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Background: Breathlessness is a prevalent symptom affecting the quality of life (QOL) of Amyotrophic Lateral Sclerosis (ALS) patients. This systematic review explored the interventions for controlling breathlessness in ALS patients, emphasizing palliative care (PALC), non-invasive ventilation (NIV), opioids, and non-pharmacological strategies. Methods: A comprehensive search of PubMed, Cochrane Library, and Web of Science databases was conducted. Eligibility criteria encompassed adults with ALS or motor neuron disease experiencing breathlessness. Outcomes included QOL and symptom control. Study designs comprised qualitative studies, cohort studies, and randomized controlled trials. Results: Eight studies were included, most exhibiting low bias risk, comprising one randomized controlled trial, three cohort studies, two comparative retrospective studies, and two qualitative studies (interviews). Most studies originated from Europe, with one from the United States of America. The participants totaled 3423, with ALS patients constituting 95.6%. PALC consultations significantly improved symptom assessment, advance care planning, and discussions about goals of care. NIV demonstrated efficacy in managing breathlessness, with considerations for device limitations. Opioids were effective, though predominantly studied in non-ALS patients. Non-pharmacological strategies varied in efficacy among patients. Conclusion: The findings underscore the need for individualized approaches in managing breathlessness in ALS. PALC, NIV, opioids, and non-pharmacological strategies each play a role, with unique considerations. Further research, especially ALS-specific self-management studies, is warranted. [ABSTRACT FROM AUTHOR]

Background Limited evidence exists on the short- and long-term safety of discontinuing versus continuing chronic opioid therapy (COT) among patients with Alzheimer's disease and related dementias (ADRD). Methods This cohort study was conducted among 162,677 older residents with ADRD and receipt of COT using a 100% Medicare nursing home sample. Discontinuation of COT was defined as no opioid refills for ≥90 days. Primary outcomes were rates of pain-related hospitalisation, pain-related emergency department visit, injury, opioid use disorder (OUD) and opioid overdose (OD) measured by diagnosis codes at quarterly intervals during 1- and 2-year follow-ups. Poisson regression models were fit using generalised estimating equations with inverse probability of treatment weights to model quarterly outcome rates between residents who discontinued versus continued COT. Results The study sample consisted of 218,040 resident episodes with COT; of these episodes, 180,916 residents (83%) continued COT, whereas 37,124 residents (17%) subsequently discontinued COT. Discontinuing (vs. continuing) COT was associated with higher rates of all outcomes in the first quarter, but these associations attenuated over time. The adjusted rates of injury, OUD and OD were 0, 69 and 60% lower at the 1-year follow-up and 11, 81 and 79% lower at the 2-year follow-up, respectively, for residents who discontinued versus continued COT, with no difference in the adjusted rates of pain-related hospitalisations or emergency department visits. Conclusions The rates of adverse outcomes were higher in the first quarter but lower or non-differential at 1-year and 2-year follow-ups between COT discontinuers versus continuers among older residents with ADRD. [ABSTRACT FROM AUTHOR]

Background: Opioid switching is common, however, conversion tables have limitations. Guidelines suggest postswitch dose reduction, yet, observations show opioid doses may increase postswitch. Objectives: To document the opioid conversion factor postswitch in cancer, and whether pain and adverse effect outcomes differ between switched opioid groups. Design/Setting: This multicenter prospective longitudinal study included people with advanced cancer in Australia. Clinical data (demographics, opioids) and validated instruments (pain, adverse effects) were collected twice, seven days apart. Results: Opioid switch resulted in dose increase (median oral morphine equivalent daily dose 90 mg [interquartile range {IQR} 45–184] to 150 mg [IQR 79–270]), reduced average pain (5.1 [standard deviation {SD} 1.7] to 3.8 [SD 1.6]), and reduced adverse effects. Hydromorphone dose increased 2.5 times (IQR 1.0–3.6) above the original conversion factor used. Conclusions: Opioid switching resulted in overall dose increase, particularly when switching to hydromorphone. Higher preswitch dosing may require higher dose conversion ratios. Dose reduction postswitch risks undertreatment and may not be always appropriate. [ABSTRACT FROM AUTHOR]

Background: Despite much research and many interventions, the opioid epidemic continues to plague the United States. According to the Centers for Disease Control and Prevention (2021), 136 people die daily from both prescription and illicit opioids. Objective: The goal of this pilot quality improvement project is to examine how the implementation of the Opioid Risk Tool (ORT) in clinical practice might impact the beliefs and attitudes of nurse practitioners (NPs) toward prescribing opioid therapy. Methods: A pre–post design was utilized. A convenience sample recruited participants from a private NP Facebook group. The intervention included a prerecorded presentation on the ORT and the use of the ORT for 8 weeks. Results: While 46 NPs completed the presurvey, only 19 NPs completed the postsurvey. Statistical results did not yield significance, but there were several significant clinical trends discovered. Conclusion: Utilizing the ORT to screen for opioid misuse risks has been shown to improve providers' confidence in opioid prescribing. ORT guides providers in discerning patient risk for developing dependence on opioids. Implications for Nursing: Screening for opioid misuse risk is feasible. ORT adds to the clinical context in deciding a course of treatment in pain management. [ABSTRACT FROM AUTHOR]

BACKGROUND: Opioid prescribing patterns, including those after surgery, have been implicated as a significant contributor to the US opioid crisis. A plethora of interventions--from nudges to reminders--have been deployed to improve prescribing behavior, but reasons for persistent outlier behavior are often unknown. STUDY DESIGN: Our institution employs multiple prescribing resources and a near real-time, feedback-based intervention to promote appropriate opioid prescribing. Since 2019, an automated system has emailed providers when a prescription exceeds the 75th percentile of typical opioid consumption for a given procedure--as defined by institutional data collection. Emails include population consumption metrics and an optional survey on rationale for prescribing. Responses were analyzed to understand why providers choose to prescribe atypically large discharge opioid prescriptions. We then compared provider prescriptions against patient consumption. RESULTS: During the study period, 10,672 eligible postsurgical patients were discharged; 2,013 prescriptions (29.4% of opioid prescriptions) exceeded our institutional guideline. Surveys were completed by outlier prescribers for 414 (20.6%) encounters. Among patients where both consumption data and prescribing rationale surveys were available, 35.2% did not consume any opioids after discharge and 21.5% consumed <50% of their prescription. Only 93 (39.9%) patients receiving outlier prescriptions were outlier consumers. Most common reasons for prescribing outlier amounts were attending preference (34%) and prescriber analysis of patient characteristics (34%). CONCLUSIONS: The top quartile of opioid prescriptions did not align with, and often far exceeded, patient postdischarge opioid consumption. Providers cite assessment of patient characteristics as a common driver of decision-making, but this did not align with patient usage for approximately 50% of patients. [ABSTRACT FROM AUTHOR]

Purpose: Illicit drug use continues to be a concern for adults on opioid therapy for chronic pain. Prescribers use tools such as urine screening and confirmatory testing with mass spectrometry to monitor adherence to chronic opioid therapy contracts. Design: A cross sectional retrospective study was conducted using electronic medical records. Methods: Data was analyzed from 6558 urine samples of adult outpatients receiving opioid therapy at an urban pain specialty clinic who consented to urine drug tests. Results: From October 18, 2021, to October 21, 2022, 569 were positive amphetamine with immunoassay testing. 310 (54%) of those samples were absent amphetamine with or without methamphetamine while 259 (45.5%) were true positive amphetamine proven by confirmation testing. Analysis of confirmatory testing results identified 281 samples positive for amphetamine with or without methamphetamine. 71 samples confirmed positive for methamphetamine with or without amphetamine. 37 (52.1%) of those methamphetamine samples screened positive for amphetamine and 34 (47.9%) samples screened negative for amphetamine. 48 of the methamphetamine samples were sent for chiral confirmation testing. 45 (93.8%) samples were positive for D-methamphetamine while 3 (6.2%) samples were positive for L-methamphetamine. Only 5 (11.1%) of the 45 patients whose samples were positive for d- methamphetamine reported the use of illicit drugs before their urine sample was tested. Discussion: Confirmatory testing with mass spectrometry can detect illicit drugs, such as methamphetamine, with high sensitivity and specificity and should be used with all samples given the low sensitivity of screening immunoassay. It is of utmost importance that opioid pain medicine prescribers know the many possible interpretations of these results so that they are equipped to make appropriate clinical decisions to ensure the safety of the patient, prescriber, and practice. [ABSTRACT FROM AUTHOR]

Introduction: The complication of delirium for hip fracture patients is a predictor of mortality. Use of opioid medication increases the incidence of delirium in the pre- and postoperative periods. Regional nerve blocks are effective in managing acute pain for acute hip fractures. This study aims to evaluate the utilization of ED physicians to perform fascia iliaca nerve blocks on hip fracture patients to decrease the incidence of delirium by decreasing usage of opioid medication. Methods: A quality improvement project for performing regional nerve blocks on patients with femoral neck fractures was implemented during fiscal year 2019. Data was collected retrospectively for frequency of ED nerve block procedures, amount of opioid medication use, and incidence of delirium in patients diagnosed with hip fracture. This data was compared to baseline data to determine success of the intervention. Results: Utilization of regional nerve blocks in the ED increased from 2% in 2018 to 96% in 2021 and 89% in 2022. Preoperative opioid usage decreased from 38 MMEs to 16.9 and 18 MMEs respectively. Daily average MMEs decreased from 34 to 12.1 and 14 respectively. Postoperative delirium decreased from 6% in 2018 to 0% from 2020 to 2022. Discussion: ED provider administration of fascia iliaca blocks and follow-up is a novel practice in our region to decrease the adverse effects of opiate use and decrease delirium rates. There was a reduction in length of stay and increased discharge home rate despite the Covid-19 pandemic. Conclusion: Administration of regional nerve blocks by ED physicians to hip fracture patients presenting to the ED results in a decrease in opioid medication usage. This also results in a decreased delirium rates in the hip fracture patient population. [ABSTRACT FROM AUTHOR]

The posterior minimally invasive spine surgery (MISS) approach—or the paraspinal muscle approach—for posterior spinal fusion and segmental instrumentation in adolescent idiopathic scoliosis (AIS) was first reported in 2011. It is less invasive than the traditionally used open posterior midline approach, which is associated with significant morbidity, including denervation of the paraspinal muscles, significant blood loss, and a large midline skin incision. The literature suggests that the MISS approach, though technically challenging and with a longer operative time, provides similar levels of deformity correction, lower intraoperative blood loss, shorter hospital stays, better pain outcomes, and a faster return to sports than the open posterior midline approach. Correction maintenance and fusion rates also seem to be equivalent for both approaches. This narrative review presents the results of relevant publications reporting on spinal segmental instrumentation using pedicle screws and posterior spinal fusion as part of an MISS approach. It then compares them with the results of the traditional open posterior midline approach for treating AIS. It specifically examines perioperative morbidity and radiological and clinical outcomes with a minimal follow-up length of 2 years (range 2–9 years). [ABSTRACT FROM AUTHOR]

Our objective was to describe suicide prevention care for individuals prescribed opioids or with opioid use disorder (OUD) and identify opportunities for improving this care. Adult patients (n = 65) from four health systems with an opioid-involved overdose and clinicians (n = 21) who had contact with similar patients completed 30–60-min semi-structured interviews. A community advisory board contributed to development of all procedures, and interpretation and summary of findings. Patients were mostly female (59%), White (63%) and non-Hispanic (77%); 52 were prescribed opioids, 49% had diagnosed OUD, and 42% experienced an intentional opioid-involved overdose. Findings included: 1) when prescribed an opioid or treated for OUD, suicide risks were typically not discussed; 2) 35% of those with an intentional opioid-involved overdose and over 80% with an unintentional overdose reported no discussion of suicidal ideation when treated for the overdose; and 3) suicide-related follow-up care was uncommon among those with unintentional overdoses despite suicidal ideation being reported by >20%. Clinicians reported that when prescribing opioids or treating OUD, post-overdose suicide-related screening or counseling was not done routinely. There were several opportunities to tailor suicide prevention care for patients who were treated for opioid-involved overdoses within health systems. [ABSTRACT FROM AUTHOR]

Background: The comparative safety of serotonin and norepinephrine reuptake inhibitors (SNRIs) as adjuvants to short‐acting opioids in older adults is unknown even though SNRIs are commonly used. We compared the effects of SNRIs versus nonsteroidal anti‐Inflammatory drugs (NSAIDs) on delirium among nursing home residents when SNRIs or NSAIDs were added to stable regimens of short‐acting opioids. Methods: Using 2011–2016 national Minimum Data Set (MDS) 3.0 and Medicare claims data to implement a new‐user design, we identified a cohort of nursing home residents receiving short‐acting opioids who initiated either an SNRI or an NSAID. Delirium was defined from the Confusion Assessment Method in MDS 3.0 assessments and ICD9/10 codes using Medicare hospitalization claims. Propensity score matching balanced underlying differences for initiating treatments on 39 demographic and clinical characteristics (nSNRIs = 5350; nNSAIDs = 5350). Fine and Gray models provided hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for the competing risk of death. Results: Hydrocodone was the most commonly used short‐acting opioid (48%). Residents received ~23 mg daily oral morphine equivalent at the time of SNRIs/NSAIDs initiation. The majority were women, non‐Hispanic White, and aged ≥75 years. There were no differences in any of the confounders after propensity matching. Over 1 year, 10.8% of SNRIs initiators and 8.9% of NSAIDs initiators developed delirium. The rate of delirium onset was similar in SNRIs and NSAID initiators (HR(delirium in nursing home or hospitalization for delirium):1.10; 95% CI: 0.97–1.24; HR(hospitalization for delirium): 1.06; 95% CI: 0.89–1.25), and were similar regardless of baseline opioid daily dosage. Conclusions: Among nursing home residents, adding SNRIs to short‐acting opioids does not appear to increase risk of delirium relative to initiating NSAIDs. Understanding the comparative safety of pain regimens is needed to inform clinical decisions in a medically complex population often excluded from clinical research. [ABSTRACT FROM AUTHOR]

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]

Objective: To determine changes in opioid prescribing among veterans with headaches during the coronavirus disease of 2019 (COVID‐19) pandemic by comparing the stay‐at‐home phase (March 15 to May 30, 2020) and the reopening phase (May 31 to December 31, 2020). Background: Opioid prescribing for chronic pain has declined substantially since 2016; however, changes in opioid prescribing during the COVID‐19 pandemic among veterans with headaches remain unknown. Methods: This retrospective cohort study utilized regression discontinuity in time and difference‐in‐differences design to analyze veterans aged ≥18 years with a previous diagnosis of headache disorders and an outpatient visit to the Veterans Health Administration (VHA) during the study period. We measured the weekly number of opioid prescriptions, the number of days supplied, the daily dose in morphine milligram equivalents (MMEs), and the number of prescriptions with ≥50 morphine equivalent daily doses (MEDD). Results: A total of 81,376 veterans were analyzed with 589,950 opioid prescriptions. The mean (SD) age was 51.6 (13.5) years, 57,242 (70.3%) were male, and 53,464 (65.7%) were White. During the pre‐pandemic period, 323.6 opioid prescriptions (interquartile range 292.1–325.8) were dispensed weekly, with an median (IQR) of 24.1 (24.0–24.4) days supplied and 31.8 (31.2–32.5) MMEs. Transition to stay‐at‐home was associated with a 7.7% decrease in the number of prescriptions (incidence rate ratio [IRR] 1.077, 95% confidence interval [CI] 0.866–0.984) and a 9.8% increase in days supplied (IRR 1.098, 95% CI 1.078–1.119). Similar trends were observed during the reopening period. Subgroup analysis among veterans on long‐term opioid therapy also revealed 1.7% and 1.4% increases in days supplied during the stay‐at‐home (IRR 1.017, 95% CI 1.009–1.025) and reopening phase (IRR 1.014, 95% CI 1.007–1.021); however, changes in the total number of prescriptions, MME/day, or the number of prescriptions >50 MEDD were insignificant. Conclusion: Prescription opioid access was maintained for veterans within VHA during the pandemic. The de‐escalation of opioid prescribing observed prior to the pandemic was not seen in our study. [ABSTRACT FROM AUTHOR]

Background: Most patients with hip fractures are elderly patients with comorbidities, and well-managed pain management is associated with positive postoperative outcomes. In recent years, new indications for regional anesthesia techniques have been defined, and they have found more place in clinical practice. Herein we investigate the effect of US-guided PENG block on positioning pain and compare that effect to intravenous opioid in patients undergoing surgery under spinal anesthesia for hip fractures. Additionally, we sought to investigate the effect of PENG block on pain scores, opioid intake, time to first analgesic requirement, and quality of recovery within the first 24 h following surgery. Methods: In this study, patients were divided into the PENG (n = 42) and control group (n = 42) one hour prior to surgery. A team who was blinded to the assigned groups, collected and evaluated all data such as spinal anesthesia positioning pain, postoperative pain, opioid requirement. Results: Patients that underwent PENG had statistically significantly lower NRS scores after interventions, immediately before positioning, at positioning and at end of spinal anesthesia. Pain scores during positioning for spinal anesthesia were statistically significantly lower in the PENG group than in the control group (p < 0.001). Total morphine use over the first 24 h was extremely statistically significantly lower in the PENG group (p < 0.001). Conclusions: Positive outcomes of PENG block in patient positioning pain before spinal anesthesia, postoperative pain scores, and morphine consumption are consistent with similar studies. High patient satisfaction in patients who underwent PENG block contributes to the literature. Trial Registration: ClinicalTrials.gov Identifier: NCT04871061 [ABSTRACT FROM AUTHOR]

Previous research linking opioid prescribing to adverse drug events has failed to properly account for the time-varying nature of opioid exposure. This study aimed to explore how the risk of opioid-related emergency department visits, readmissions, or deaths (composite outcome) varies with opioid dose and duration, comparing different novel modeling techniques. A prospective cohort of 1,511 hospitalized patients discharged from 2 McGill-affiliated hospitals in Montreal, 2014–2016, was followed from the first postdischarge opioid dispensation until 1 year after discharge. Marginal structural Cox proportional hazards models and their flexible extensions were used to explore the association between time-varying opioid use and the composite outcome. Weighted cumulative exposure models assessed cumulative effects of past use and explored how its impact depends on the recency of exposure. The patient mean age was 69.6 (standard deviation = 14.9) years; 57.7% were male. In marginal structural model analyses, current opioid use was associated with a 71% increase in the hazard of opioid-related adverse events (adjusted hazard ratio = 1.71, 95% confidence interval: 1.21, 2.43). The weighted cumulative exposure results suggested that the risk cumulates over the previous 50 days of opioid consumption. Flexible modeling techniques helped assess how the risk of opioid-related adverse events may be associated with time-varying opioid exposures while accounting for nonlinear relationships and the recency of past use. [ABSTRACT FROM AUTHOR]

Background: Robot-assisted total hip arthroplasty (RA-THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA (mTHA), but optimal dosage for peri-RA-THA and mTHA pain relief remains unclear. This study aimed to compare pain control with opioids between patients undergoing direct anterior approach THA with the use of a novel, fluoroscopic-assisted RA-THA system compared to opioid consumption associated with fluoroscopic-assisted, manual technique. Methods: Retrospective cohort analysis was performed on a consecutive series of patients who received mTHA and fluoroscopy-based RA-THA. The average amount of postoperative narcotics in morphine milligram equivalents (MME) given to each cohort was compared, including during the in-hospital and post-discharge periods. Analyses were performed on the overall cohort, as well as stratified by opioid-naïve and opioid-tolerant patients. Results: The RA-THA cohort had significantly lower total postoperative narcotic use compared to the mTHA cohort (103.7 vs. 127.8 MME; P < 0.05). This difference was similarly seen amongst opioid-tolerant patients (123.6 vs. 181.3 MME; P < 0.05). The RA-THA cohort had lower total in-hospital narcotics use compared to the mTHA cohort (42.3 vs. 66.4 MME; P < 0.05), consistent across opioid-naïve and opioid-tolerant patients. No differences were seen in post-discharge opioid use between groups. Conclusions: Fluoroscopy-based RA-THA is associated with lower postoperative opioid use, including during the immediate perioperative period, when compared to manual techniques. This may have importance in rapid recovery protocols and mitigating episode burden of care. [ABSTRACT FROM AUTHOR]

Background: This study explored the risk mitigation practices of multidisciplinary oncology health-care personnel for the nonmedical use of opioids in people with cancer. Methods: An anonymous, cross-sectional descriptive survey was administered via email to eligible providers over 4 weeks at The Ohio State University's Arthur G. James Cancer Hospital. The survey asked about experiences and knowledge related to opioid use disorders. Results: The final sample of 773 participants included 42 physicians, 213 advanced practice providers (APPs consisted of advanced practice nurses, physician assistants, and pharmacists), and 518 registered nurses. Approximately 40% of participants responded feeling "not confident" in addressing medication diversion. The most frequent risk reduction measure was "Checking the prescription drug monitoring program" when prescribing controlled medications, reported by physicians (n = 29, 78.4%) and APPs (n = 164, 88.6%). Conclusion: People with cancer are not exempt from the opioid epidemic and may be at risk for nonmedical opioid use (NMOU) and substance use disorders. Implementing risk reduction strategies with every patient, with a harm reduction versus abstinence focus, minimizes harmful consequences and improves. This study highlights risk mitigation approaches for NMOU, representing an opportunity to improve awareness among oncology health-care providers. Multidisciplinary oncology teams are ideally positioned to navigate patients through complex oncology and health-care journeys. This study explored the risk mitigation practices of multidisciplinary oncology health-care personnel for the nonmedical use of opioids in people with cancer. [ABSTRACT FROM AUTHOR]

Background: According to § 27 and § 87 1b of the German Social Code, Book V, general outpatient palliative care (GOPC) aims to promote, maintain, and improve the quality of life and self-determination of seriously ill people. It should enable them to live in dignity until death in their preferred environment. Instead of a curative approach GOPC treatment focuses on the multiprofessional objective of alleviating symptoms and suffering on a case-by-case basis using medication or other measures, as well as the management of an individual treatment plan. The aim of this study was therefore to investigate to what extent medication differs from 12 months prior GOPC treatment within 12 months following GOPC treatment. Methods: A retrospective database cross sectional study based on the IQVIA Disease Analyzer (DA) was performed, including adult patients with cancer diagnosis and at least one documentation of palliative support between January 1st, 2018 and December 31st, 2021, in 805 general practices (GP). Results: The results of this study show, that in the context of general general outpatient palliative care, there is a significant increase in the prescription of opioids (18.3% vs. 37.7%), sedatives (7.8% vs. 16.2%) and antiemetics (5.3% vs. 9.7%), as well as a significant reduction in other medications such as statins (21.4% vs. 11.5%), proton pump inhibitors (PPI) (41.2% vs. 35.3%), or antihypertensives (57.5% vs. 46.6%). Conclusions: Our results support the role of GOPC as an important element in improving pharmacological symptom control and deprescription to improve quality of life of patients at the end of their life. [ABSTRACT FROM AUTHOR]

Objectives: (1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity. Methods: This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors. Results: A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS. Conclusions for Practice: MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy. Significance: What is already known on this subject? The use of MOUD during pregnancy improves fetal outcomes, while antenatal exposure to MOUD increases the risk of NOWS. The severity of NOWS is influenced by MOUD type, co-exposures, adequacy of prenatal care, and the infant's gestational age. What this study adds? This study identifies factors that mediate the direct influence of antenatal MOUD exposure on the severity of NOWS and quantifies the degree to which this mediation influences outcomes in a large and geographically diverse population. Thus, providing clinicians with potential targets to improve care for this vulnerable population. [ABSTRACT FROM AUTHOR]

Primary care physicians are well-positioned to integrate lifestyle interventions into the management of patients with unhealthy substance use, who may also have mental and physical chronic health comorbidities. However, the COVID-19 pandemic exacerbated the U.S.'s poor state of health, revealing that its current approach to chronic disease management is neither effective nor sustainable. Today's full spectrum comprehensive care model requires an expanded toolkit. Lifestyle interventions broaden current treatment approaches and may enhance Addiction Medicine care. Primary care providers have the potential to have the greatest impact on unhealthy substance use care because they are experts in chronic disease management and their frontline accessibility minimizes healthcare barriers. Individuals with unhealthy substance use are at an increased risk of chronic physical conditions. Incorporating lifestyle interventions with unhealthy substance use care at every level of medicine, from medical school through practice, normalizes both as part of the standard care of medicine and will drive evidence-based best practices to support patients through prevention, treatment, and reversal of chronic diseases. [ABSTRACT FROM AUTHOR]

PURPOSE Opioids are often necessary for patients experiencing high-intensity pain. However, side effects exist and some patients may misuse opioids. To better understand how opioids are prescribed to patients with early-stage cancer and how to enhance opioid safety, clinicians' views of opioid prescribing were explored. METHODS This was a qualitative inquiry including any Alberta clinician prescribing opioids to patients with early-stage cancer. Semistructured interviews were conducted with nurse practitioners (NP), medical oncologists (MO), radiation oncologists (RO), surgeons (S), primary care physicians (PCP), and palliative care physicians (PC) between June 2021 and March 2022. Interpretive description was used to analyze the data using two coders (C.C. and T. W.). Debriefing sessions were used to resolve and discrepancies. RESULTS Twenty-four clinicians were interviewed (NP [n 5 5], MO [n 5 4], RO [n 5 4], S [n 5 5], PCP [n 5 3], and PC [n 5 3]). The majority had been in practice at least 10 years. Prescribing practices were related to disciplinary perspective, goals of care, patient condition, and resource availability. Most clinicians did not see opioid misuse as a problem but were aware that specific patient risk factors are present and that long-term use can be problematic. Most clinicians undertake safe prescribing approaches tacitly (eg, screening for past opioid misuse and reviewing number of prescribers) and not all agreed they should be universally applied. Barriers (eg, procedural and time) and facilitators (eg, education) to safe prescribing approaches were identified. CONCLUSION To enhance uptake and cross-disciplinary consistency of safe prescribing approaches, clinician education regarding opioid misuse and benefits of safe prescribing practices, and addressing procedural barriers are necessary. [ABSTRACT FROM AUTHOR]

Purpose: Analgesics (painkillers) are one of the most widely used medications to reduce and control pain. The objective of this study was to investigate the self-medication with analgesics (narcotic or non-narcotic) in controlling odontogenic pain in patients visiting dental offices, dental clinics, and the dental school of Kerman.Materials and Methods: This was a descriptive-analytic study, conducted in 2018. The study sample included patients referring to dental offices, dental clinics and the dental school of Kerman. After obtaining informed consent, a questionnaire consisting of demographic data and questions regarding the consumption of different types of analgesics for relieving and controlling odontogenic pain and their impact on patients was given by the researcher to the respondents. The patients were asked to complete and return the forms. The questionnaire consisted of three categories of questions, including demographic data, pain characteristics (severity, aggravating factors, relieving factors, etc) and the drug used to relieve the pain. Pain severity was measured using a visual analogue scale (VAS). Mann-Whitney and chi-squared tests were used for statistical analysis in SPSS.Results: This study included 230 males and 351 females (male:female ratio = 0.66) in the age range of 18 to 71 years old (38.21 ± 7.45). 2.6% of respondents were illiterate and 11.3% of respondents were unemployed. The mean value of pain intensity was 6.21 ± 1.11 on a scale of 1 to 10. The types of drugs used for pain relief included 71.8% analgesics, 12.1% complementary medicines and 16.1% antibiotics. The most commonly used medication was NSAIDS, followed by acetaminophen codeine. In this study, the fourth most common medication consumed by patients as an analgesic was amoxicillin. Moreover, it showed that 44.3% (257 individuals) of study participants had used analgesics as self-medication to relieve odontogenic pain, of which 46.08% were males (N = 107) and 42.68% were females (N = 150). The gender of respondents, level of education, and occupation were significantly associated with the consumption of opioid drugs (p = 0.023, p = 0.041, p = 0.011, respectively). Consumption of opioid medications was not statistically significantly correlated with pain intensity (p = 0.115).Conclusion: The factors affecting the appropriate use of medications are social, economic, cultural, and flaws in the health-care system of a society. This study showed that the medications used to reduce pain included analgesics, traditional drugs, and antibiotics. The rate of self-medication was higher among men and among those having a higher level of education. [ABSTRACT FROM AUTHOR]

Background Limited information exists about testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among Medicaid enrollees after starting medication for opioid use disorder (MOUD), despite guidelines recommending such testing. Our objectives were to estimate testing prevalence and trends for HIV, HBV, and HCV among Medicaid enrollees initiating MOUD and examine enrollee characteristics associated with testing. Methods We conducted a serial cross-sectional study of 505 440 initiations of MOUD from 2016 to 2019 among 361 537 Medicaid enrollees in 11 states. Measures of MOUD initiation; HIV, HBV, and HCV testing; comorbidities; and demographics were based on enrollment and claims data. Each state used Poisson regression to estimate associations between enrollee characteristics and testing prevalence within 90 days of MOUD initiation. We pooled state-level estimates to generate global estimates using random effects meta-analyses. Results From 2016 to 2019, testing increased from 20% to 25% for HIV, from 22% to 25% for HBV, from 24% to 27% for HCV, and from 15% to 19% for all 3 conditions. Adjusted rates of testing for all 3 conditions were lower among enrollees who were male (vs nonpregnant females), living in a rural area (vs urban area), and initiating methadone or naltrexone (vs buprenorphine). Associations between enrollee characteristics and testing varied across states. Conclusions Among Medicaid enrollees in 11 US states who initiated medications for opioid use disorder, testing for human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and all 3 conditions increased between 2016 and 2019 but the majority were not tested. [ABSTRACT FROM AUTHOR]

Purpose: The previous literature suggests that 25–30% of patients who undergo total knee arthroplasty (TKA) are using opioids prior to their surgery. This study aims to investigate the effect of preoperative opioid use on clinical outcomes and patient-reported outcome measures (PROMs) following TKA. Methods: We retrospectively reviewed 329 patients who underwent primary TKA from 2019 to 2020, answered the preoperative opioid survey, and had available PROMs. Patients were stratified into two groups based on whether they were taking opioids preoperatively or not: 26 patients with preoperative opioid use (8%) and 303 patients without preoperative opioid use (92%) were identified. Demographics, clinical data, and PROMs [Forgotten Joint Score (FJS-12), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR), and Veterans RAND-12 Physical and Mental components (VR-12 PCS and MCS)] were collected. Demographic differences were assessed with Chi-square and independent sample t-tests. Outcomes were compared using multilinear regression analysis, controlling for demographic differences. Results: Preoperative opioid users had a significantly longer length-of-stay (2.74 vs. 2.10; p = 0.010), surgical time (124.65 vs. 105.69; p < 0.001), and were more likely to be African-American (38.5 vs. 14.2%; p = 0.010) compared to preoperative opioid-naive patients. Postoperative FJS-12 did not statistically differ between the two groups. While preoperative KOOS, JR scores were significantly lower for preoperative opioid users (41.10 vs. 46.63; p = 0.043), they did not significantly differ postoperatively. Preoperative VR-12 PCS did not statistically differ between the groups; however, both 3-month (33.87 vs. 38.41; p = 0.049) and 1-year (36.01 vs. 44.73; p = 0.043) scores were significantly lower for preoperative opioid users. Preoperative VR-12 MCS was significantly lower for preoperative opioid users (46.06 vs. 51.06; p = 0.049), though not statistically different postoperatively. Conclusion: At 8%, our study population had a lower percentage of opioid users than previously reported in the literature. Preoperative opioid users had longer operative times and length of stay compared to preoperatively opioid-naive patients. While both cohorts achieved similar clinical benefits following TKA, preoperative opioid users reported lower postoperative scores with respect to VR-12 PCS scores. Level III Evidence: Retrospective Cohort. [ABSTRACT FROM AUTHOR]

Objectives: We aimed (1) to systematically review the efficacy of transdermal nicotine patches (NP) for postoperative analgesia, (2) to establish the current quality of evidence and assist clinical decision-making on the subject, and (3) to identify methodological limitations and the need for more well-designed studies. Materials and methods: We searched six electronic databases, protocol records, and other sources without date or language restriction until March 2022. To develop the search strategy, we formulated a clinical question by using the PICOD method. Eligibility criteria included randomised placebo-controlled trials on the analgesic potential of NP for surgical procedures. This systematic review followed the PRISMA 2020 statement, and we registered the protocol in PROSPERO (#CRD42020205956). Results: We included 10 randomised placebo-controlled trials (535 patients). The NP administered before induction of anaesthesia and at beginning of surgery reduced the pain immediately after surgery (−0.38; 95% confidence interval [CI]: −0.73 to −0.02), and 6 h (−0.34; 95% CI: −0.68 to −0.01), 12 h (−0.43; 95% CI: −0.71 to −0.15) and 24 h (−0.35; 95%CI: −0.59 to −0.10) after surgery, compared with the placebo patch (PP) group. Sensitivity testing suggests that opioid use could underestimate NP analgesia. Late demand for the first analgesic and consumption of rescue analgesics tended to be lower in the NP group. Conclusions: The current findings suggest, with low certainty of evidence, the analgesic potential of NP for surgical procedures. Clinical relevance: Perioperative use of NP significantly improved postoperative pain, even when opioids were administered or prescribed. Nevertheless, the clinical relevance should be interpreted with caution, owing to the effect sizes of the summary measures and methodological issues. The analgesic potential of NP as an adjuvant therapy to regulate pain and acute inflammation may offer certain clinical advantages, thus warranting further investigation. [ABSTRACT FROM AUTHOR]

Background: Immediate postoperative pain relief following arthroscopic partial meniscectomy remains a critical contributor to improved patient experience, early recovery of range of motion, and enhanced rehabilitation. Purpose: To evaluate the effect of intra-articular versus extra-articular bupivacaine on pain intensity and analgesic intake after arthroscopic partial meniscectomy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a prospective double-blind, randomized clinical trial. All patients included underwent arthroscopic partial meniscectomy under general anesthesia. Patients were randomized into 2 groups, with 20 patients in each group. At the conclusion of the arthroscopic procedure, the intra-articular group received 10 mL 0.5% bupivacaine introduced intra-articularly and 10 mL isotonic saline 0.9% infiltrated subcutaneously around the portals. The extra-articular group received the isotonic saline intra-articularly and the bupivacaine around the portals. The primary outcome was the visual analog scale (VAS) for pain. Assessments were performed 0 to 0.5, 1 to 2, 2 to 4, and at 24 and 48 hours postoperatively. In addition, analgesic and narcotic consumption was monitored. Results: There were no differences between the groups in terms of patient demographics. VAS scores for the intra-articular group were 6, 8, 3.25, 4.3, and 4.5 at 0 to 0.5, 1 to 2, 2 to 4, 24, and 48 hours postoperatively, respectively. VAS scores for the extra-articular group were 3.8, 5, 2.9, 5.2, and 5.25, respectively. No statistically significant differences were observed between the 2 groups regarding pain intensity at all time points. There was also no statistically significant difference in analgesic consumption. Dipyrone was the preferred drug by patients from the intra-articular group, while the extra-articular group preferred to use opioids and nonsteroidal anti-inflammatory drugs. Conclusion: There were no differences in pain severity and analgesic intake between intra- or extra-articular bupivacaine administration after arthroscopic partial meniscectomy. [ABSTRACT FROM AUTHOR]

Objectives: Although health care practitioners have become more cognizant of the hazards of opioid use, opioid misuse has emerged as a leading public health problem in the United States, accounting for 20% of all deaths among older adolescents and young adults. Opioid analgesics are an important component of dental pain management following dental procedures. The aim of this study was to assess the status of literature on dental opioid prescriptions, their misuse, and relevant prevention strategies in the US. Data sources: A keyword search of MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL (EBSCO), and Web of Science was conducted in July 2018. The search criteria were carefully selected to include all practitioners treating patients presenting with dental issues and was not restricted to dentists. All peer-reviewed publications in the US written in English about patients with dental problems were included. Results: The initial search led to 267 publications; after removing duplicates, the set consolidated to 196. After an appraisal of the title and abstract for relatedness, 82 publications were selected. Three major themes were identified: epidemiology of dental opioid prescriptions; recognition of the dental providers' contribution to opioid prescription practice; pain management protocols and guidelines in dentistry. Conclusions: There is moderate recognition of the contribution of dental prescriptions to the opioid epidemic. Several tools are available to increase patient education and practitioner knowledge about the safe use of opioids with a focus on patients at greatest risk. [ABSTRACT FROM AUTHOR]

Background: Guidelines recommend to prescribe a laxative with an opioid to prevent constipation. We aimed to determine the adherence by general practitioners (GPs) to this recommendation and to explore which GP- and patient related factors were associated with it from the perspective of the GP. Methods: We conducted an observational study using GPs' prescription data from the Nivel Primary Care Database combined with a questionnaire asking for reasons of non-adherence. The proportion of first opioid prescriptions prescribed together with a laxative was determined as primary outcome. Possible explanatory factors such as the quality of registration, the level of collaboration with the pharmacy, familiarity with the recommendation and use of a clinical decision support system were explored, as were the self-reported reasons for non-adherence (classified as either GP-related or patient-related). We assessed the association of factors with the primary outcome using univariable multilevel logistic regression analysis. Results: The recommendation was measured in 195 general practices. The median proportion of first opioid prescriptions prescribed together with a laxative in these practices was 54% (practice range 18–88%). None of the determinants was consistently associated with the primary outcome. GPs from 211 practices filled out the questionnaire and the most frequently mentioned reason not to prescribe a laxative was that the patient has laxatives in stock, followed by that the patient doesn't want a laxative; both were patient-related factors. Conclusion: There was room for improvement in following the guideline on laxative prescribing in opioid use. A main reason seemed to be that the patient refuses a laxative. Improvement measures should therefore focus on communication between GPs and patients on the relevance of co-using a laxative with opioids. Future studies need to establish the effect of such improvement measures, and determine whether reasons for non-adherence to the guideline changed over time. [ABSTRACT FROM AUTHOR]

This study evaluated the early drug prescription patterns as predictors of final workers compensation claim costs and closure based on an updated analysis on a large cohort. The result would provide claim management with tools to estimate final claims outcomes in the first 3- or 6-months post-injury. Objective: The aim of the study is to determine the associations of workers' compensation claim costs and return to work with drugs prescribed for early symptom management. Methods: Claims filed from 1998 to 2007 were followed for 10 years from the injury date. Drugs analyzed included gabapentin, pregabalin, antipsychotics, antidepressants, sedatives, benzodiazepines, carisoprodol, and opioids, controlling for initial reserve, sex, age, physical therapy, attorney involvement, and surgery. Results: Gabapentin, antipsychotics, antidepressants, and sedatives used in the first 3 months after injury were significantly associated with higher claim cost (≥$100,000). All opioid morphine equivalent doses greater than or equal to 5 mg/d for the first 6 months was significantly associated with higher cost (≥$100,000) and not being released to work at end of third year after injury with dose-response relationships. Conclusions: Prescription patterns in the first 3 months or first 6 months of workers' compensation claim development may be used as predictors of claim outcomes. [ABSTRACT FROM AUTHOR]

Objective: The neurotoxic effect of opioid has not been thoroughly described. No studies have been conducted to explain the effect of opioids in chronic non-cancer pain therapy on the neurotrophic factors level. Due to the ability to cross the blood-brain barrier, it seems the determination of serum Brain-derived neurotrophic factor (BDNF) concentration is a reliable presentation of the concentration in the central nervous system. The aim of the study was to explore the changes of plasma BDNF concentration during long-term opioid therapy. Methods: The study group included 28 patients with chronic low back pain treated with opioid therapy buprenorphine (n=10), tramadol (n=8), oxycodone (n=6), morphine (n=3), fentanyl (n=1). The control group included 11 patients. Measurements of plasma BDNF concentrations were performed, and information about opioid therapy were recorded (age, sex, opioid substance type, daily dose and the duration of opioid therapy). Data were analyzed using nonparametric tests. Results: The median BDNF level in the study group was significantly lower (2.73 ng/mL) than that in the control group (5.04 ng/mL, P<0.05). BDNF levels did not differ among groups based on the type of opioid substance used, but the lowest median value was observed for tramadol (2.62 ng/mL), and the highest median value was observed for buprenorphine (2.73 ng/mL). The widest minimum-maximum ranges of BDNF for oxycodone were noted, minimum 1.23 ng/mL and maximum 4.57 ng/mL, respectively. BDNF concentrations were correlated with age in the tramadol group and with the duration of opioid therapy in the buprenorphine group. Conclusion: Chronic opioid therapy for noncancer pain induces specific changes in the BDNF concentration. Tramadol and buprenorphine exerted an important effect on BDNF levels in the examined patients. The BDNF level depends on duration of opioid therapy with buprenorphine, and age in tramadol therapy. [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]

Background: Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair, including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM.Methods: A retrospective review of all patients who underwent an open ventral hernia repair with retromuscular mesh between 2016 and 2020 was conducted. LOS was used as the primary outcome. Secondary outcomes included post-operative pain and 90-day post-operative complications.Results: An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min; P < 0.05) and larger area of mesh (461.85 vs. 338.17 cm2; P < 0.05) when compared to the TAP block group. Hospital LOS was significantly shorter for the TAP block group compared to the epidural group (4.22 vs. 5.62 days; P < 0.05). There were no differences in post-operative complications between the groups. The epidural group reported significantly lower post-operative day one (POD1) pain scores measured on a 10-point scale, compared to the IVPM and TAP block groups (5.00 vs. 6.91 vs. 7.50; P < 0.05).Conclusion: Patients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs. [ABSTRACT FROM AUTHOR]

Background: Post-operative pain relief after abdominal operations is critical for patient satisfaction and rapid recovery. Narcotics have been a traditional part of postoperative analgesia, with transversus abdominis plane (TAP) block introduced recently. The aim of this study is to assess the efficacy of laparoscopic TAP block on postoperative pain control in patients undergoing minimally invasive adrenalectomy.Methods: This was an institutional review board-approved retrospective study. Parameters related to postoperative pain control were compared between patients who underwent robotic transabdominal lateral adrenalectomy with (after December 2018) or without laparoscopic TAP block (control group) (before December 2018) by one surgeon. Statistics were performed using Mann Whitney U and Chi-square tests.Results: There were 86 patients in the TAP and 83 patients in the control group. Groups were similar regarding demographic and clinical parameters. Despite the availability of intravenous acetaminophen to a higher percentage of patients in the control (31.3%) versus the TAP group (8.1%), 0-24 h lowest postoperative pain scores were significantly lower in the TAP group (P < 0.0001). In TAP versus control group, percentage of patients requiring narcotics and amount of narcotics used was lower (P = 0.04 vs P = 0.0004, respectively). Mainly due to less pain-related over-stay, percentage of patients requiring more than a day of hospital stay was less in the TAP (12%) versus control group (18%) (P = 0.01).Conclusion: To our knowledge, the utility of TAP block in patients undergoing minimally invasive adrenalectomy has not been reported in the past. This study shows that there may be benefits of laparoscopic TAP block in reducing post-operative narcotic usage while improving pain control in these patients. [ABSTRACT FROM AUTHOR]

Significant advances in ablative and endovascular therapies have allowed interventional radiology to play a substantial role in the management of patients with malignant neoplasms. The evolution of these procedures and the optimization of patient outcomes and experience must take into account various elements of the periprocedural period. Some of the most important considerations within the periprocedural period are the pharmacologic agents used to avoid infectious complications, decrease pain, and manage side effects. In this article, we discuss some of the most commonly used medications in interventional oncology procedures including antibiotics, narcotics, sedatives, antiemetics, and others. [ABSTRACT FROM AUTHOR]

The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services. [ABSTRACT FROM AUTHOR]

Dentin hypersensitivity (DH) is a common problem with multifactorial etiology. It is characterized by a short, sharp pain due to exposed dentin usually at the cervical margin. This randomized clinical trial aimed to evaluate the efficacy of two desensitizing agents for reduction of dentin hypersensitivity (DH) following periodontal surgeries. Method and materials: This study evaluated 96 patients who had one or two teeth with DH (120 teeth). The teeth were randomly allocated into four groups for treatment with 10% ethanolic extract of propolis (group 1), 30% ethanolic extract of propolis (group 2), Single Bond Universal dentin bonding agent (group 3), and distilled water as placebo (group 4). The degree of DH was determined according to the patients' response to tactile and air blast stimuli using a visual analog scale (VAS). The level of pain was also recorded before treatment and at 1, 7, 14, 21, 60 and 90 days after the treatment. Results: All interventions (groups 1 to 3) were significantly effective in decreasing DH, and 10% and 30% ethanolic extracts of propolis were equally effective. The dentin bonding agent was completely effective at all time points. All three interventions (groups 1 to 3) effectively decreased DH at 60 and 90 days. Conclusions: This clinical trial showed all interventions were more effective than the placebo in decreasing DH. The tested propolis extracts were equally effective irrespective of their concentration. Application of Single Bond Universal had a fast relieving effect on DH. Propolis extracts and dentin bonding agent were equally effective in relieving DH in the long term. Clinical relevance: DH following periodontal surgery causes patient discomfort and hinders everyday activities. Propolis is a natural desensitizing agent with antimicrobial and anti-inflammatory properties, healing effects, and cariostatic activity. It also stimulates reparative dentin formation. Flavonoids and cinnamic acid derivatives are the main biologically active components in the composition of propolis. According to the results of this study, application of propolis is recommended for patients with mild or moderate pain. Dentin bonding agent could be a better choice when immediate effect is needed. [ABSTRACT FROM AUTHOR]

Aim: Little is known about whether pain can be effectively managed in pregnant women with opioid use disorder (OUD) during delivery hospitalization, particularly those undergoing surgery and taking buprenorphine as medication for OUD (MOUD). To address this question, we compared pain scores and opioid analgesic utilization during delivery hospitalization in women taking their pre-hospital dose of buprenorphine who delivered by cesarean section to matched controls. To inform future research efforts, we also began to explore opioid analgesic utilization and pain scores by type of anesthesia as this variable is often not included in related literature. Methods: Retrospective matched cohort study of 46 women prescribed buprenorphine during pregnancy who delivered by cesarean section during a 7-year period. Results: When compared to matched controls, women taking their pre-hospital dose of buprenorphine undergoing cesarean section utilized more opioid analgesics as measured by morphine milligram equivalents (MME) (mean MME first 48 hours 153.0 mg vs 175.1 mg, respectively, P <.01) but had similar pain scores during delivery hospitalization. There was no difference in MME utilization by maternal dose of buprenorphine though sample sizes were small. Women on buprenorphine who received spinal anesthesia with morphine had mean pain scores that were 1.4 points lower (P =.01) during the first 48 hours than women on buprenorphine receiving other methods of anesthesia. Discussion And Conclusions: Pregnant women taking their pre-hospital dose of buprenorphine throughout their surgical delivery hospitalization were able to achieve pain relief similar to women not on MOUD but had higher MME requirements. Our results add to the emerging body of evidence suggesting that individuals on MOUD can achieve adequate post-surgical pain management without adjusting their pre-hospital dose of buprenorphine. Further research is required to fully understand the optimal buprenorphine dosing regimen during surgical hospitalizations. Our results also provide important preliminary evidence that spinal anesthesia containing opioids can be used effectively in individuals with OUD requiring surgical intervention. [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]

Introduction: Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures. Materials and Methods: This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups. Results: Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P =.066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P =.015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P =.012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging. Discussion: Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ. Conclusion: Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries. [ABSTRACT FROM AUTHOR]

BACKGROUND: Because pharmacological therapies may play an important role in managing musculoskeletal pain, the appropriate use of medicines for common conditions like low back pain (LBP) is critical. New evidence on the effects and safety of paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, muscle relaxants, antibiotics, and antidepressants for LBP warrants an updated overview for musculoskeletal clinicians on this topic. CLINICAL QUESTION: How effective and safe are paracetamol, NSAIDs, opioid analgesics, muscle relaxants, antibiotics, and antidepressants compared with placebo for treating LBP? KEY RESULTS: For acute LBP (<12 weeks), muscle relaxants and NSAIDs may be superior to placebo for reducing pain, but the effects of opioids, antibiotics, and antidepressants are unknown. Paracetamol provides no additional benefit for acute LBP. For chronic LBP (>12 weeks), NSAIDs, antidepressants, and opioids may be superior to placebo for reducing pain, but opioids have an established profile of harms. Antibiotics may also reduce pain for people with chronic LBP with Modic type 1 changes, although the risks may outweigh their benefits. The effects of paracetamol and muscle relaxants for chronic LBP were unclear. CLINICAL APPLICATION: NSAIDs may have a role in managing acute and chronic LBP, with cautious use in people who may be at greater risk of experiencing adverse events. Paracetamol, opioid analgesics, antibiotics, muscle relaxants, and antidepressants should only be prescribed following a discussion between the treating clinician and the patient, considering the risks and possible benefits, and after or in conjunction with recommended nonpharmacological strategies for improving LBP. [ABSTRACT FROM AUTHOR]

Background: Pain management with opioids and underutilization of prophylaxis for constipation can prolong a patient's hospital length of stay and impede pain management efforts. Problem: In pediatric postoperative cardiac patients, opioid therapy is a common approach to pain management but often places them at greater risk for constipation due to anatomy and age. Methods: A retrospective review of 50 patients' medical records for baseline data was conducted, and a survey evaluated providers' current knowledge and practice. Interventions: The intervention was an electronic order set that provided decision support. Additionally, prophylactic measures were supported by a validated assessment tool that created a common language to report constipation risk. Results: Although not statistically significant, postintervention data demonstrated a 21.5% decrease in postoperative constipation and a 57% increase in ordered bowel regimens. Conclusion: More focus is needed toward prophylactic bowel regimens to reduce the risk in this already high-risk population. [ABSTRACT FROM AUTHOR]

Keywords: Opioid epidemic; Enhanced surgical recovery; Opioid-free anesthesia; Patient safety EN Opioid epidemic Enhanced surgical recovery Opioid-free anesthesia Patient safety 1 3 3 12/06/22 20221202 NES 221202 The nationwide opioid addiction epidemic was in large part boosted by the surgeons' liberal practice of prescribing opioids for perioperative pain control in the 1990s [[1]]. At our own institution, opioid-free anesthesia represents the modality of choice for reducing the risks associated with traditional opioid-based anesthesia. A recent randomized controlled trial in gynecological surgery furthermore corroborated that opioid-free anesthesia was associated with significant improvement in postoperative analgesia, compared to traditional opioid-based anesthesia [[17]]. Opioids were introduced to the anesthesia practice as a method of decreasing the amount of volatile anesthetic necessary for surgical anesthesia, thereby decreasing the risk of toxic side effects from volatile agents [[4]]. [Extracted from the article]

Background: To compare the postoperative analgesic effect of propofol total intravenous anaesthesia (TIVA) versus inhalational anaesthesia (GAS) in patients using morphine patient-controlled analgesia (PCA). Methods: A retrospective cohort study was performed in a single tertiary university hospital. Adult patients who used PCA morphine after general anaesthesia across 15 types of surgeries were included. Patients who received propofol TIVA were compared to those who had inhalational anaesthesia. Primary outcomes assessed were postoperative numerical rating scale (NRS) pain scores and postoperative opioid consumption. Results: Data from 4202 patients were analysed. The overall adjusted NRS pain scores were significantly lower in patients who received propofol TIVA at rest (GEE: β estimate of the mean on a 0 to 10 scale = -0.56, 95% CI = (-0.74 to -0.38), p < 0.001; GAS as reference group) and with movement (β estimate = -0.89, 95% CI = (-1.1 to -0.69), p < 0.001) from postoperative days (POD) 1–3. Propofol TIVA was associated with lower overall adjusted postoperative morphine consumption (β estimate = -3.45, 95% CI = (-4.46 to -2.44), p < 0.001). Patients with propofol TIVA had lower adjusted NRS pain scores with movement for hepatobiliary/pancreatic (p < 0.001), upper gastrointestinal (p < 0.001) and urological surgeries (p = 0.005); and less adjusted postoperative morphine consumption for hepatobiliary/pancreatic (p < 0.001), upper gastrointestinal (p = 0.006) and urological surgeries (p = 0.002). There were no differences for other types of surgeries. Conclusion: Propofol TIVA was associated with statistically significant, but small reduction in pain scores and opioid consumption in patients using PCA morphine. Subgroup analysis suggests clinically meaningful analgesia possibly for hepatobiliary/pancreatic and upper gastrointestinal surgeries. Trial registration: This study is registered at ClinicalTrials.gov (NCT03875872). [ABSTRACT FROM AUTHOR]

Background: Palliative sedation requires no formal registration in Belgium. For euthanasia, however, there are clear guidelines in certain countries, including mandatory registration and evaluation of cases. Official guidelines have been developed for palliative sedation, but research still shows unskilled use of sedation and unclear demarcation between palliative sedation and euthanasia. Registration could be used to avoid unskilled use of sedation and to avoid use or abuse of sedation to hasten the patient's death (described as "slow/passive euthanasia"). Objective: To evaluate the current practice of palliative sedation and use of opioids and sedatives at the end of life by using a registration document. Design: Retrospective observational study. Setting/Subjects: We included all in-hospital deaths at an academic hospital in Belgium of patients (age ≥18 years) who had received parenteral opioids, benzodiazepines, barbiturates, or other anesthetics during the last 24 hours. Measurements: We investigated indications for palliative sedation, patients' and physicians' characteristics, types of medication used, and the decision-making process with the patients and family. The questionnaires were collected between July 9 and November 25, 2016. The study was approved by the Biomedical Ethics Committee of UZ Brussel (B.U.N. 1432016293). Results: In a population of 124 patients, refractory symptoms were reported in 94.4%. All patients received parenteral opioids (intravenously). Benzodiazepines were used in 51.6%. In 75.8%, physicians reported no change in treatment plan during end of life. Hastening death by increasing analgesics and/or sedatives was mentioned in 19.3%. The treatment plan was discussed with patients in 26.6% of cases. In 6 cases, an explicit intention to hasten death was mentioned; in 36 cases, doses of opioids/sedatives may not have been strictly proportional to symptoms. Conclusion: This Belgian study shows that objective reporting of palliative sedation can be used as a tool to ensure good clinical practice where patients receive the most appropriate end-of-life care, avoiding abusive and injudicious or unskilled use of sedation. [ABSTRACT FROM AUTHOR]

Context: The International Narcotics Control Board's (INCB) opioids consumption data are often cited in the literature and by policy makers to benchmark the adequacy of pain management among different countries. This practice may be inaccurate as INCB data does not account for variations in disease burden and use of other pain medications and only controls for population sizes differences among countries.Objective: To demonstrate that INCB consumption data may not be an accurate/sensitive indicator for pain management adequacy due to significant inter-country variations in disease burden and in the use of pain medications that are not reported by INCB.Methods: We compared opioid consumption data between 2012 and 2016 for Jordan and King Hussein Cancer Center vs five high-income countries (United States of America, United Kingdom, France, Sweden, and Japan) taking into consideration the cancer burden in those countries. In addition, we examined the significance of tramadol utilization in the setting of cancer pain management.Results: Jordan's INCB-reported opioid consumption is ostensibly low at a median of 291 sDDD/million inhabitants/day. Compared to Jordan, the median consumption in the five HICs is 34 (range 4-172) times that of Jordan. However, when consumption is adjusted to cancer burden data, the gap is significantly reduced to a median of 2 (range 0.2-24) times that of Jordan and in the case of one institution's experience, the gap is eliminated. Furthermore, Jordan's tramadol's median consumption between 2012-2016 of 176 kg is equivalent to 127% of morphine consumption on an equianalgesic basis.Conclusion: INCB data should not be utilized to benchmark the adequacy of pain management among different countries without taking into consideration variations in disease burden and the use of tramadol and other pain drugs. [ABSTRACT FROM AUTHOR]

Introduction: Opioid use after surgery or trauma has been implicated as a contributing factor to opioid dependence. The Acute Care Surgery (ACS) service at our community-based trauma center instituted an opioid-minimizing, multi-modal pain control (MMPC) protocol. The classes of pain medication included a non-opioid analgesic, a non-steroidal anti-inflammatory drug, a gabapentinoid, a skeletal muscle relaxant, and a topical anesthetic. We hypothesize that the MMPC will result in lower opioid consumption compared with the prior STP as evidenced by lower morphine milligram equivalents (MME) per day.Methods: All adult patients (≥18 years) admitted to the ACS service from Jan 2014 to Dec 2015 and Jan 2018 to Dec 2019 were screened for inclusion. The standard pain control group (STP) and MMPC groups were defined by the year of admission. The primary outcome is opioid use per day, calculated in MME received. Secondary outcomes of the study include daily pain scores, incidence of opioid-related complications, death, ventilator days, intensive care unit length of stay, and hospital length of stay (HLOS) days.Results: Multi-modal pain control protocol group was older and less injured than STP group. Daily opioid utilization was significantly less in the MMPC group (22.5 MMEs/d vs 60MMEs/d in the STP group, P < .0001). Additionally, daily pain scores were not different between groups. Secondary outcomes did not vary between the two groups.Conclusion: This study shows that implementation of a MMPC protocol resulted in lower opioid consumption in injured patients. Pain was equivalently controlled during the MMPC protocol period as demonstrated by similar pain scores. [ABSTRACT FROM AUTHOR]

Background and Aims: The individual‐level effectiveness of opioid agonist treatment (OAT) in reducing mortality is well established, but there is less evidence on population‐level benefits. We use modeling informed with linked data from the OAT program in New South Wales (NSW), Australia, to estimate the impact of OAT provision in the community and prisons on mortality and the impact of eliminating excess mortality during OAT initiation/discontinuation. Design Dynamic modeling. Setting and participants: A cohort of 49 359 individuals who ever received OAT in NSW from 2001 to 2018. Measurements Receipt of OAT was represented through five stages: (i) first month on OAT, (ii) short (1–9 months) and (iii) longer (9+ months) duration on OAT, (iv) first month following OAT discontinuation and (v) rest of time following OAT discontinuation. Incarceration was represented as four strata: (i) never or not incarcerated in the past year, (ii) currently incarcerated, (iii) released from prison within the past month and (iv) released from prison 1–12 months ago. The model incorporated elevated mortality post‐release from prison and OAT impact on reducing mortality and incarceration. Findings Among the cohort, mortality was 0.9 per 100 person‐years, OAT coverage and retention remained high (> 50%, 1.74 years/episode). During 2001–20, we estimate that OAT provision reduced overdose and other cause mortality among the cohort by 52.8% [95% credible interval (CrI) = 49.4–56.9%] and 26.6% (95% CrI =22.1–30.5%), respectively. We estimate 1.2 deaths averted and 9.7 life‐years gained per 100 person‐years on OAT. Prison OAT with post‐release OAT‐linkage accounted for 12.4% (95% CrI = 11.5–13.5%) of all deaths averted by the OAT program, primarily through preventing deaths in the first month post‐release. Preventing elevated mortality during OAT initiation and discontinuation could have averted up to 1.4% (95% CrI = 0.8–2.0%) and 3.0% (95% CrI = 2.1–5.3%) of deaths, respectively. Conclusion: The community and prison opioid agonist treatment program in New South Wales, Australia appears to have substantially reduced population‐level overdose and all‐cause mortality in the past 20 years, partially due to high retention. [ABSTRACT FROM AUTHOR]

Background: Neurofeedback (NF) has been described as "probably efficacious" when used in conjunction with other interventions for substance use disorders, including the recent studies in the population of individuals with opioid use disorder. Despite these promising outcomes, the seriousness of the opioid epidemic, and the high rate of relapse even with the most effective medication-assisted maintenance treatments NF continues to be an under-researched treatment modality. This article explores factors that affected the feasibility of adding Alpha/Theta Neurofeedback to treatment as usual for opioid dependence in an outpatient urban treatment center. The study strived to replicate previous research completed in Iran that found benefits of NF for opioid dependence.Methods: Out of approximately two dozen patients eligible for Alpha/Theta NF, about 60% (n = 15) agreed to participate; however, only 2 participants completed treatment. The rates of enrollment in response to active treatment were monitored.Results: The 4 factors affecting feasibility were: (1) the time commitment required of participants and providers, (2) ineffectiveness of standard incentives to promote participation, (3) delayed effects of training, and (4) the challenges of researching treatment options not reimbursed by the insurance companies.Conclusions: The findings indicate that a large-scale study examining the use of NF for the treatment of opioid use disorder in the United States will likely be difficult to accomplish without modification to the traditional randomized control study approach and suggests challenges to the implementation of this treatment in an outpatient setting. A single-case methodology is proposed as a viable alternative. [ABSTRACT FROM AUTHOR]