Background: There are increasing rates of opioid prescriptions for chronic pain worldwide. Long-term opioid use for chronic noncancer pain is reported to be associated with problematic use and dependence. An effective way of improving patients’ safety who are on high doses of potent opioids is utilizing buprenorphine rotation. Opioid rotation can be challenging due to the risk of precipitated withdrawals, which require mild-to-moderate opioid withdrawal symptoms. This can be highly stressful for patients and often leads to failure of the transition attempt. Ketamine is a short-acting N-methyl-d-aspartate antagonist analgesic with opioid-sparing properties. It can help mitigate opioid withdrawal symptoms and manage severe pain in individuals with opioid dependence.Case series: This case series presents four patients with noncancer chronic pain with comorbid opioid dependency, all of whom have failed outpatient attempts at opioid rotation to buprenorphine. These patients were admitted as inpatients, and ketamine infusion was utilized as an adjunct therapy in the facilitation of opioid rotation to buprenorphine/naloxone. All patients were successful in their opioid rotations. On follow-up, these patients had subjectively improved functioning without further aberrant behaviors pertaining to their opioids. All had either remained or reduced on the buprenorphine dose with follow-up.Conclusion: Ketamine infusion can be an effective adjunct therapy in facilitating opioid rotation for patients with chronic noncancer pain.
The Journal of Opioid Management marks with respect and sadness the passing of Robert L. Barkin, MBA, PharmD, FCP, a long-standing member of our Editorial Review Board and a colleague whose presence helped shape the journal from its earliest days.
BACKGROUND:Surgical intervention triggers nociception, whereas the main aim of anesthesia is to suppress nociceptive signal processing. The impact of different methods of anesthesia on the nociceptive response and their correlation with post-operative outcomes remains unclear. Regional anesthesia affects transduction, transmission, and modulation by interrupting the conduction of pain impulses by local anesthetics. Moreover, nerve blocks influence pain perception by reducing opioid consumption (OC), which helps prevent the development of pain sensitization and opioid tolerance. Owing to this mechanism, an essential balance between nociception and antinociception is sustained, and violation of this balance can lead to post-operative complications. AIM:To compare the impact of general anesthesia (GA) with erector spinae plane block (ESPB) versus GA without ESPB on intraoperative nociceptive response index (NRI), OC, post-operative pain intensity (PPI), and hyperalgesia in patients undergoing spine surgery. METHODS:This prospective, randomized controlled study was conducted in a clinical hospital with an affiliate university department, from December 2021 to November 2022. A total of 151 patients who underwent spine surgery via the posterior approach were randomly assigned to either the GA control group (CG) or the GA with ESPB study group (SG). OUTCOMES:NRI, OC, PPI, and hyperalgesia. This study was registered at ClinicalTrials.gov (identification number: NCT04697498 at December 12, 2020, https://clinicaltrials.gov/study/NCT04697498). RESULTS:Average NRI during surgery differed between groups: 0.66 ± 0.28 in the SG and 0.86 ± 0.19 in the CG. Amount of fentanyl and morphine was lower in the SG (1.84 ± 0.75 µg/kg; 5.62 ± 5.00 mg) compared with the CG (3.64 ± 1.2 µg/kg; 28.97 ± 9.75 mg), respectively. PPI at rest and during movement was higher in the CG after surgery than in the SG at all stages of observation. Mechanical pain threshold (MPT) did not differ before surgery: 21.05 ± 6.64 in the SG; 21.55 ± 6.06 in the CG. After surgery, the MPT was lower in the CG, 5.60 ± 1.93, than in the SG, 23.26 ± 6.8. NRI had the strongest negative correlation with hyperalgesia in comparison with other data. CONCLUSIONS:ESPB, as a component of GA, decreases NRI, OC, and PPI. As a result, it does not trigger hyperalgesia after spine surgery.
Objective: Pregabalin and gabapentin have shown efficacy in reducing pain and opioid use, but limited data exist on their effectiveness in acute trauma patients. This study aimed to evaluate their impact on pain relief and opioid consumption in this population.Design: A prospective, unblinded, randomized trial.Setting: This study was conducted at a tertiary, academic Level I trauma center located in the southeastern region of the United States between 2021 and 2024.Patients: A total of 101 patients were included in the study and randomized into three groups: pregabalin, gabapentin, and a control group.Interventions: The pregabalin group received 50 mg of pregabalin, the gabapentin group received 300 mg of gabapentin, and the control group received neither. Drugs were administered every 8 or 12 hours, based on patients’ creatinine clearance.Main outcome measure: Patients’ daily opioid intake during enrollment. Results: Total opioid and nonopioid analgesic use was similar across all groups. Median total opioid use was 69.5 morphine milligram equivalent (MME), 81.0 MME, and 66.3 MME, and nonopioid use was 5,362.5 mg, 6,600.0 mg, and 7,225.0 mg in the pregabalin, gabapentin, and neither groups, respectively. Likewise, average daily use of both opioid and nonopioid analgesics was comparable across groups. Median average daily pain scores ranged from 6.2 to 6.4, with no significant differences observed among the groups.Conclusions: Multimodal pain management in hospitalized trauma patients needs to be considered, especially in areas known for opioid misuse. Nonopioid analgesics aside from gabapentinoids may serve as an appropriate approach to manage pain in these individuals.
This article aims to perform a comparative systematic review of regulations of narcotic substances between the years 2017 and 2024. The regulation of narcotics and psychotropic substances encompasses a complex web of international treaties, national laws, and regulatory frameworks aimed at controlling their production, distribution, prescription, and use. The current review explores the import and prescription regulations of narcotics in various countries. Key regulatory agencies include the Drug Enforcement Agency and Food and Drug Administration in the United States (US), Office of Drug Control (ODC) in Australia, Narcotics Control Department in Japan, and United Nations (UN) Office of Drugs and Crime and Commission on Narcotic Drugs under the UN. In the US, the Controlled Substances Act categorizes substances based on abuse potential and medical utility. Australia’s regulatory framework is overseen by the Therapeutic Goods Administration and ODC. Japan regulates through the Stimulants Control Act and the Narcotics and Psychotropic Substances Control Act, 1953. The United Kingdom enforces the Misuse of Drugs Act 1971, while India employs the Narcotic Drugs and Psychotropic Substances Act, 1985. It was observed that there were certain lacunae in the regulation, such as the lack of Prescription Monitoring Programs in a few countries, nonavailability of global database containing information about drug trafficking operations, such as routes, techniques, etc., and the nonuniformity within the regulations. Overall, the regulation of narcotics and psychotropic substances involves a delicate balance between control and accessibility, with ongoing debates and reforms shaping the global drug control regime. The current article provides a useful resource for policymakers and stakeholders in the field of narcotic substances.
Objectives: Effective post-operative pain management enhances patients’ quality of life and reduces post-operative immobility. To compare the analgesic efficacy of preoperative tizanidine versus baclofen in patients undergoing femoral fracture surgery.Design: In this double-blind clinical trial, 50 patients were randomized to receive either 4 mg tizanidine (Group A) or 25 mg baclofen (Group B) orally before surgery. Post-operative pain was managed with an analgesic pump containing morphine and paracetamol. Pain intensity, nausea, vomiting, pruritus, and analgesic use were assessed upon entering the recovery ward and at 2, 4, 6, 12, 24, and 48 hours post-surgery.Results: Pain intensity, measured by the Visual Analog Scale (VAS), decreased significantly over time in both the tizanidine and baclofen groups (p < 0.001). Although a group-by-time interaction was initially observed (p = 0.042), further analysis revealed this to be a trend rather than a robust difference in the primary outcome. Specifically, at 6, 24, and 48 hours post-surgery, VAS scores were 3.08 ± 1.63, 2.88 ± 1.01, and 2.08 ± 1.04 in the tizanidine group, compared to 3.92 ± 1.29, 3.56 ± 1.16, and 2.84 ± 1.57 in the baclofen group. While uncorrected p-values for these intervals were 0.049, 0.032, and 0.049, respectively, none reached statistical significance after applying the Bonferroni correction for multiple comparisons (p > 0.0167). Additionally, there were no significant differences between groups regarding total morphine consumption or the incidence of adverse effects.Conclusions: Preoperative administration of 4 mg tizanidine and 25 mg baclofen showed comparable efficacy in post-operative pain management. As this study lacked a placebo control, it cannot confirm the absolute analgesic efficacy of either drug over no treatment. Although tizanidine demonstrated a trend toward lower pain scores at certain intervals, these differences were not statistically significant after adjustment for multiple comparisons. Both drugs exhibited similar safety profiles and supplemental analgesic requirements.
INTRODUCTION:The recent emergence of novel synthetic opioids (NSOs), including fentanyl analogs-eg, carfentanil, acetylfentanyl-and nonfentanyl drugs-eg, U-47700, nitazenes-on the drug market has caused high levels of morbidity and mortality. Even though their systemic toxicities have been well documented, their ocular effects have not been well explored. This review thus engages to systematically review the currently available clinical and experimental data on NSO-related ocular complications. METHODS:According to Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 guidelines, the literature search was performed on PubMed, Scopus, Web of Science, ScienceDirect, and Google Scholar, which included all studies published up to May 2025. Our inclusion criterion entailed peer-reviewed articles on ocular outcomes following exposure of people to NSOs or in experimental animal models. Data extraction included study peculiarities, the type of opioids, ocular signs, and methodological quality. A narrative synthesis was performed due to heterogeneity in designs and outcomes. RESULTS:After a thorough search of the literature, 759 records were retrieved, with five being included in the study: one observational case series, two narrative reviews, one animal study, and one literature review. The reported ocular symptoms included miosis, blurred vision, dry eye syndrome, and corneal dysfunction. Increased activity of the µ-opioid receptor was associated with pupillary constriction and ocular surface disease. In one study, topical naltrexone was highlighted as a promising tool that can reverse the effects of opioids on the cornea. CONCLUSION:Evidence suggests that NSOs, in particular, fentanyl analogs and U-47700, are related to a consortium of ocular manifestations. Such effects are especially significant in cases of overdose. Future studies should explore long-term visual outcomes and assessment of targeted interventions, including ocular µ-opioid receptor antagonists.
Objective: Poor post-operative pain management after cesarean section (C-section) can have adverse effects on the mother and baby and is associated with increased opioid intake. This study aims to evaluate the effects of the dopamine antagonist, metoclopramide, on the management of post-operative pain among women undergoing elective C-sections.Method: This double-blinded randomized study included women who underwent C-sections at our center. The patients were divided into an intervention group and a control group. The intervention group received 20 mg metoclopramide, whereas the control group was given 2 cc of distilled water as a placebo, intravenously, post-operatively, before the closing of the surgical site. At 2, 4, 6, 8, 12, and 24 postoperative hours, data regarding pain (measured via a visual analog scale), nausea and vomiting, and resumption of physical activity were obtained along with the demographic information of the patients.Results: Fifty patients were included in both groups. The mean age, body mass index, number of previous deliveries, education, smoking status, and number of previous C-sections were not significantly different between the two groups. Metoclopramide reduced early post-cesarean pain (Visual Analog Scale [VAS]: 7.38 vs 8.48 at 2 hours, *p < 0.001) and morphine use (18.7 mg vs 22.3 mg, *p = 0.032), with transient antiemetic effects at 2 hours. The mean VAS scores at 2 and 4 post-operative hours were significantly different between both groups, respectively. The incidence of nausea and vomiting was significantly different at the second post-operative hour only.Conclusion: Metoclopramide significantly reduced early post-operative pain and opioid requirements, with reductions exceeding minimal clinically important difference thresholds. While statistically robust, these benefits should be weighed against its transient antiemetic effects and the need for larger trials to confirm functional recovery benefits.
Objective: Terminology used in scientific literature is associated with resource allocation, research prioritization, and public perception. The aim of this study is to describe how research on fentanyl is associated with a change in terminology used to refer to its use.Design: The study utilized bibliometric analysis of 11,982 publications from 2000 to 2023 from Web of Science using the topic search terms “Fentanyl” and “Humans.” These articles were then analyzed via VOSViewer and Microsoft Excel.® Results: Publications adopting nonstigmatizing terminology were more frequently connected to research on substance use treatment, rehabilitation, and medication-assisted treatments (methadone, naltrexone, buprenorphine). The adaptation demonstrated greater connections to these medications, methadone, naltrexone, and buprenorphine, and reflects an emerging focus on fentanyl-specialized addiction medicine.Conclusions: Older publications frequently utilized stigmatizing terminology and lacked a coherent research direction. Conversely, recent adoption of nonstigmatizing language coincides with increased research output focusing on treatment, emergency overdose management, epidemiology, and public health. Notably, the adoption of nonstigmatized terms coincides with increased publications and a new focus on fentanyl-related research.
Background: Opioid use disorder (OUD) poses significant public health threats at epidemic levels in the United States. Injection drug use (IDU) is particularly associated with serious infections, leading to increased risk for complications and poor outcomes. This study aims to characterize the complications and outcomes among patients with OUD who are hospitalized for the management of various infections. Additionally, a comparison of outcomes was performed between the group of patients with OUD who do not inject drugs (non-PWID) and the group of persons who inject drugs (PWID).Methods: We performed a retrospective chart review using data obtained via the hospital electronic medical record. The study population included adults with inpatient hospitalizations at Westchester Medical Center and Mid-Hudson Regional Hospital, with International Classification of Diseases, Tenth Revision codes for opioid dependence, OUD, and infections from December 2020 to December 2021. The sample size included 51 patients. Statistical analysis was performed to assess outcomes such as length of stay (LOS), complications during hospitalization, and duration of antibiotic use.Results: Among the 51 patients who met the inclusion criteria, 26 (51.0 percent) had a history of IDU, 20 (39.2 percent) had opioid dependence but did not inject drugs, and five (9.8 percent) were patients with unspecified OUD diagnosis. Of the 26 patients in the PWID group, 16 (61.5 percent) experienced complications during their hospitalization compared to three out of 20 (15 percent) in the non-PWID group (p = 0.002). Complications included either metastatic spread of infection or a requirement for surgical intervention. The mean age in the PWID group was 39.9 years compared to 56.7 years in the non-PWID group (p < 0.001). Mean LOS for PWID was 10.35 days, compared to 9.25 days in the other group (p = 0.708). The mean duration of antimicrobial therapy was longer in the PWID group, 21.32 days compared to 13.68 days in the non-PWID group (p = 0.010).Conclusions: PWID were younger, more likely to experience complications during their hospitalization, and required a longer duration of antibiotics compared to those who have OUD but do not inject drugs. Infection-related hospitalization of patients with OUD represents an opportunity to provide addiction treatment, counseling, and harm reduction strategies.
We examined the effects of age on the metabolism of 18 drug pairs using urinary metabolic ratio (MR), defined as metabolite concentration/parent drug concentration. These drug pairs include dextrorphan/dextromethorphan, oxymorphone/oxycodone, hydromorphone/hydrocodone, O-desmethyltramadol/tramadol, hydromorphone/morphine, norbuprenorphine/buprenorphine, norfentanyl/fentanyl, noroxycodone/oxycodone, norhydrocodone/hydrocodone, 7-aminoclonazepam/clonazepam, α-hydroxyalprazolam/alprazolam, norquetiapine/quetiapine, meprobamate/carisoprodol, N-desmethyltapentadol/tapentadol, norketamine/ketamine, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine/methadone, desipramine/imipramine, and nortriptyline/amitriptyline. MR data were log-transformed for analysis. This was a retrospective study that used specimens submitted for urine drug testing by patients on chronic pain medications and those undergoing substance abuse rehabilitation. We included patients who were 20 years old and older, and subdivided age groups in 10-year increments. Due to small sample sizes, meprobamate, tapentadol, and imipramine were subdivided into 20-year increments. Specimens were filtered for potential drug–drug interactions. Testing was performed with a clinically validated liquid chromatography–tandem mass spectrometry method on the Shimadzu LC-20 XR paired with a Sciex 6500+ mass spectrometer. Chromatographic separation was achieved with a methanol–formic acid–water gradient on a Kinetex phenyl-hexyl column. Results were analyzed using Indigo Bio Automation Ascent software with a four-point calibration curve. We used a two-sample t-test to assess statistically significant differences between subsequent age groups and the control age group of 20-29 or 20-39 (p-value < 0.05) and measured the effect size using Hedges' g. All data analyses were performed in RStudio using the R language. Our data showed that drug metabolism is altered by age, captured as changes in the urinary MRs with increasing age. Most drugs showed the expected pattern of alteration over age, ie, their MRs decreased with increasing age. These drugs were largely processed by cytochrome (CYP)3A4, including buprenorphine, fentanyl, alprazolam, quetiapine, ketamine, methadone, imipramine, and amitriptyline. The metabolism of carisoprodol, which is processed by CYP2C19, also decreased with increasing age. Findings suggest decreased metabolic capacity in the elderly, probably due to decreased activities of CYP3A4 and CYP2C19. The metabolism of other drugs, which includes dextromethorphan, oxycodone, hydrocodone, and tramadol, showed an unexpected increase in MRs in the older age group (70 years and beyond). These drugs are largely processed by CYP2D6. Findings suggest minimal effect of age on CYP2D6 activity, or that CYP2D6 activity is not impaired in the elderly. Selection bias may also play a role. While we observed a slight increase in the MRs of oxycodone (→noroxycodone) and hydrocodone (→norhydrocodone), the overall effect is decreasing metabolism in the older age group (60-70 years and beyond). Metabolism of clonazepam also showed an unexpected increase in MR in the elderly. The metabolism of morphine and tapentadol was not significantly affected by age. Although data showed considerable variation in the effects of age on drug metabolism, it is evident that metabolism of most drugs is impaired in the elderly. Thus, our studies show that unusual metabolism can be due to aging. Monitoring MRs can be useful to assess drug metabolism, which allows for proper dose selection and optimal drug therapy, especially in the elderly.
OBJECTIVE:In response to opioid use among students in the United States (US), many colleges have made naloxone available on campus. However, the exact prevalence of such campus programs is unknown. As such, the objective of this study was to determine the prevalence and methods of naloxone distribution programs and training programs at 4-year public universities in the US. DESIGN:A cross-sectional, simple random sample of 237 medium and large four-year public colleges in the US was included in the study. MAIN OUTCOME MEASURES:The presence and types of naloxone distribution programs and related training programs. RESULTS:Of the 237 colleges included in the study, 67 (28 percent) had a naloxone distribution program on their campus. The most common locations for naloxone distribution were through a campus wellness center (39 percent), opioid rescue boxes (32 percent), and health services (18 percent). Of the colleges with a naloxone distribution program, only 28 (42 percent) included student training. Most (68 percent) training was implemented in person, compared to online. CONCLUSIONS:Given the nation's opioid epidemic, this study underscores the need for more naloxone distribution programs and educational training programs on college campuses to save the lives of those experiencing an opioid overdose.
BACKGROUND:The opioid epidemic remains a critical public health issue, with orthopedic surgeons being among the highest prescribers of opioids for post-operative pain management. OBJECTIVE:To elucidate the provisions of the Non-Opioid Prevent Addiction in the Nation (NOPAIN) Act and its implications for reducing opioid use in orthopedic surgery. METHODS:A comprehensive review of the NOPAIN Act's legislative framework, historical opioid use in orthopedic practices, current nonopioid pain management strategies, and insights from relevant reports was conducted. RESULTS:The NOPAIN Act, effective January 1, 2025, mandates Medicare reimbursement for Food and Drug Administration-approved nonopioid pain treatments at 106 percent of the average sales price (+6 percent) in hospital outpatient departments and ambulatory surgery centers. This legislation incentivizes the adoption of nonopioid alternatives, promoting multimodal analgesia and regional anesthesia techniques. The Act may improve patient outcomes, reduce opioid-related adverse events, and help offset institutional costs. CONCLUSION:Implementation of the NOPAIN Act may influence orthopedic surgeons in adopting evidence-based, nonopioid pain management protocols, enhancing patient outcomes and contributing to national efforts against the opioid crisis. The Act's financial incentives and structured reimbursement framework may contribute to the transition toward safer practices.
OBJECTIVE:To assess barriers to providing buprenorphine as medication for opioid use disorder (MOUD) and identify differences among providers who prescribed buprenorphine more recently versus those who prescribed it less recently. DESIGN:A 10-minute online survey was fielded between August and November 2021. PARTICIPANTS:All Illinois providers (N = 2,996) who had a DATA-waiver to prescribe buprenorphine as MOUD were invited to complete an online survey; 623 (21 percent) completed the survey. MAIN OUTCOME MEASURES:The survey measured provider-identified barriers to providing MOUD and collected suggestions to improve delivery. Barriers and suggestions for improvement were analyzed using weighted descriptive statistics. Weighted logistic regression analyses were conducted to determine differences between participants who prescribed buprenorphine more recently versus those who prescribed it less recently, as determined by prescriptions in the past year. RESULTS:Among the 623 participants who completed the survey, 73.5 percent prescribed buprenorphine in the past year. Insufficient behavioral health treatment and insufficient training were frequently cited barriers. Compared to recent prescribers, participants who had not prescribed in the past year were six times more likely to report that their practice does not support MOUD providers (adjusted odds ratio: 6.20, p < .001). To improve prescribing capacity, participants requested training on prescribing to patients with comorbidities, assistance in identifying treatment options, and guidance on implementing MOUD in their practice. CONCLUSIONS:While the DATA-waiver was eliminated, barriers to prescribing buprenorphine remain. This study contributes to understanding those barriers and, importantly, offers suggestions to expand prescribing through trainings and access to resources. As more providers are eligible to prescribe buprenorphine, practices, educational institutions, and decisionmakers must equip them with the support needed to care for patients with an opioid use disorder.
BACKGROUND:Population-based screenings for substance use are highly recommended, but little is known about the screening status of substances in primary care settings (PCSs). This systematic review aims to understand what screening tools are used, the barriers that impact screenings, and the opportunities to improve screenings. METHODS:Articles focusing on the utilization of screening tools for substance use disorders (SUDs) within PCSs were considered for inclusion. Searches on PubMed and Embase databases were conducted from April 25, 2022, to July 22, 2022, which yielded 487 results; only 32 articles meeting the inclusion and exclusion criteria were included. RESULTS:Among all substances, alcohol was the most frequently screened substance at PCSs, with 20 studies included in this article. This was followed by opioids (n = 11), other illicit drugs (n = 8), cannabis (n = 6), and nicotine (n = 2). The Alcohol Use Disorders Identification Test was the most commonly used screening tool. Most studies utilized different screening tools to screen for the same substances. Identified barriers include no referral to treatment upon positive screenings, lack of training in providing interventions, and no recognition of the effectiveness of intervention services. CONCLUSION:Our search resulted in only 32 studies focusing on substance screening at PCSs, indicating that substance screening may not be conducted as recommended or formally. Integrating patient-centered SUD screening in PCSs is challenging but could be feasible via implementation strategies to address barriers. Future studies focusing on the feasibility, acceptability, and effectiveness of screening tools in PCSs may increase the screening rates for early identification and intervention for SUDs.
OBJECTIVE:To assess the clinical effectiveness of a pilot multifaceted intervention to prevent persistent opioid use among patients undergoing orthopedic and spine surgery. DESIGN:Pre-post pilot study. SETTING:Two hospitals (academic medical center and affiliated community hospital) in a single healthcare system. Preintervention period was July 1, 2021 to June 1, 2022; post-intervention period was June 2, 2022 to February 28, 2023. PATIENTS:A total of 171 inpatient orthopedic and neurosurgical spine patients. INTERVENTION:Multifaceted persistent Opioid use Prevention Program (MOPP), including standardized order sets, pharmacist-led discharge counseling, a virtual post-discharge visit, and a mobile app for tracking pain, function, and opioid use for up to 180 days after hospital discharge. MAIN OUTCOME MEASURES:Persistent opioid use within 180 days post-discharge. RESULTS:Outcome assessors were blinded. Of 115 patients in the intervention group, 91 (79 percent) received at least one component of MOPP. Persistent opioid use was observed in 10.9 percent of usual care patients and 4.5 percent in intervention patients (weighted difference -6.4 percent, 95 percent confidence interval [CI] -21 percent, +8.2, p = 0.37). In subgroup analyses, the intervention demonstrated a significant reduction in persistent opioid use among nonopioid-naive patients (weighted difference -40 percent, 95 percent CI -76 percent, -4.2 percent), with evidence of effect modification by opioid-naive status (p value for interaction term 0.005). CONCLUSIONS:This pilot study demonstrated a nonsignificant overall effect on the primary outcome, with significant effects on nonopioid-naive patients. Further research with a larger trial is needed to validate these findings.
BACKGROUND:Opioid misuse has become a widespread public health issue, affecting diverse patient populations, including those with heart failure. Given that heart failure with preserved ejection fraction (HFpEF) constitutes nearly half of all heart failure cases, understanding its management and the influence of various factors on patient outcomes is essential. This study seeks to evaluate the outcomes of chronic opioid therapy in patients with HFpEF. METHODS:Utilizing the National Inpatient Sample (2016-2020), adult HFpEF patients were identified using the appropriate International Classification of Diseases, Tenth Revision codes, excluding those with end-stage renal disease. Outcomes were compared between chronic opioid users and nonusers. Multivariate logistic and linear regression analyses were conducted, controlling for various patient and hospital confounders. The primary outcome measured was all-cause in-hospital mortality, with secondary outcomes including acute kidney injury/hemodialysis (AKI/HD), cardiogenic shock, cardiac arrest, mechanical ventilation, length of stay, and total hospital charges. RESULTS:Among 1,557,344 HFpEF patients, 21,655 (1.4 percent) were on chronic opioid therapy. No significant difference in inpatient mortality was found (adjusted odds ratio [aOR] 1.04, 95 percent confidence interval [CI]: 0.88-1.24, p = 0.58). A nonsignificant increase in cardiogenic shock (aOR 1.12, 95 percent CI: 0.85-1.48, p = 0.39) and cardiac arrest (aOR 1.06, 95 percent CI: 0.81-1.38, p = 0.65) was noted in chronic opioid users. However, chronic opioid use was associated with a higher risk of AKI/HD (aOR 1.15, 95 percent CI: 1.07-1.24, p < 0.001) and mechanical ventilation (aOR 1.27, 95 percent CI: 1.14-1.41, p < 0.001). Opioid use was also linked to longer hospital stays (adjusted mean difference [aMD] 1.15 days, 95 percent CI: 0.83-1.47, p < 0.001) and a nonsignificant increase in total charges (aMD USD 3,615, 95 percent CI: USD -1.014 to USD 8,245, p = 0.12). CONCLUSIONS:While chronic opioid use in hospitalized HFpEF patients did not significantly affect in-hospital mortality, it was associated with a higher risk of other adverse events and longer hospital stays.
OBJECTIVE:Guidelines for safer chronic opioid prescribing recommend regular urine drug testing (UDT); however, evidence on the best use of this testing is less clear, and wide variation exists in practice. Our objective in this qualitative study was to assess provider attitudes, barriers, and facilitators to ordering and interpreting UDT for patients prescribed chronic opioids. DESIGN, SETTING, AND SUBJECTS:Qualitative study among family and internal medicine physicians working at several clinics within a large community and academic health system. METHODS:Semistructured interviews were analyzed with qualitative thematic analysis. RESULTS:Themes were (1) perceived medical benefit outweighs concerns, (2) UDT requirement has a push-pull relationship with professional autonomy, (3) standardization of UDT as key to reduce bias, (4) systematic process eases confusion, and (5) desire for training for "gray areas." DISCUSSION:A key facilitator was also a key barrier: Guideline-required urine drug tests as the requirement both reduced conflict between primary care physicians (PCPs) and patients around ordering urine drug tests and reduced professional autonomy and shared decision-making. Education on ordering and interpreting urine drug tests was endorsed as important to facilitate use. CONCLUSIONS:PCPs generally view urine drug tests favorably but have mixed attitudes toward urine drug test mandates and desire comprehensive education on urine drug test management.
OBJECTIVE:To compare the efficacy of single-dose anesthetic (SDA) erector spinae plane block (ESPB) versus continuous ESPB via thoracic catheters (CATs) in managing pain and reducing opioid use in cardiac surgery patients. DESIGN:Prospective, observational, longitudinal study. SETTING:A tertiary-level hospital. PATIENTS:A total of 70 patients aged 18 and above undergoing cardiovascular surgery involving sternotomy were included (35 per group). INTERVENTIONS:Patients received either a single-dose ESPB with bupivacaine or continuous ESPB via thoracic CATs with automatic intermittent boluses of bupivacaine for 72 hours. MAIN OUTCOME MEASURES:Opioid use (primary outcome) was measured in morphine milligram equivalents (MMEs), while pain intensity (secondary outcome) was assessed using the Numeric Rating Scale (NRS). RESULTS:The CAT group demonstrated significantly lower cumulative opioid use at 72 hours (median 12.0 MME [interquartile range {IQR} 9.0-20.0]) compared to the SDA group (median 17.0 MME [IQR 12.0-37.0], p = 0.029). Pain intensity scores on NRS showed no significant differences between groups. Post-operative nausea was less frequent in the CAT group (17.1 percent vs 40.0 percent, p = 0.034). No major complications were observed in either group. CONCLUSIONS:Continuous ESPB via thoracic CATs provides superior opioid-sparing effects compared to single-dose ESPB in cardiac surgery patients while maintaining comparable pain relief and safety. This technique may enhance recovery protocols by reducing opioid-associated side effects. Further research is warranted to explore adjuvants and optimize ESPB protocols in cardiac surgery.
Hospitalizations for opioid use disorder (OUD) are rising, yet overnight clinicians rarely receive targeted OUD education. Our interprofessional initiative implemented two overnight training sessions specifically for night-shift physicians, nurses, pharmacists, and advanced practice providers, emphasizing buprenorphine initiation, stigma reduction, harm reduction, and patient-centered communication. Participants in the program demonstrated increased confidence in OUD management and a self-reported rise in overnight buprenorphine initiation, highlighting the impact of this tailored night-shift education. Administrative support enabled participation through scheduling adjustments and incentives, while collaboration with TeachOUD enriched content with community resources. To improve overnight care in resource-limited hospitals, we highlight no-cost resources, including teleconsultation hotlines, quick-reference tools, and training designated night-shift OUD champions, promoting accessible and sustainable strategies to enhance OUD care at all hours of the day.
