The Role of Science in Addressing the Opioid Crisis

Opioid misuse and addiction is an ongoing and rapidly evolving public health crisis, requiring innovative scientific solutions | New England Journal of Medicine

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Image source: Marina Caruso – Wellcome Images // CC BY-NC-ND 4.0

In response, and because no existing medication is ideal for every patient, the National Institutes of Health (NIH) is joining with private partners to launch an initiative in three scientific areas: developing better overdose-reversal and prevention interventions to reduce mortality, saving lives for future treatment and recovery; finding new, innovative medications and technologies to treat opioid addiction; and finding safe, effective, nonaddictive interventions to manage chronic pain. Each of these areas requires a range of short-, intermediate-, and long-term research strategies

Full reference: Volkow, N.D. & and Collins, F.S. (2017) The Role of Science in Addressing the Opioid Crisis.  New England Journal of Medicine. Issue 377: pp.391-394

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Confronting the Perioperative Pain Paradox

Pain medications, especially opioids, have understandably undergone intense scrutiny due to recent public concern over prescription drug abuse, as well as the known side effects of opioids limiting enhanced recovery programs | Anesthesiology News

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The problem with eliminating opioid use is that major surgery comes with major pain, and opioids are effective at treating major pain. Furthermore, when opioids are finally introduced after attempting to avoid their use, it is usually done “emergently”—only after the patient is in extreme, inconsolable pain that disrupts recovery. This will likely lead to giving patients larger doses and increasing the risk for adverse events that we are all trying to avoid.

Note that severe acute pain is a risk factor for the development of chronic pain, sleep disturbances, changes in mood and behavior (especially in children), poor wound healing and delayed recovery. This avoidance of opioids in the face of intense pain due to their potential short- and long-term negative effects has created, what I call, the “perioperative pain paradox.”

Full reference: Answine, J.F. (2017) Confronting the Perioperative Pain Paradox. Anesthesiology News. Published online: 15 June 2017

Opioid doses and the survival of advanced cancer patients receiving palliative care

Sathornviriyapong, A. et al. BMC Palliative Care. Published online: 21 November 2016

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Image source: Adrian Wressell, Heart of England NHSFT – Wellcome Images // CC BY-NC-ND 4.0

Background: Concerns that opioids may hasten death can be a cause of the physicians’ reluctance to prescribe opioids, leading to inadequate symptom palliation. Our aim was to find if there was an association between different opioid doses and the survival of the cancer patients that participated in our palliative care program.

 

Conclusions: Our study has demonstrated that different opioid doses in advanced cancer patients are not associated with shortened survival period.

Read the full abstract and article here

Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery

Guay, J. et al. Anesthesia & Analgesia. Published online: November 2 2016

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Background: The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery.

Methods: Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale.

Results: Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited.

Conclusions: An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).

Read the abstract here

Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities

Joshi, G. (2016) Journal of Clinical Anesthesia. 35, pp. 524–529

Highlights

  • Peripheral nerve block (PNB) improves pain control and reduces opioid requirements compared with opioids alone.
  • Continuous PNB prolongs analgesia but introduces significant risks and challenges.
  • The ideal PNB technique would have a sufficient duration of action and minimal risk of complications.

Abstract

Peripheral nerve blocks (PNBs) are increasingly used as a component of multimodal analgesia and may be administered as a single injection (sPNB) or continuous infusion via a perineural catheter (cPNB). We undertook a qualitative review focusing on sPNB and cPNB with regard to benefits, risks, and opportunities for optimizing patient care. Meta-analyses of randomized controlled trials have shown superior pain control and reductions in opioid consumption in patients receiving PNB compared with those receiving intravenous opioids in a variety of upper and lower extremity surgical procedures. cPNB has also been associated with a reduction in time to discharge readiness compared with sPNB. Risks of PNB, regardless of technique or block location, include vascular puncture and bleeding, nerve damage, and local anesthetic systemic toxicity. Site-specific complications include quadriceps weakness in patients receiving femoral nerve block, and pleural puncture or neuraxial blockade in patients receiving interscalene block. The major limitation of sPNB is the short (12-24 hours) duration of action. cPNB may be complicated by catheter obstruction, migration, and leakage of local anesthetic as well as accidental removal of catheters. Potential infectious complications of catheters, although rare, include local inflammation and infection. Other considerations for ambulatory cPNB include appropriate patient selection, education, and need for 24/7 availability of a health care provider to address any complications. The ideal PNB technique would have a duration of action that is sufficiently long to address the most intense period of postsurgical pain; should be associated with minimal risk of infection, neurologic complications, bleeding, and local anesthetic systemic toxicity; and should be easy to perform, convenient for patients, and easy to manage in the postoperative period.

View the full article here

Cancer patients not getting adequate pain relief

Many terminal cancer patients are not getting adequate pain relief early enough, according to an English study.| Science Daily | PAIN

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Many terminal cancer patients are not getting adequate pain relief early enough, according to a University of Leeds study.  The researchers found that, on average, terminal cancer patients were given their first dose of a strong opioid such as morphine just nine weeks before their death.  Yet many people with terminal cancer suffer with pain a long time before that, the researchers said.

The research team used UK Cancer Registry data to study a sample of 6,080 patients who died of the disease between 2005 and 2012. They found that 48 per cent of the patients were issued a prescription in general practice (primary care) for a strong opioid medication, such as morphine, during the last year of their life.

The study, published in the medical journal Pain, said efforts to improve treatment of cancer pain may be being hindered by concern over the ongoing ‘opioid epidemic’.

They cited NHS data which showed that overall opioid prescribing increased by 466 per cent between 2000 and 2010, but only increased by 16 per cent for patients with cancer.

Full reference: Lucy Ziegler et. al. Opioid prescribing for patients with cancer in the last year of life. PAIN, Published Ahead of Print 2016

Techniques of opioid administration

Green, C.J.G. & Tay,Y.C. Anaesthesia & Intensive Care Medicine. Published online: 4 August 2016

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Opiates remain the mainstay of the management of severe pain in acute, chronic and palliative settings across all population ages. Pharmacological advancement allows alternative routes of drug delivery best suited to individual patients and their conditions, with improved efficacy and safety.

The different approaches to administration vary in their convenience, both to staff and patients, which can translate to differences in prescription compliance. Furthermore, the choice of technique can reduce the amount of drug administered, thereby improving the side effect profile.

All opiates, regardless of the technique employed, require meticulous and careful titration based upon sound understanding. Training of staff and education of patients regarding the logistics of the chosen route is important to ensure optimal opiate delivery and detection of undesirable adverse events. Abuse and diversion of opiates warrants judicious administration and prescription considerations.

Read the abstract here