribing Guideline (CDCG). While reductions in over-prescribing have occurred, these measures have also resulted in decreased access and adverse outcomes for some stable opioid-treated chronic pain patients. The TOWard SafER Opioid Prescribing (TOWER) intervention was designed to support HIV primary care providers in use of the CDCG and in decision-making and patient–provider communication regarding safe opioid prescribing. Eleven HIV primary care providers and 40 of their patients were randomized into intervention and control groups. Transcripts from 21 patient visits were analyzed, focusing on opioid and pain-related communications. Findings from this research indicate greater alignment with the CDCG among visits carried out with providers in the TOWER intervention group. However, control group visits were notably consistent with guideline recommendations in several key areas. Differences observed between the intervention and control group visits demonstrate intervention strengths, as well as areas where additional work needs to be done to ensure prescribing and communication consistent with the CDCG. [ABSTRACT FROM AUTHOR]

Although it is extremely necessary to reduce the number of opioids taken postoperatively after sinonasal surgery, this is the subject of controversial discussion. The objective of this study was to identify factors that predict higher postoperative pain scores (PPS) and the need for opioid analgesics after sinonasal surgery. This was a retrospective study of n = 492 patients who underwent functional endoscopic sinus surgery (FESS), septoplasty or a combination of both in the Otolaryngology Department in Erlangen between January and December 2018. Postoperative pain using the numeric rating scale and the postoperative need for non-opioid and opioid analgesics in relation to demographic and surgical parameters were evaluated. Significant predictors for a higher pain score were depression (p =.009) and female gender (p <.001). A significant predictor of the need for postoperative opioids was the female gender (p <.001), whereas FESS alone showed a significantly lower need for opioids (p =.035) and a significantly lower PPS compared to septoplasty (p <.001). The study identified risk factors for a higher PPS and the need for opioids. The results indicated that reducing postoperative opioids might be possible in patients without these risk factors and might help guide individualized postoperative therapy. [ABSTRACT FROM AUTHOR]

A large body of research demonstrates the safety and efficacy of medication for opioid use disorder to reduce opioid misuse and related harms. However, stigma is a substantial barrier to broader use of these medications. This endpage reviews the impact of stigma toward medication for opioid use disorder on treatment access, uptake, retention, and outcomes. I then suggests areas for future research and social change. As one of the primary service providers for people with opioid use disorder, social workers should be at the forefront of efforts to destigmatize medication treatments. Social workers are well positioned to address the consequences of stigma toward medication for opioid use disorder through research, education, practice, and systems change. [ABSTRACT FROM AUTHOR]

Purpose: Adolescents with cerebral palsy may need a feeding tube due to feeding challenges, since nutritional intake and mealtimes may be negatively affected. The purpose of the study was to describe and better understand how one adolescent with cerebral palsy and her parents experienced mealtimes before and after a nasogastric and gastrostomy tube insertion and how the use of these feeding tubes was experienced in daily life. Methods: Individual interviews were performed with one adolescent and each of her parents. In total, six interviews were conducted on two separate occasions. The qualitative approach known as Interpretive Description was used during the analysis. Results: Four thematic patterns were identified within the data: (i) struggling with nutritional intake, (ii) the paradox of using an aid, (iii) being different, and (iv) challenges of public mealtimes. Conclusions: The results showed that four themes influenced daily mealtimes in adolescents with cerebral palsy and a gastrostomy tube. Nutritional intake and mealtimes may be difficult, which is why using a gastrostomy tube can be a relief. However, the gastrostomy tube can also pose a challenge and a paradox. Time of change and acceptance seems necessary in order to meet these challenges. [ABSTRACT FROM AUTHOR]

To describe the pain management and clinical course of patients with severe Pemphigus Vulgaris (PV) admitted to a third-level Intensive Care Unit (ICU). This was a retrospective cohort study conducted in the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán over the period 2013–2020. Study population comprised patients with severe PV admitted to the ICU. Eleven patients with severe PV were included. Mean age of presentation was 43.6 years. Percentage of the total body surface area affected ranged from 70 to 85% (mean: 80%). Visual Analogue Scale was used for pain assessment upon admission. Nine patients (72%) reported a 10/10 pain. The median Morphine Equivalent Daily Dose was 200 mg (range: 90–518 mg). Mortality was 27% during the ICU stay. One patient (9%) continued to experience severe pain and consume opioids after discharge. PV is a life-threatening disease characterized by painful, persistent erosions and ulcers. Integrated and multidisciplinary approach is often required. Opioids remain the mainstay for acute pain control in patients with severe PV. Biological, psychological, and social factors influence patients' daily opioid requirements and dose escalation. Successful pain management contributes to improving the quality of life, and the suppression and remission of PV. [ABSTRACT FROM AUTHOR]

Effective strategies that are evidence-based and non-addictive are needed to manage chronic pain and combat the opioid crisis. One potential strategy is to utilize a shared medical appointment (SMA), which is a model of providing clinical care in a group setting with multiple healthcare team members for comprehensive pain management. The purpose of this retrospective chart review is to evaluate the impact of a pain management SMA at the William S. Middleton Veterans Affairs (VA) West Clinic on opioid use and behaviors. Quantitative and qualitative data was obtained from the electronic medical record of 16 Veterans who participated in the pain SMA and analyzed using descriptive statistics. In addition to a reduction in opioid doses six months post SMA, participants gained non-pharmacological referrals, addition of non-opioid pain medications, and a mix of didactic and experiential education on pharmacologic and non-pharmacologic treatment modalities to help manage their chronic pain. This SMA allowed for greater access to healthcare professionals with a sole focus on pain management and provided Veterans with a holistic approach to their pain management. [ABSTRACT FROM AUTHOR]

opioid use, which includes both prescribed and non-prescribed drugs, is relatively common amongst marginalized populations. Past research has shown that among those who use non-prescribed or diverted opioids recreationally, many were first exposed to the drug as prescribed pain medication. Objective: to better understand the relationship between pain and opioid use in tenants of precarious housing. Methods: in the present study, 440 individuals from a cohort living in homeless or precariously housed conditions in a neighborhood with high rates of poverty and drug use were interviewed for their bodily pain and opioid use. We examined the relationship between bodily pain levels, assessed using the Maudsley Addiction Profile questionnaire, and prescribed, non-prescribed and combined self-reported opioid use in the prior 28 days assessed using the Timeline Followback and Doctor-Prescribed Medication Timeline Followback questionnaires. Results: Analysis of the results indicated that sex (female), age (younger) and early exposure to opioids (≤ age 18) predicted current opioid use, but there was no association between current bodily pain levels and opioid use. Conclusions: these unexpected findings indicate the complex nature of the relationship between pain and opioid use in this population. [ABSTRACT FROM AUTHOR]

Considering most people who inject drugs (PWID) received help with the first injection, understanding the perspective of potential 'initiators' is a priority to inform harm reduction interventions. This paper examines how PWID narrate their experiences with injection initiation and assistance from the lens of their lived experience and perceptions of harm reduction. In-depth interviews were conducted with individuals who reported injection drug use and recent (past 30 days) opioid use in Baltimore (N = 19) and Anne Arundel County (N = 4), Maryland and analyzed using a narrative approach. Respondents cast initiation events as meaningful transitions to a life characterized by predictable harms, including homelessness, infections, and social stigma. Respondents used examples from their personal experience to explain experiences with initiation and assistance by strategically attributing personal agency and predicting specific injection-related harms for initiates. In their narratives, respondents balanced notions of individual agency with harm reduction intentions by distinguishing between two forms of harm: perceived inevitable distal harm caused by long-term injection (e.g. socioeconomic decline) and potentially avoidable proximal harm caused by risky injection practices (e.g. overdose, HIV). These findings highlight opportunities for interventions targeting injection initiation events and support the implementation of safer injection training in interventions. This identity of the 'responsible drug user' could be leveraged to support employing peers to help mitigate harm among inexperienced PWID either through peer outreach or formal venues, such as overdose prevention sites. [ABSTRACT FROM AUTHOR]

Among persons with opioid use disorder (OUD), co-occurring depression is linked to a greater risk of opioid misuse, overdose and suicide. Less is known about characteristics and other comorbid health conditions of persons with co-occurring opioid use and depressive disorders. This study used electronic health record (EHR) encounters from the Geisinger Health System prior to the fall of 2019. Adult patients were recruited from a medication-based treatment clinic and had an OUD diagnosis (N = 692). Co-occurring depression was defined by a depression diagnosis in the EHR. Multivariable logistic regression was performed to assess differences in characteristics, behavioral health and medical diagnoses, as well as opioid overdose and suicide attempt or ideation between individuals with and without comorbid depression. Forty-seven percent of patients with OUD had a lifetime depression diagnosis. Individuals with co-occurring depression were more likely to be female and have comorbid chronic pain or other medical conditions. Co-occurring depression was associated with an increased likelihood of other mental health and substance use disorders, as well as opioid overdose and/or suicide attempt or ideation. While it is established that co-occurring depression is associated with increased risk of overdose and suicide, this study adds that other health conditions, including chronic pain and common medical conditions, are more prevalent among persons with co-occurring depressive disorders. Results highlight the need to consider these complex health needs when developing treatment plans and services. [ABSTRACT FROM AUTHOR]

Pain remains a global health challenge affecting approximately 1.5 billion people worldwide. Pain has been an implicit variable in the equation of human life for many centuries considering different types and the magnitude of pain. Therefore, developing an efficacious drug delivery system for pain management remains an open challenge for researchers in the field of medicine. Lack of therapeutic efficacy still persists, despite high throughput studies in the field of pain management. Research scientists have been exploiting different alternatives to curb the adverse side effects of pain medications or attempting a more substantial approach to minimize the prevalence of pain. Various drug delivery systems have been developed such as nanoparticles, microparticles to curb adverse side effects of pain medications or minimize the prevalence of pain. This literature review firstly provides a brief introduction of pain as a sensation and its pharmacological interventions. Second, it highlights the most recent studies in the pharmaceutical field for pain management and serves as a strong base for future developments. Herein, we have classified drug delivery systems based on their sizes such as nano, micro, and macro systems, and for each of the reviewed systems, design, formulation strategies, and drug release performance has been discussed. [ABSTRACT FROM AUTHOR]

Local law enforcement in Tippecanoe County Indiana identified a need for training to be better prepared for encounters with people that were using opioids. In response, an interactive video series was created to provide comprehensive opioid education. The video scripts were reviewed by content experts for clinical accuracy. The videos include people from the recovery community and law enforcement. Community Corrections staff participated in pilot testing of the videos by completing a pre-viewing survey, post-viewing survey, and a six months follow up survey. The videos were shown to effectively increase knowledge about opioids, increase confidence in working with people using opioids, and reduce some stigma. Significant stigma still existed related to people in healthcare and education using buprenorphine (Suboxone) for medication-assisted treatment. Some of the largest increases in knowledge were related to the pharmacological action of naltrexone (Vivitrol) and opioid use by pregnant women. This pilot test of the publicly available Pathways to Recovery: Training Modules for Opioid Use Disorder shows that it can be an effective training tool for law enforcement seeking to improve interactions with people that use opioids. Further study among a variety of law enforcement is recommended. [ABSTRACT FROM AUTHOR]

This paper explores how poor health outcomes in the HIV/AIDS and opioid epidemics in the United States are undergirded by iatrogenesis. Data are drawn from two projects in Southern California: one among men who have sex with men (MSM) engaging with pre-exposure prophylaxis to HIV (PrEP) and the other in a public hospital system encountering patients with chronic pain and opioid use disorder (OUD). Ethnographic evidence demonstrates how efforts to minimize risk via PrEP and opioid prescription regulation paradoxically generate new forms of risk. Biomedical risk management paradigms engaged across the paper's two ethnographic field sites hinge on the production and governance of deserving patienthood, which is defined by providers and experienced by patients through moral judgments about risk underlying both increased surveillance and abandonment. This paper argues that the logic of deservingness disconnects clinical evaluations of risk from patients' lived, intersectional experiences of race, class, gender, and sexuality. This paper's analysis thus re-locates patients in the context of broader historical and sociopolitical trajectories to highlight how notions of clinical risk designed to protect patients can in fact imperil them. Misalignment between official, clinical constructions of risk and the embodied experience of risk borne by patients produces iatrogenesis. [ABSTRACT FROM AUTHOR]

The Joint Commission standards now include identification and monitoring patients at high-risk for adverse outcomes of opioid use. Our institution does not have a method to identify at-risk patients. This pilot aimed to assess feasibility of pharmacist-led identification of a population for pain management and opioid stewardship. All patients admitted to the hospital were screened; electronic health record reports identified all opioid, antidepressant, and benzodiazepine administrations within the previous 24 hours, and pertinent family and social history risk factors for Opioid Use Disorder (OUD) and opioid-induced respiratory depression (OIRD). Data were exported to spreadsheets and calculated risk scores for OUD and OIRD, and opioid utilization and morphine milligram equivalents (MME) were tabulated. Chart reviews were completed on patients identified as high risk for OUD or OIRD, if MME was 90 or greater, or those receiving four or more "as needed" opioid doses in the previous 24 hours. Potential regimen adjustments based on the primary investigator's judgment were categorized. Mean number of patients identified per day to receive stewardship was 13, and 18.6 potential interventions per day were identified. Based on results of this pilot, pharmacist-led identification of inpatients warranting pain and opioid stewardship is feasible at our institution. [ABSTRACT FROM AUTHOR]

Over the past two decades, opioid use and overdose have increased substantially. Naloxone, an opioid overdose reversal agent, has been one of many risk mitigation strategies for preventing mortality due to overdose. Most literature describing naloxone utilization has been about populations of illicit drug users and patients in hospitals, primary care, and pharmacies. There is limited information regarding naloxone prescribing and training for opioid users in specialty pain management clinics. Furthermore, there are no known publications concerning patients receiving palliative care services and overdose prevention. Pain and palliative care patients are commonly at risk of opioid overdose. In an interdisciplinary outpatient pain and palliative care clinic, pharmacists implemented naloxone prescribing and education. Eleven patients at increased risk for overdose were prescribed naloxone and educated on overdose risk factors, recognition, and management. Seven patients reported picking up their naloxone prescription from the pharmacy, and none reported using it within two weeks of the initial education. This intervention was deemed successful within the clinic, but small sample size and the pharmacist role may not be replicable within other pain and palliative care settings. It encourages further research of overdose risk and prevention in pain management and palliative care. [ABSTRACT FROM AUTHOR]

Opioid related drug overdose deaths are a leading cause of death and injury in the United States. While research demonstrates that where people live has a major impact on drug use and abuse, most work looks at social dynamics at the county level or under the rubric of the urban/rural divide. Only recently, scholarship has become attuned to the post-industrialized areas located on the fringes of urban cores. Data presented in here are from field research conducted in McKeesport, Pennsylvania, a small river town located east of Pittsburgh. Once a thriving industrial city, it is now deteriorated and has documented high levels of overdose experience. Preliminary results suggest that McKeesport residents, even before the emergence of SARS-CoV-2 (COVID-19), practice social and physical distancing as a way of life; data indicate how the pandemic potentially exacerbates the risk of accidental opioid overdose among a population defined by both geographic and social isolation. [ABSTRACT FROM AUTHOR]

Opioid misuse during pregnancy is increasing at an alarming rate across the United States. To determine the prevalence, temporal trends, and resource usage of delivery-related hospitalizations of women who misuse opioids in North Carolina from 2000 to 2014. A retrospective, cross-sectional study was conducted using the State Inpatient Databases. Annual prevalence was calculated, and linear trends were assessed using logistic regression. Temporal trends in hospital charges and length of stay (LOS) were analyzed using ordinary least squares regression with a loge-transformed response. Of 1,937,455 delivery-related hospitalizations in NC, 6,084 were associated with opioid misuse, a prevalence of 3.14 cases per 1,000 delivery-related discharges. During the study period, the prevalence of opioid misuse during pregnancy in NC increased 955%, from 0.9 cases per 1,000 discharges in 2000 to 9.5 cases per 1,000 discharges in 2014, an average annual rate increase of 1.18 cases (95% CI, 1.16–1.21; P < 0.0001). Median LOS for women who misuse opioids remained stable at three days, whereas the median charge per delivery-related hospitalization significantly increased from $6,311 in 2000 to $9,019 in 2010 (annual average change [AAC], 282.2; 95% CI, 182.9–381.5; P < 0.0001) and from $8,908 in 2011 to $10,864 in 2014 (AAC, 667.5; 95% CI, 275.2–1059.9; P < 0.0001). Health care providers and policymakers in NC are advised to introduce system-wide public health responses focused on prevention and increased access to evidence-based treatment that improves the health of the mothers and neonates who are exposed to opioids. [ABSTRACT FROM AUTHOR]

Estimates from the National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019) suggest 3.6% of persons aged 12 and older misused prescription pain relievers in the past year and 0.3% used heroin. However, research suggests that most individuals drastically overestimate rates of substance use and misuse. Those who overestimate substance misuse are often more likely to misuse substances themselves (Kilmer et al., 2015; McCabe, 2008). Purpose: To compare perceived versus actual rates of prescription pain reliever misuse and heroin use among a statewide sample of adults and identify correlates of these differences. Methods: Participants (N = 689) recruited through social media estimated rates of prescription pain reliever misuse and heroin use. Participants also indicated whether they engaged in pain reliever misuse or heroin use, and whether they knew anyone who misused prescription pain medications or heroin. Results: Almost all participants (98.11%) overestimated the prevalence of prescription pain reliever misuse (mean estimate = 41.25%) and heroin use (99.71%, mean estimate =25.46%). Women and African Americans were more likely to overestimate prescription pain reliever misuse and heroin use. Knowing someone who misused prescription pain relievers was significantly associated with overestimating prescription pain reliever misuse. Personal use was not associated with overestimating prevalence of either substance. Conclusions: Adults consistently overestimate rates of prescription pain reliever misuse and heroin use. Overestimation may increase normative perceptions of substance use and ultimately lead to increased substance use. Social-norms based education and interventions may be particularly important among groups that are more likely to overestimate use. [ABSTRACT FROM AUTHOR]

Many algorithms, checklists, and escalation pathways have been created to encourage perioperative teams to share a mental model and approach patient care as a team. Respecting and empowering the many voices involved in patient care is crucial to avoid errors and improve patient safety. None of the concepts described herein are novel; however, sustained improvements in operating room culture remain elusive in many organizations. The implementation of practices directed toward driving change in operating room culture has led to improvements in Occupational Safety and Health Administration (OSHA) recordables, perioperative communication, and patient care practices. In this paper, we will review the importance of culture, mutual accountability, and communication in improving patient care, and share several of the processes that have been created at our pediatric tertiary care center. [ABSTRACT FROM AUTHOR]

This study examined the changes in comfort when adding ritualized chanting to the palliative care of cancer patients at the end of life. The method was a randomized control trial (RCT) performed with 60 cancer patients. Comfort was measured using the End of Life Planning Questionnaire (EOLPQ) with 30 participants in each group [ritualized chanting with palliative care (RCPC) and palliative care alone (PCA)] at baseline (T1), at a 3-week (T2) and the 6-week (T3) time frame. Comfort data were analyzed using two (groups) X three (time) repeated measures MANOVA. There were no significant statistical differences between the groups at baseline. Between-group differences indicated that comfort experienced by participants with the addition of ritualized chanting to palliative care significantly increased (p <.001) over time. The addition of ritualized chanting to the palliative care for cancer patients at the end of life can create changes in their comfort. [ABSTRACT FROM AUTHOR]

Opioid availability and accessibility represent major challenges to cancer patients, particularly in low- and middle-income countries. When palliative care service is available, referrals mostly occur late during the course of disease. In this retrospective study, we examined the pattern and predictors of opioids utilization during the final hospitalization for patients admitted to a tertiary cancer center in Jordan, we assessed factors contributing to opioid use among patients with cancer during the final hospitalization and estimated opioid use in oral morphine equivalents (OME). A total of 297 patient files were reviewed. Patients received the highest doses of opioids at 48 and 24 h prior to death (median dose 34.8 mg OME and 34.5 mg OME, respectively). The palliative care service prescribed higher OME doses than other services (OR 3.54; P < 0.001). The median OME dose used by patients above 65 years was lower than the dose used by the younger group (OR 1.04/years of age; P < 0.001). Spine and bone metastasis were associated with increased opioid consumption (OR 2.45; P < 0.002). We concluded that palliative care patients received higher doses of opioids in the final hospitalization compared to patients in other services. A palliative care referral may be helpful for patients with pain requiring opioids. [ABSTRACT FROM AUTHOR]

The mainstay of treatment in advanced cancer pain is opioids; however, non-opioid medications such as acetaminophen continue to be included in guidelines despite a lack of clear, convincing evidence for their use. The aim of our study was to determine if acetaminophen improves pain control or reduces opioid utilization in hospitalized patients receiving strong opioids for cancer pain managed by the palliative care consult service (PCCS). We carried out at single-center retrospective cohort study of 194 adult cancer patients seen by the PCCS and who received strong opioids. Patients who received acetaminophen during their admission were compared to those who did not. The primary outcome was a 30% reduction in average daily pain score from admission to discharge using a numeric rating scale. There was no difference between groups in achieving a 30% reduction in pain (35.8% vs. 35.4%, adjusted odds ratio 0.87, 95% confidence interval [CI] 0.46 to 1.63). Acetaminophen was associated with a longer LOS (8 days vs. 6 days, adjusted relative risk 1.67, 95% CI 1.30 to 2.15). In this study of cancer patients receiving strong opioids, acetaminophen use was not associated with improved pain control or reduced opioid utilization, but was associated with a greater LOS. [ABSTRACT FROM AUTHOR]

Pain is a common symptom leading to referrals to specialized home palliative care (SHPC) services and is known to affect patients' quality of life. To date, little is known about the impact of referral source on its management. To assess changes to pain medication profile in the course of SHPC and to identify potential differences in relation to referral source. This exploratory study is a retrospective analysis of 501 electronic medical records of a SHPC team in Germany. This included the assessment of baseline pain medication profiles according to the WHO analgesic ladder and changes to analgesic treatment in the course of SHPC with respect to referral source. At the time of admission, 77.4% of patients referred by a hospital and 78.8% of patients referred by the outpatient sector received a fixed analgesic regimen. In all, 61.9% of the inpatient group versus 62.9% of the outpatient group were treated with opioids, and 79.0% received modifications to pain medication at one point in time following admission. Thereby, patients referred by the outpatient sector received significantly earlier modifications and more supplementations of pain medication. Our study suggests positive development in the prescription of opioid analgesics compared to earlier studies in Germany. On the one hand, it highlights the relevance of thorough assessment and responsive evaluation of pain in SHPC, and on the other hand it reveals possible training needs of referring physicians, particularly those working in the outpatient sector. Our results inspired further research examining more closely the links between referral source and pain management. [ABSTRACT FROM AUTHOR]

Non-medical use (NMU) of prescription opioids is of concern due to the opioid epidemic in the United States. Objective: We examined sex differences in the effect of age of first use of prescription opioids on prescription opioid NMU among 17- and 18-year olds. Methods: The National Monitoring of Adolescent Prescription Stimulants Study (N-MAPSS) recruited youth 10–18 years from 10 United States cities between 2008 and 2011 (n = 11,048). The cross-sectional survey included questions on past 30 day prescription opioid use (10,965 provided responses; 278 age 17 to 18 years who used opioids in past 30 days), with NMU defined as non-oral use and/or use of someone else's opioids. Nonparametric survival analysis with lifetable estimates was used to examine age at first use. Binomial logistic regression was conducted predicting any NMU, adjusted for covariates. Results: Among 278 youth 17 to 18 years, a significant difference in age of first use between those with MU only and any NMU (p <.0001) was observed. Each one year increase in age resulted in a 33% decrease in the odds of any prescription opioid NMU compared to MU only, after controlling for covariates (Odds Ratio = 0.67, 95% Confidence Interval: 0.47,0.96). Sex differences in age at first use were not observed. Conclusions: Risk of past 30 day prescription opioid NMU decreased by a third for each one year increase in age of first use, after adjustment for other covariates. Use of prescription opioids in young adolescents may need to be limited where possible and researched further. [ABSTRACT FROM AUTHOR]

Current guidelines recommend that, when prescribing opioids, providers use urine drug testing (UDT) for harm reduction. Objective: To identify whether Medicaid beneficiaries in Nevada at increased risk for opioid misuse received UDT. Methods: We used Nevada Medicaid claims data (2017–2018) to describe UDT among three samples: opioid naïve patients (N = 11,326), opioid naïve patients with a second follow-up prescription (N = 8,910), and long-term opioid patients (N = 19,173). Predictors of opioid misuse include past diagnoses of mental health and substance use, demographic characteristics and potentially risky behaviors. Outcomes include receiving UDT prior to opioid prescription among the two naïve samples and within six months for the long-term sample. We report predicted probabilities (PP) from logistic regressions and hazard ratios (HR) and Kaplan-Meier curves. Results: A small percentage of patients received UDT (naïve sample: 2.5%; naïve with a second follow-up prescription sample: 3.5%; long-term sample: 9.9%). Adults with alcohol disorders and other substance use disorders had the highest PP of UDT, among both the naïve (alcohol related disorder: 3.1%; other substance use disorder: 7.7%) and the naïve with a second follow-up prescription (alcohol related disorder: 4.1%; other substance use disorder: 11.7%) samples. Among the long-term sample, similar predictors were significant. Conclusions: Although there was an association between having risk factors for opioid misuse (e.g. past alchohol disorders and other substance use disorder diagnoses) and receiving UDT, the percentage of patients who received UDT was unexpectedly low, pointing to the need to increase guideline adherence and implementation among providers who prescribe opioids. [ABSTRACT FROM AUTHOR]

Opioid overdose remains the leading cause of accidental death, with 64,000 deaths attributable to opioid-related overdoses in 2016 and a 20% increase in mortality since 2015. Advanced practice registered nurses (APRNs) are now eligible to prescribe buprenorphine. The purpose of this project was to develop educational training materials regarding opioid use management; widely disseminate these materials; monitor reach and intervention efficacy in precipitating practice change; and to evaluate barriers and facilitators of buprenorphine prescribing. The authors developed a three-webinar series pertaining to opioid use management. A broad marketing and dissemination approach was utilized. Demographic data was collected when individuals registered to participate in the webinar series. Follow-up data was collected post-webinar and sought to assess practice change, and barriers to and facilitators of buprenorphine prescribing. Of the 670 individuals that viewed one or more of the live webinars, 218 (32.5%) completed a portion of one or both of the follow-up surveys (at 3- and 6-months post-webinar). Of the respondents, 39 (18%) had obtained the DATA 2000 (buprenorphine) waiver since viewing the webinar series, and 11 (5.1%) were in the process of obtaining the DATA 2000 waiver. Barriers to buprenorphine prescribing included regulatory factors, patient-specific factors, and provider-specific factors. Facilitators to buprenorphine prescribing included institutional support and mentorship, collaboration with professional organizations, increased community awareness, and patient outcomes. APRNs should be abreast of best practices in the management of opioid use disorders. Barriers to and facilitators of buprenorphine prescribing must be understood and addressed. [ABSTRACT FROM AUTHOR]

Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan's SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed. [ABSTRACT FROM AUTHOR]

To assess the opinion and the level of satisfaction of patients concerning analgesia during external cephalic version (ECV), we present the results of a survey of 120 women undergoing ECV at term during a randomised controlled trial (July 2012 to February 2013) comparing remifentanil and nitrous oxide. Overall, 110 (91.7%) women said they would repeat the procedure and 111 (92.5%) that they would recommend it to another pregnant woman, with no significant differences by type of analgesia. The administration and sense of comfort were rated better in the remifentanil group (p < .01). In conclusion, the use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women.Impact statementWhat is already known on this subject? ECV is commonly a painful manoeuvre for the woman. This pain triggers maternal reactive abdominal muscle contraction and involuntary abdominal tensing, reducing the likelihood of successful version and causing some women to reject the technique.What do the results of this study add? The use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women. The sense of comfort during ECV was also significantly better in the remifentanil group, probably because of its greater analgesic power and greater comfort during its administration.What are the implications of these findings for clinical practice and/or further research? ECV should be carried out under analgesia, when available, not only to decrease pain but also to encourage wider adoption of the technique and enable more women to benefit from it. [ABSTRACT FROM AUTHOR]

Objectives: Multiple reasons for suboptimal treatment of breakthrough cancer pain (BTcP) have been reported in the literature. We aimed to ascertain the perception of physicians on the potential inappropriate use and prescription of rapid-onset opioids (ROOs) for breakthrough cancer pain (BTcP) and the causes thereof.Methods: Observational study based on an online survey addressed to doctors from different specialties (radiation oncology, medical oncology, anesthesia, palliative care and general practitioners) with experience in the management of BTcP in the Spanish public health setting.Results: A total of 114 eligible specialists mainly from radiation oncology (37.7%), medical oncology (24.6%) and pain units (18.4%) participated in the study. Most agreed on important aspects of BTcP management, such as their preference for ROOs or the need for early follow-up after treatment initiation. However, their answers revealed a lack of standardization of BTcP diagnosis. Half of respondents believed that their BTcP patients might misuse ROOs. Physicians polled believed that lack of training in pain management (71.9%) and inadequate BTcP diagnosis and evaluation (66.7%) were the greatest obstacles for prescribing opioids. Specialists also thought that they do not provide the necessary information to patients (51.8%) and caregivers (57.9%) to guarantee the correct use of these drugs.Conclusions: These results are of utmost importance as they highlight the need to increase physicians' awareness of BTcP and its management and the need to improve communication with patients and their caregivers. Our findings also indicate the need for future research on the possible misuse of opioids in BTcP patients and its causes. [ABSTRACT FROM AUTHOR]

Opioid use disorder (OUD) can encompass a number of behavioral, psychological, physiological, and interpersonal symptoms which collectively impair one's functioning to different degrees. Of all the personal and societal problems associated with OUD, the most destructive and absolute is death. Given the caustic effects of OUD on quality of life and mortality, evidence-based pharmacotherapy and psychosocial interventions are necessary. It is the collective potential for buprenorphine to increase safety and concurrent cognitive-behavioral group therapy (CBGT) to address substance use triggers as well as comorbid psychiatric conditions, which makes this combination particularly promising for RCT of effectiveness. The purposes of this article are to (1) identify specific ethical issues which may hinder community partners from collaborating with clinical trialist wishing to conduct CBGT buprenorphine efficacy-effectiveness trials at their agency and (2) provide some basic guidelines (Yale CARE strategies) and methods for addressing these community partner ethical concerns. The purpose of the manuscript is to facilitate university and substance use/mental health center community collaborations that will result in ethical clinical trial methodology and findings that meaningfully translate to efficacious, effective, and generalizable CBGT and buprenorphine hybrid interventions for OUD. [ABSTRACT FROM AUTHOR]

This is a commentary on Preis et al.'s (2020) article "Improving Assessment, Treatment, and Understanding of Pregnant Women With Opioid Use Disorder: The Importance of Life Context," which I have written based on my experiences developing and administering research programs in health disparities and drug abuse. Two issues not explicitly addressed in their article were sparked by their arguments. First, we need to discuss racism, not just race as an individual factor, in understanding the life context of pregnant women of color in regard to pregnancy outcomes and addiction treatment. Second, we must become more successful advocates in implementing into policy and practice what we know to be responsive, appropriate treatment for all women. Recommendations for research are suggested. [ABSTRACT FROM AUTHOR]

To assess the validity of the Westmead PTA scale in school-aged children treated with opiate analgesics. Twenty-eight hospitalized children without brain injury, aged between 8 and 16 years treated with opiate analgesics for pain relief following surgery were tested on the Westmead PTA scale. Pain and stress levels were also self-reported each day. Only 29% (n = 7) of children assessed over four days obtained a maximum score of 12/12 on three consecutive days, thus 71% would have been deemed to have been in PTA when they were not. The percentage of children who obtained a maximum score significantly decreased over consecutive days of assessment, due to an increase in error rate on picture memory items. Self-reported pain and stress ratings were not correlated with PTA scores. Opiate analgesia can disrupt performance on the Westmead PTA scale in school-aged children resulting in a high false-positive error rate. It is therefore important to record pain medication schedules and interpret results cautiously when opiate analgesia is used following a TBI. Alteration of the method of administration of the memory items should be researched as this may increase the validity of the scale for children with TBI treated with opiate analgesics. [ABSTRACT FROM AUTHOR]

Background: Opioid overdose is a national health priority and curbing inappropriate prescribing is critical. In 2016, the Centers for Disease Control and Prevention (CDC) issued appropriate prescribing guidelines. Objectives: Examine associations between care networks defined by shared patients and problematic opioid prescribing. Methods: Analysis was at the provider-year level. Social network analysis (SNA) applied to the Medicaid MarketScan® Research Database for the years 2010–2015 identified care communities, each community's level of integration (centralization), and each provider's integration (centrality). Nested multivariable logistic regressions controlling for patient mix and provider specialty simultaneously examined the risk of any (incident) and repeated (prevalent) inappropriate prescribing. Outcomes: Four behaviors defined by the CDC guidelines were examined: (1) more than 90 days continuous supply of high-dose opioid analgesics for chronic pain, (2) overlapping opioid supplies, (3) overlapping opioid and benzodiazepine prescriptions, and (4) prescribing an extended release opioid for an acute pain diagnosis. Results: Provider centrality was associated with reduced incidence of outcome (2) (OR: 0.95) and decreased prevalence of outcomes (1), (2), and (3). However, higher incidence (OR: 1.32) and prevalence (OR: 1.027) of outcome (4) were observed. Conversely, centralization associated with decreased incidence of (1) and (2) and lower prevalence of (1), (2), and (3). Conclusions: Greater provider integration is associated with a lower risk of a provider's patients repeatedly having potentially inappropriate prescription fills; however, the association with a provider having any potentially problematic prescription is more ambiguous. [ABSTRACT FROM AUTHOR]

Studies have shown barriers to appropriate narcotic use in the Middle East have negatively impacted patient outcomes. This study aimed to explore health professionals' perspectives regarding opioid use for cancer patients in Qatar. Eight focus groups were conducted with physicians, pharmacists, and nurses. An eight-question topic guide framed discussions and targeted contextual barriers and cultural beliefs. Focus groups were audio-recorded and transcribed verbatim. Thematic analysis was used to identify the following themes: narcotic use process, patient-related factors, and healthcare professional-related factors. Laws and regulations were identified as major barriers to appropriate narcotic access, prescribing, and administration. Government-imposed restrictions on permitted dispensed quantities and associated paperwork impeded continuity of patient care and pain relief. The influence of a patient's culture underpinned patient-related barriers, including fear of addiction and family members discouraging opioid use. Fear of prescribing for patient addiction and accusation of inappropriate prescribing by authorities were identified as health professional-related barriers. Facilitators included patient and provider education, as well as the availability of specialized teams to assess and treat cancer-related pain. Findings show narcotic utilization is not simply influenced by a single factor or subset of factors but by a multitude of factors that can be both independent and interrelated. [ABSTRACT FROM AUTHOR]

Objective: To evaluate opioid consumption among parturients with varying degrees of perineal lacerations.Methods: This was a retrospective analysis of women who delivered vaginally at our institution from 1 January 2014 to 12 April 2015. We collected information regarding the degree of perineal lacerations (no lacerations, first-/second-degree, third-/fourth-degree), analgesic consumption, and postpartum pain scores. The primary outcome was opioid use from 0-48 h postpartum. Univariate and multivariable regression analyses were performed to test for the association of laceration severity with opioid use.Results: We included 5598 women in the analysis; 1948 had no lacerations, 3434 had first-/second-degree lacerations, and 216 had third-/fourth-degree lacerations. In univariate analysis, parturients with third-/fourth-degree lacerations had significantly higher use of opioids within 48 h postpartum (53.2%) compared to women with no lacerations (30.03%) or first-/second-degree lacerations (28.6%) (p < .001). In the multivariable analysis, women with third-/fourth-degree lacerations had higher odds of opioid use than those without laceration [OR (95% CI) = 2.61 (1.75-3.85), p < .001]. In pairwise comparisons, those with third-/fourth-degree lacerations had higher odds of opioid use than those without lacerations [OR (95% CI) = 3.55 (2.20-5.74)], and those with first-/second-degree lacerations [OR (95% CI) = 2.15 (1.49-3.10)] (p < .001). Oxycodone equivalent consumption was significantly different among groups with a median (IQR) of 5.00 mg (0.00-27.50), 0.00 mg (0.00-5.00) and 0.00 mg (0.00-5.00) in women with third-/fourth-degree, first-/second-degree, and no lacerations, respectively, during the 0-48 h postpartum (p < .001).Conclusion: The use of opioids and opioid doses are higher in women with third-/fourth-degree perineal lacerations compared to those with first-/second-degree or no lacerations. [ABSTRACT FROM AUTHOR]

Objective: This paper presents and discusses recent evidence on the pathophysiological mechanisms of pain. The role of tapentadol - an opioid characterized by an innovative mechanism of action (i.e. µ-opioid receptor [MOR] agonism and inhibition of noradrenaline [NA] reuptake [NRI]) - in the modulation of pain, and the most recent pharmacological evidence on this molecule (e.g. the µ-load concept) are also presented and commented upon.Methods: Narrative review.Results: Solid evidence has highlighted the importance of central sensitization in the transition from acute to chronic pain. In particular, the noradrenergic system holds a major role in limiting central sensitization and the progression to chronic pain. Therefore, pharmacological modulation of the noradrenergic system appears to be a well-grounded strategy for the control of chronic pain. Tapentadol is characterized by a to-date-unique mechanism of action, since it acts both as a MOR agonist and as an inhibitor of NA reuptake. The synergistic interaction of these two mechanisms allows a strong analgesic effect by acting on both ascending and descending pathways. Of note, the reduced µ-load of tapentadol limits the risk of opioid-related adverse events, such as gastrointestinal disturbances. Moreover, the NA component becomes predominant, at least, in some types of pain, with consequent specific clinical efficacy in the treatment of neuropathic and chronic pain.Conclusions: According to these characteristics, tapentadol appears suitable in the treatment of severe uncontrolled chronic pain characterized by both a nociceptive and a neuropathic component, such as osteoarthritis or back pain. [ABSTRACT FROM AUTHOR]

Our study assessed the trends and patterns of tramadol prescriptions and possible correlations of a person being prescribed tramadol using the Korean National Health Insurance Service Sample Cohort from 2003 to 2013. The study population consisted of patients who were prescribed tramadol, opioids, or nonsteroidal anti-inflammatory drugs (NSAIDs) in an outpatient setting. From 2003 to 2013, the number of tramadol users increased from 2,476 (19.9% of the study population in 2003) to 124,592 (33.3% of the 2013 study population). The absolute change in the proportion of study patients prescribed tramadol (%) was +13.4%, a relative change (%) of +67.3%. In contrast, absolute changes in the number of opioid and NSAID users were -4.78% and -8.65%, respectively, which were relative changes of -73.5% and -11.8%, respectively. Of the studied pain types, arthritis and back pain were the most prominent diagnoses in tramadol users. Notable correlations for tramadol prescriptions, when compared with NSAIDs, were rural area (adjusted odds ratio (aOR): 1.64; 95% CI 1.61-1.66), co-prescription of a benzodiazepine (aOR 2.01; 95% CI 1.97-2.05), and tertiary hospital (aOR: 3.08, 95% CI 3.00-3.17). [ABSTRACT FROM AUTHOR]

Objective: Daily opioid dependence for maternal pain management, methadone maintenance, or buprenorphine/naloxone therapy is an increasing trend in modern obstetrics. Opioids may produce depressive effects on fetal neurobehavioral status and thus on fetal heart rate patterns. Our primary objective was to describe the current methods utilized in antenatal monitoring of the daily opioid exposed fetus; and to describe interventions based upon monitoring which precipitated a recommendation for delivery. Our ultimate goal was to determine an optimal, evidence-based recommendation for fetal assessment of the daily opioid exposed pregnancy.Study design: A retrospective review of patients undergoing antenatal assessment from January 2016 through April 2017 at two maternal-fetal medicine testing centers identified singleton, fetuses without a known major genetic abnormality with daily opioid exposure. Nonstress tests, amniotic fluid indexes, biophysical profiles, umbilical artery Doppler measurements, and serial biometry were analyzed. Test characteristics and frequency of interventions for abnormal monitoring were quantified.Results: Criteria for daily opioid exposure was identified in 27 patients (77.8% on methadone (n = 21), 14.8% on prescription opioid for chronic pain (n = 4), and 7.4% on buprenorphine/naloxone (n = 2)). Mean maternal age was 30.3 years ±5.5 (range 21-42 years). Parity zero was 6/27 (22.2%). Identified race was 52% Caucasian, 26% African American, 19% Hispanic, and 4% Pacific Islander. There were 112 growth scans, 102 biophysical profiles, 10 isolated nonstress tests, and 81 umbilical artery Doppler studies reviewed. Delivery precipitated by abnormal testing occurred in 6/27 patients (22.2%). Gestational ages of delivery were all between 36 and 38 weeks. Indications for delivery were isolated oligohydramnios 2/6 (one at 37 weeks, one at 38 weeks), oligohydramnios with associated intrauterine growth restriction 2/6 (both at 36 weeks), isolated nonreactive nonstress test 1/6 (occurring at 38 weeks), and low biophysical profile score 1/6 (occurring at 36 weeks). The average nonstress test baseline was 131 (±11) beats per minute (range of 120-150), with no episodes of significant fetal bradycardia or tachycardia. Overall, 94.6% (106/112) of the nonstress tests were reactive, all nonstress tests had variability, 96.4% (108/112) had moderate variability, and 99.1% (111/112) had no decelerations. Time to nonstress test reactivity was <20 min in 93% (104/112), with a mean time to first acceleration of 5.3 (±7.7) min (range of 1-44). Umbilical artery Doppler measurements had an elevated systolic to diastolic ratio >95% for gestational age in 9/83 cases, with no measurements demonstrating absent or reversed end diastolic flow. Umbilical artery Doppler studies did not initiate changes in management.Conclusion: In our population, antepartum assessment with a biophysical profile at no later than 36-week gestation identified all fetuses with testing abnormalities necessitating delivery in the daily opioid exposed fetus (6/27, 22.2%). Oligohydramnios was the most frequent indication for delivery. Serial growth ultrasounds by 32 weeks were necessary to identify the 11.1% of growth restricted, opioid exposed fetuses. A depressive effect of daily opioids on nonstress test reactivity or variability was not evident in our cohort. Future studies should attempt to define optimal monitoring based upon category of opioid dependence, type and dose of opioid consumed, and timing of opioid administration. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were to assess comparative effectiveness and harms of opioid and nonopioid analgesics for the treatment of moderate to severe acute pain in the prehospital setting. Methods: We searched MEDLINE®, Embase®, and Cochrane Central from the earliest date through May 9, 2019. Two investigators screened abstracts, reviewed full-text files, abstracted data, and assessed study level risk of bias. We performed meta-analyses when appropriate. Conclusions were made with consideration of established clinically important differences and we graded each conclusion's strength of evidence (SOE). Results: We included 52 randomized controlled trials and 13 observational studies. Due to the absence or insufficiency of prehospital evidence we based conclusions for initial analgesia on indirect evidence from the emergency department setting. As initial analgesics, there is no evidence of a clinically important difference in the change of pain scores with opioids vs. ketamine administered primarily intravenously (IV) (low SOE), IV acetaminophen (APAP) (low SOE), or nonsteroidal anti-inflammatory drugs (NSAIDs) administered primarily IV (moderate SOE). The combined use of an opioid and ketamine, administered primarily IV, may reduce pain more than an opioid alone at 15 and 30 minutes (low SOE). Opioids may cause fewer adverse events than ketamine (low SOE) when primarily administered intranasally. Opioids cause less dizziness than ketamine (low SOE) but may increase the risk of respiratory depression compared with ketamine (low SOE), primarily administered IV. Opioids cause more dizziness (moderate SOE) and may cause more adverse events than APAP (low SOE), both administered IV, but there is no evidence of a clinically important difference in hypotension (low SOE). Opioids may cause more adverse events and more drowsiness than NSAIDs (low SOE), both administered primarily IV. Conclusions: As initial analgesia, opioids are no different than ketamine, APAP, and NSAIDs in reducing acute pain in the prehospital setting. Opioids may cause fewer total side effects than ketamine, but more than APAP or NSAIDs. Combining an opioid and ketamine may reduce acute pain more than an opioid alone but comparative harms are uncertain. When initial morphine is inadequate, giving ketamine may provide greater and quicker acute pain relief than giving additional morphine, although comparative harms are uncertain. Due to indirectness, strength of evidence is generally low, and future research in the prehospital setting is needed. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the real-life effectiveness, safety, tolerability and patient-reported outcomes (PRO) of the sufentanil sublingual tablet system (SSTS) for postoperative pain management (POPM).Methods: This prospective, multicenter, noninterventional, study included adults with acute moderate to severe postoperative pain who self-administered sufentanil using the SSTS. Main outcome measures were pain intensity at rest (numerical rating scale [NRS]: 0 [no pain] to 10 [most intense pain imaginable]); most intense pain intensity (0-10); 4-point patient assessment of the pain control method ("excellent", "good", "fair", "poor"); patient satisfaction with the pain control level and the method of administration of pain medication (6-point scale: "extremely satisfied", "very satisfied", "satisfied", "dissatisfied", "very dissatisfied", "extremely dissatisfied"). Adverse drug reactions were recorded.Results: The SSTS reduced resting pain intensity in patients (n = 341) from a mean ± SD NRS score of 5.2 ± 2.3 (at SSTS handover) to 1.8 ± 1.6 (3rd day after handover). The proportion of patients with severe pain (for the PRO measure "most intense pain") decreased steadily during the 72 hours of treatment. Overall, 87.1% of the patients reported the method of pain control to be "good" or "excellent"; 91.8% reported being "extremely/very satisfied" or "satisfied" with the level of pain control; and 95.9% were at least satisfied with the method of pain medication administration. SSTS safety and tolerability was typical for opioids and as described in the SSTS Summary of Product Characteristics.Conclusions: The SSTS is a valuable option for real-life POPM and is effective in a wide range of surgical procedures. [ABSTRACT FROM AUTHOR]

Opioid analgesic consumption has led to an unprecedented epidemic of overdose death and opioid addiction in the US history. The treatment of chronic pain in patients with opioid addiction who receive prescriptions for opioid medications presents a clinical dilemma. Continuing opioid medication could result in hyperalgesia rendering opioids ineffective and results in iatrogenic therapeutic damage as evidenced by the worsening of addiction. Discontinuing opioid medications could result in severe pain and cravings that often leads the patient to the illicit market. This study compared methadone and buprenorphine/naloxone in patients with failed back surgery syndrome and opioid addiction. Nineteen participants were randomly assigned to methadone or buprenorphine/naloxone and were followed for 6 months. In an intent-to-treat analysis analgesia, craving, functioning, drug use, depression, and treatment retention were assessed monthly. It was planned to enroll 66 patients with failed back surgery syndrome and opioid addiction; however, enrollment was closed early due to suspected abuse of medications. Patients in both treatment conditions exhibited significantly improved 24-hour pain severity with up to 20% reduction of pain severity at the last follow-up (p <.05). However, patients receiving methadone reported significantly reduced current pain severity, whereas patients receiving buprenorphine/naloxone did not. Patients reported significantly improved functioning, fewer cravings, less opioid use, and depression (p <.05) across the treatment conditions. When given a choice between methadone and buprenorphine/naloxone, buprenorphine/naloxone is recommended due to its superior safety profile. Treatment with either needs to be monitored closely. [ABSTRACT FROM AUTHOR]

Background: Among patients with chronic pain using long-term opioid therapy, the incidence of opioid abuse, addiction, overdose, and associated death are not well quantified. The range of estimates for these adverse outcomes varies drastically and may depend on how they are measured (i.e. study definitions of outcomes) and on patient characteristics and opioid-use factors (e.g. regimen, daily dose).Methods: Based on a review of the literature, the US Food and Drug Administration (FDA) required companies that manufacture and sell extended-release/long-acting (ER/LA) opioids conduct as a postmarketing requirement (PMR) a series of observational studies to estimate the rates of treatment-emergent misuse, abuse, addiction, overdose, and death using validated measures. The companies formed a consortium, the Opioid PMR Consortium (OPC), to conduct the studies.Results: The FDA initially requested four observational studies (a cohort study, a questionnaire validation study, a code validation study, and a doctor-shopping validation study), but in order to achieve the FDA's goals of the 4 studies, OPC and FDA agreed to 10 observational studies (a prospective cohort study, a retrospective database cohort study, three questionnaire validation studies, two code validation studies, and three doctor-shopping validation studies). The studies are continuing through 2020.Conclusions: A series of 10 observational studies was or are being conducted in response to the FDA's postmarketing requirement. All studies have been feasible to conduct, although a validated algorithm for measuring abuse and addiction in databases was not successful. [ABSTRACT FROM AUTHOR]

Health-care professionals are faced with a daunting task: balancing appropriate care for chronic pain with their responsibility to keep patients and others safe from treatment-related harm. Whereas opioids have historically been considered an effective tool in the analgesic armamentarium, the rise of opioid abuse has caused the pendulum to swing away from prescribing opioids to an emphasis on safety. This paradigm shift risks neglecting the very real consequences of untreated/undertreated pain. Using data from the medical literature, this review examines influences on the real and perceived benefit-to-risk ratio for opioids and provides clinicians with a practical approach to prescribing opioids that minimizes the risk for abuse/misuse. There is appreciable clinical trial and observational evidence of efficacy/effectiveness with opioids used for pain management over the short or long term when considered in the context of pharmacologic alternatives. Enhancing the relative safety and minimizing the risk for abuse/misuse may be achieved through proactive prescription practices that include careful patient selection, risk assessment, individualized and multimodal treatment plans with established goals, initiating opioid treatment cautiously with an exit plan in place, ongoing assessments of response to therapy, and routine patient monitoring. Additionally, prescribing opioids with a lower potential for abuse or misuse (e.g. abuse-deterrent formulations) may provide a benefit. Using a pragmatic approach to prescribing practices, we postulate that the balance between benefit and risk can be favorable for opioid therapy in select patients, even for long-term treatment of chronic pain. [ABSTRACT FROM AUTHOR]

Objective: Our institution implemented six multimodal, sliding scale protocols for managing pain in non-surgical inpatients. The purpose of this study was to compare the use of these acute pain protocols with traditional prescribing in regard to pain management efficacy and safety measures.Methods: This retrospective cohort study evaluated hospital in-patients who were prescribed one of the protocols during the first 6 months following implementation, admitted to the hospitalist service, and had received at least two doses of PRN analgesic medication within a 24-hour period. Data collected included baseline demographics, verbal pain rating scores to determine time to achieve analgesia, total opioid use in oral morphine equivalent doses (MEDs), and safety measures. A sample of patients admitted during the same time frame, meeting inclusion/exclusion criteria, but who received traditional analgesic prescribing served as controls.Results: Forty-six adult, non-surgical patients were included in the analysis, and 46 served as controls. The average baseline pain scores were similar between groups (7.26 in protocol, 7.43 in control, p = 0.684). Protocol patients required significantly less time to achieve meaningful analgesia (average 507.52 min) compared to the control group (894.33 min, p = 0.045). Patients in the protocol group used an average of 35.81 MEDs per day compared to 65.77 MEDs in controls (p = 0.019). Patients in the protocol group used significantly fewer PRN analgesic doses (12.70 vs. 24.02, p < 0.0001).Conclusion: Analysis of the implementation of acute pain management protocols indicates that using standardized pain management protocols of opioids, non-opioids, and medications to prevent opioid-related adverse events is more effective than traditional analgesic prescribing for our patient population. [ABSTRACT FROM AUTHOR]

Background: Treatment with methadone is effective in reducing heroin use, HIV risk, and death; however, not all patients respond to treatment. Better outcomes may emerge with personalized treatment based on factors that influence treatment courses. Objectives: To investigate psychosocial variables contributing to treatment response, using a comprehensive definition of treatment response. Methods: Seventy participants seeking treatment for heroin and cocaine addiction completed up to 40 weeks of daily methadone. At week 22, we administered a semi-structured interview for DSM-IV symptoms. We defined opioid treatment responders as people still enrolled at 22 weeks, not meeting past 30-day criteria for DSM-IV opioid abuse or dependence or DSM-5 opioid use disorder, and providing ≥75% opioid-negative urine samples in the 30 days prior to week 22. The same criteria were applied to assess cocaine treatment response. Results: Sample was 71% male, 41% White, and averaged 39.4 ± 7.9 years old. Opioid treatment response was more likely in participants who had been employed over the past 3 years (OR: 8.1, 95% CI: 1.2–55) and less likely in those who spent more time on hobbies (OR: 0.45, 95% CI: 0.23–0.88). Cocaine treatment response was more likely in participants who had a good relationship with their father (OR: 5.3, 95% CI: 1.2–24) and less likely if positive for hepatitis C (OR: 0.15, 95% CI: 0.03–0.75). Conclusions: Pretreatment characteristics differentially predict treatment response for heroin and cocaine use. Similar research in diverse patient groups may aid in the development of personalized treatment combining biologic treatment with targeted psychosocial interventions. [ABSTRACT FROM AUTHOR]

The article addresses the librarian Involvement in a Health System Clinical Practice Council. It focuses that the Allina Health has established governance and infrastructure for the development of best practices across the system and address the complexity and also highlights the designation of a system-wide, multidisciplinary Clinical Practice Council (CPC) to act as the final arbiter of evidence-based care debates.