Chronic Narcotic Use Research Articles

Clinical chronic pancreatitis.

To summarize observations in clinical chronic pancreatitis in the past year. A predisposing genetic mutation was identified in 67% of cases of pediatric chronic pancreatitis. A novel susceptibility gene involving a hybrid allele is associated with idiopathic chronic pancreatitis. ABO blood type B and FUT2 nonsecretor status is associated with asymptomatic hyperlipasemia and chronic pancreatitis. Alcohol consumption impairs cystic fibrosis transmembrane conductance regulator (CFTR) activity leading to decreased bicarbonate secretion and patients with susceptible CFTR mutations can develop clinical pancreatitis. Computed tomography imaging findings in chronic pancreatitis correlate poorly with pain patterns. Endoscopic ultrasound features correlate poorly with fibrosis. Circulating epithelial cells are present in chronic pancreatitis patients but not healthy volunteers. Surgery is superior to endoscopic treatment in providing durable pain relief (>5 years). Repetitive pancreatic duct stent placements and chronic narcotic use are preoperative predictors of poor outcome after total pancreatectomy with islet cell auto transplantation. Novel genetic mutations for idiopathic chronic pancreatitis are being identified. Alcohol impairs CFTR activity and may explain a mechanism for pancreatitis. Current imaging modalities correlate poorly with clinical pain presentation and fibrosis in chronic pancreatitis. Novel imaging modalities are needed. As total pancreatectomy with islet cell auto transplantation grows, rigorous outcomes analysis is needed to drive patient selection.

Pubic Bone Resection Provides Objective Pain Control in the Prostate Cancer Survivor With Pubic Bone Osteomyelitis With an Associated Urinary Tract to Pubic Symphysis Fistula

To investigate pain intensity perception in prostate cancer survivors with pubic bone osteomyelitis with an associated urinary tract to pubic symphysis fistula before and after definitive surgical management. We performed a review of an institutional review board-approved database of prostate cancer survivors with pubic bone osteomyelitis from 2010 to 2015. Demographic and clinical data were extracted. Pain scores were assessed in patients at varying points before and after definitive treatment using an 11-point numeric rating scale. Statistical analysis was performed using a Wilcoxon signed-rank test and NcNemar's test. We identified 16 patients with a median age of 72 who met inclusion criteria. Chronic narcotic use for pain management was noted in 6 of 16 (37.5%) patients preoperatively. No statistical difference was identified between the pain score at the time of diagnosis and after completion of conservative measures (5.5 vs 5.5, P = .76). A statistically significant decrease in median pain score at the first follow-up appointment was seen compared to the preoperative pain score (0 vs. 5.5, P = .0005). At a median follow-up of 9.4 months (interquartile range 3.7-16.5), a sustained decrease in the median pain intensity score was noted in our cohort compared to their preoperative baseline pain score (5.5 vs 0, P = .0005) and pain score at the time of diagnosis (5.5 vs 0, P = .004.) CONCLUSION: Pubic bone resection provides immediate and sustained improvement in pain intensity perception in the prostate cancer survivor with pubic bone osteomyelitis with an associated urinary tract to pubic symphysis fistula.

3:54 PMAbstract No. 383 - Clinical predictors of pain after transarterial embolization of hepatocellular carcinoma

Transarterial embolization (TAE) of HCC, while effective, can cause post-embolization syndrome with potentially severe pain. Some centers routinely admit patients overnight in case of severe pain requiring intravenous narcotic pain medications. However, in patients without significant pain, the overnight admission may be costly and unnecessary. The purpose of this study is to determine whether baseline patient and procedure characteristics are predictive of post-embolization pain. Retrospective review of our procedural database was undertaken for all patients undergoing TAE for HCC. For the purpose of assessing lobar embolization, only right lobe TAE was analyzed. In total, analysis was performed on 198 patients with HCC (149 males, 49 females, mean age 61.7 years) undergoing either right lobar TAE (n=113) or superselective TAE within the right lobe (n=85). All patients were empirically admitted for at least one night with a patient controlled analgesia pump. The amount of narcotics administered was determined. Hydrocodone dosing was converted to fentanyl equivalence for the purpose of comparison. Factors such as phrenic artery embolization, chronic narcotic use, tumor burden, subcapsular tumor location, prior cholecystectomy, particle size, and tumor hypervascularity were assessed. Post-TAE admission for more than one night for pain control was more common in patients undergoing lobar TAE than superselective TAE (16% vs 5%, p=0.01). Lobar TAE was also associated with higher narcotic utilization (p=0.01). Substantial narcotic utilization was less common in patients with prior cholecystectomy (20% versus 58%, p=0.002). The only factor correlated with nausea was high narcotic utilization. The only factor predictive of a maximum 10/10 reported pain score was tumor burden (p=0.02). Chronic narcotic use was not associated with any metric. Several factors correlated significantly with narcotic usage and hospital stay after TAE, including superselective versus lobar TAE, prior cholecystectomy, and tumor burden. These factors may be helpful as selection criteria for anticipating which patients are most likely to benefit from empiric admission after TAE.

Is ICU admission associated with chronic narcotic use? a 4-year follow up of ICU survivors

Patient comfort is a priority in the Intensive Care Unit (ICU). Narcotics are used to ensure optimal comfort and to facilitate patient management, including mechanical ventilation and other interventions. Previous studies indicate that chronic pain is common for an extended period after ICU discharge [1]. However, little data is available on the use of narcotic medications before and after ICU admission. We sought to describe narcotic use in this population over a multi-year time period.

Periprosthetic Anesthetic for Postoperative Pain After Laparoscopic Ventral Hernia Repair: A Randomized Clinical Trial.

Laparoscopic ventral hernia repair (LVHR) using mesh is a well-established intervention for ventral hernia, but pain control can be challenging. To determine whether instillation of a long-acting local anesthetic between the mesh and the peritoneum after LVHR reduces pain or narcotic requirements. A prospective, double-blind, randomized clinical trial with data collection during a brief hospital stay in a tertiary care, community teaching hospital over 3 years between December 15, 2011, and March 28, 2014. Of 120 screened patients undergoing LVHR in this intention-to-treat analysis, 99 eligible patients were randomized. Forty-two patients received the study drug, and 38 patients received placebo. Patients with a history of chronic narcotic use were excluded. After mesh placement, a long-acting local anesthetic (bupivacaine hydrochloride, 0.50%) or placebo (0.9% normal saline) was injected between the mesh and the peritoneum. Postoperative pain (on a standard scale ranging from 0 to 10), and narcotic medication use (intravenous morphine equivalents). There were no adverse events. Baseline and operative characteristics were similar except that the treatment group was older (61.8 vs 52.3 years, P = .001). After surgery, pain scores in the recovery room (3.2 vs 4.7, P = .003), interval total narcotic use (6.7 vs 12.5 mg, P = .003 at <4 hours and 0 vs 2.7 mg, P = .01 at 8-12 hours), and total intravenous narcotic use (9.2 vs 17.2 mg of morphine sulfate equivalents, P = .03) were significantly less in the treatment group. Administration of a long-acting local anesthetic between the mesh and the peritoneum significantly reduces postoperative pain and narcotic use after LVHR. clinicaltrials.gov Identifier: NCT01530815.

Quality of life after en bloc resection of tumors in the mobile spine

Background contextLittle has been reported regarding the patient-centered quality-of-life (QOL) outcomes after en bloc spondylectomy (ES). Despite lower local recurrence rates, it is unknown whether outcomes justify the surgical morbidity. PurposeThe purpose of this study was to report on patient QOL after ES as measured by validated instruments and to identify factors that may predict better postoperative QOL. Study designThis is a retrospective case-control study (Level III). Patient sampleThirty-five consecutive patients with mobile spine tumors were included. Twenty-seven patients underwent en bloc resection, whereas 8 patients received definitive radiation and no surgery. Minimum follow-up was 6 months (median, 32 months). Outcome measuresThe outcome measures were European Quality Group 5-Dimensional Questionnaire (EQ5D), four Patient-Reported Outcome Measurement Information System (PROMIS) short-form metrics, Neck Disability Index, and Oswestry Disability Index (ODI). MethodsWe performed statistical comparisons between the surgery and radiation groups, of the general US population, and within the study group itself to identify predictors of higher QOL scores. ResultsWe identified a significant difference in QOL between the surgery and radiation groups in only one instrument, PROMIS pain interference, with surgery having more pain interference (15.7 vs. 10.1, p=.04). For most metrics, including EQ5D, pain interference, pain behavior, and ODI, scores were around one standard deviation worse than the US population mean. Multivariable linear regression for each instrument demonstrated that preoperative factors such as better performance status, tumor location in the cervical spine, lack of mechanical back or neck pain, and shorter fusion span were independently predictive of better QOL scores. Postoperative factors such as poor performance status, chronic narcotic use, and local recurrence were more dominant than preoperative factors in predicting worse QOL. ConclusionsPatients may experience more pain interference after surgery as opposed to definitive radiotherapy, but we did not identify a difference for most metrics. Quality of life in our study group was significantly worse than the general population for most metrics. Cervical tumors, lack of mechanical pain, better baseline performance status, and less extensive surgery predict better QOL after surgery.

Narcotic use and misuse in Crohn's disease.

The rate of narcotic misuse in the inflammatory bowel disease population is not well studied. The primary aim of this study was to determine in Crohn's disease (CD) whether a concurrent functional gastrointestinal disorder (FGID) was associated with increased rates of chronic narcotic use. Second, we aimed to identify potential risk factors for narcotic misuse. A retrospective chart review of patients with CD followed at the University of Virginia's Gastroenterology Clinic from 2006 to 2011 was performed. The prescription monitoring program was accessed to confirm narcotic prescription filling histories. Narcotic misuse was defined as narcotic prescriptions filled from 4 or more prescribers and at 4 or more different pharmacies. Nine hundred thirty-one patients with CD were included in the study cohort. Eighty-seven (9.3%) patients were identified as having a concurrent FGID, and 192 (20%) were taking chronic narcotics. Patients with FGID were more likely to be taking chronic narcotics (44% versus 18%, P < 0.001). Thirty-seven percent (32/87) of patients with an FGID were misusing narcotics, compared with 9.6% (81/844) (P < 0.0001). Multivariate logistic regression demonstrated a significant association of misuse in patients with a concurrent FGID (odds ratio = 3.33, 95% confidence interval, 1.87-5.93). Twenty percent of patients with CD were using chronic narcotics with higher rates in those with FGID. Using the prescription monitoring program, a significant proportion of patients with CD with an FGID were misusing narcotics. We would recommend screening for narcotic misuse in patients with CD with a concomitant FGID and consider using prescription monitoring programs to identify others at risk for misuse.

Chronic Narcotic Use Before and After Liver Transplantation Increases Three-Year Mortality and Has Deleterious Effects on the Rate of Rejection, Rehospitalization, and One-Year Mortality

Chronic Narcotic Use Before and After Liver Transplantation Increases Three-Year Mortality and Has Deleterious Effects on the Rate of Rejection, Rehospitalization, and One-Year Mortality

Prevalence of Chronic Narcotic Use Among Children With Inflammatory Bowel Disease

Narcotic analgesics are not recommended for long-term management of pain for patients with inflammatory bowel disease (IBD), particularly pediatric patients. We compared chronic use of narcotics among children with IBD and the general population and investigated factors associated with narcotic use in the pediatric IBD population. This cross-sectional study included children (younger than 18 years old) with continuous enrollment in a large administrative claims database from 2010 through 2011 (n= 4,911,286). Children with IBD were identified through diagnosis codes and dispensation of IBD medication (n= 4344); they were matched for age, sex, and region with 5 children without IBD (n=21,720). Chronic narcotic use was defined as ≥3 dispensements of narcotics. We estimated prevalence odds ratios (PORs) and 95% confidence intervals (CIs), comparing narcotic use on the basis of IBD status and evaluating variables associated with narcotic use by patients with IBD by using conditional and unconditional logistic regression. The prevalence of chronic narcotic use was 5.6% among children with IBD vs 2.3% in the general population (POR, 2.6; 95% CI, 2.2-3.0). Compared with the general population, POR for chronic narcotic use was significantly higher for pediatric IBD patients with psychological impairment (POR, 6.8; 95% CI, 4.3-10.6) than those without (POR, 2.3; 95% CI, 1.9-2.7). Older age, increased healthcare utilization, fracture, and psychological impairment were strongly associated with chronic use of narcotics among children with IBD. Chronic narcotic use is common in pediatric IBD patients, particularly among those with anxiety and depression. Increased awareness of psychological comorbidity, screening, and treatment may reduce symptoms that lead to narcotic use and its complications.

Total pancreatectomy with islet cell auto-transplantation: update and outcomes from major centers.

Chronic pancreatitis is the result of irreversible damage to pancreatic acinar cells, and can result in debilitating chronic pain for patients. Treatment centers on pain relief, often with chronic narcotic use. Surgical therapy consists of both resection procedures to remove affected pancreatic parenchyma and drainage procedures to facilitate drainage of the main pancreatic duct. Total pancreatectomy historically was utilized in extreme cases due to the brittle glucose control that followed from the total loss of islet cells. Total pancreatectomy with islet cell auto-transplantation (TP-AIT) is gaining in popularity due to the maintenance of beta cell mass and the ability of patients to potentially be insulin independent post-operatively. TP-AIT is very helpful in the treatment of pain for patients with chronic pancreatitis. The overall majority of patients have an improvement in pain and quality-of-life scores. AIT also allows the majority of patients to have minimal insulin requirements post-operatively. With proper patient selection, these outcomes can be achieved.

Cyclic vomiting syndrome: treatment options.

Cyclic vomiting syndrome is a disorder characterized by recurrent episodes of severe nausea and vomiting separated by symptom-free periods. Our aims were to review treatments of adult cyclic vomiting syndrome as well as to identify areas for further clinical research and the unanswered questions in this field. We conducted a PubMed search using such keywords as "cyclic vomiting syndrome," "nausea," "vomiting," "treatment," "trigger factors" and "tricyclic antidepressants" and combined this information with the knowledge and clinical research from the authors. Available data show that in adult cyclic vomiting syndrome, there is an impressive and sustained response to high-dose tricyclic antidepressants. In up to 13% who are regarded as poor responders to tricyclic antidepressants, a predictable profile can be identified related to coexisting psychological disorders, marijuana use, poorly controlled migraine headache or chronic narcotic use. Cyclic vomiting syndrome in adults is being an increasingly recognized entity. Tricyclic antidepressants are the main treatment for controlling symptoms. Eliminating and addressing trigger factors are an essential part of management.

In Preliminary Data, Cell Phone Users Have Longer ABR Latencies

In Preliminary Data, Cell Phone Users Have Longer ABR Latencies

Pain and Analgesic Use After Robot-Assisted Radical Prostatectomy

While robot-assisted radical prostatectomy (RARP) is associated with shortened convalescence and decreased blood loss over open prostatectomy, little objective data is available regarding postoperative pain/discomfort and use of analgesic medications after RARP. We sought to examine these parameters in a contemporary cohort. From 2011 to 2013, patients undergoing RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while the patient recovered in the hospital. After discharge, the patients were asked to fill out a daily questionnaire regarding their pain parameters and self-report opiate usage. All questionnaires were based on the Wong-Baker FACES pain rating scale (0-10). Opiate dosages were converted to the approximate oral morphine sulfate equivalent dose (MSE). A total of 60 patients, mean age 61 years, were enrolled in the study, underwent RARP, and completed follow-up questionnaires. None had a history of chronic narcotic use. Intraoperative opiate use was 94.1 mg MSE. There were 73.3% who received immediate postoperative ketorolac. After RARP, the main source of pain/discomfort was abdominal/incisional, followed by urethral catheter-related, penile, and bladder spasm-related discomfort. Abdominal pain was generally moderate for most patients and decreased significantly after about 4 days. Penile and urethral catheter-related discomfort was mild throughout the study period. Opiate analgesic medication use quickly decreased as the subjective pain scores improved. After RARP, most patients experience mild/moderate abdominal discomfort, which improves steadily over several days. There is also a quick decline in the average opiate pain medication use that corresponds to the subjective improvement in pain symptoms. This information is useful for clinicians counseling patients on the pain associated with RARP and can serve as a reference to compare the convalescence associated with the other options for treatment of patients with localized prostate cancer.

P-091 Functional GI Disorders are Associated with High Rates of Chronic Narcotic Use and Misuse in Patients with Crohn’s Disease

P-091 Functional GI Disorders are Associated with High Rates of Chronic Narcotic Use and Misuse in Patients with Crohn’s Disease

Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing Test Accuracy

The diagnosis of small intestinal bacterial overgrowth (SIBO) has increased considerably owing to a growing recognition of its association with common bowel symptoms including chronic diarrhea, bloating, abdominal distention, and the irritable bowel syndrome. Ideally, an accurate and objective diagnosis of SIBO should be established before initiating antibiotic treatment. Unfortunately, no perfect test exists for the diagnosis of SIBO. The current gold standard, small-bowel aspiration and quantitative culture, is limited by its high cost, invasive nature, lack of standardization, sampling error, and need for dedicated infrastructure. Although not without shortcomings, hydrogen breath testing provides the simplest noninvasive and widely available diagnostic modality for suspected SIBO. Carbohydrates such as lactulose and glucose are the most widely used substrates in hydrogen breath testing, with glucose arguably providing greater testing accuracy. Lactose, fructose, and sorbitol should not be used as substrates in the assessment of suspected SIBO. The measurement of methane in addition to hydrogen can increase the sensitivity of breath testing for SIBO. Diagnostic accuracy of hydrogen breath testing in SIBO can be maximized by careful patient selection for testing, proper test preparation, and standardization of test performance as well as test interpretation.

Laparoscopic versus robot-assisted surgery for median arcuate ligament syndrome

Median arcuate ligament syndrome (MALS) is an uncommon disorder characterized by postprandial abdominal pain, weight loss, and vomiting related to the compression of the celiac artery by the median arcuate ligament. This syndrome has been classically treated with an open surgical approach. More recently, laparoscopic and robotic approaches have been used. We present our outcomes with laparoscopic and robot-assisted treatment of MALS. We performed a retrospective review of all patients treated for MALS from March 2006 to August 2012 at a single institution. A total of 16 patients with MALS were treated: 12 patients via a laparoscopic approach and 4 patients via a robot-assisted approach. Patient characteristics and comorbidities were similar between groups. We experienced no intraoperative or perioperative conversions, complications, or deaths. The mean operative time for the laparoscopic approach was significantly shorter than for the robotic approach (101.7 vs. 145.8 min; P = 0.02). However, we found no significant difference in length of hospital stay (1.7 vs. 1.3 days, P = 0.23). The mean length of follow-up for laparoscopically treated patients was 22.2 months and for robotically treated patients it was 20 months. Eight patients (67 %) in the laparoscopic group and two patients (50 %) in the robotic group had full resolution of their abdominal pain. Three patients in the laparoscopic group and two patients in the robotic group ceased chronic narcotic use after surgery. Both laparoscopic and robotic approaches to MALS treatment can be performed with minimal morbidity and mortality. The laparoscopic approach was associated with a significantly shorter operative time. While innovative, the true advantages to robot-assisted MALS surgery are yet to be seen.

Application of Dual Mask for Postoperative Respiratory Support in Obstructive Sleep Apnea Patient

In some conditions continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) therapy alone fails to provide satisfactory oxygenation. In these situations oxygen (O2) is often being added to CPAP/BIPAP mask or hose. Central sleep apnea and obstructive sleep apnea (OSA) are often present along with other chronic conditions, such as chronic obstructive pulmonary disease (COPD), congestive heart failure, pulmonary fibrosis, neuromuscular disorders, chronic narcotic use, or central hypoventilation syndrome. Any of these conditions may lead to the need for supplemental O2 administration during the titration process. Maximization of comfort, by delivering O2 directly via a nasal cannula through the mask, will provide better oxygenation and ultimately treat the patient with lower CPAP/BIPAP pressure.

An Unusual Case of Ogilvie Syndrome in a Pediatric Oncology Patient Receiving Palliative Care after Failed Treatment with Neostigmine

We present a case of severe refractory constipation in an adolescent oncology patient with widely metastatic clear cell osteosarcoma who was ultimately found to have Ogilvie syndrome, also known as acute colonic pseudo-obstruction (ACPO). Ogilvie syndrome is characterized by dilatation of the large intestine in the absence of mechanical obstruction, usually occurring in adult patients with serious underlying medical conditions and rarely seen in children. It is likely that chronic narcotic use, abdominal metastasis, and a paraneoplastic process contributed to development of ACPO in this patient. This case highlights an infrequent, but important, gastrointestinal complication that can occur in pediatric patients with serious comorbid disease. Ogilvie syndrome should be included on the differential diagnosis list in pediatric patients with refractory constipation. Our case illustrates the progression of therapies, including surgical intervention that can be undertaken to treat this disorder in children and adults while providing important considerations for clinicians treating patients of any age with this unusual clinical complication.

Multisociety sedation curriculum for gastrointestinal endoscopy

Multisociety sedation curriculum for gastrointestinal endoscopy

Ogilvie Syndrome in a Child With Incurable Malignancy (779)

1.Recognize the signs and symptoms of acute colonic pseudo-obstruction (Ogilvie Syndrome) in patients with serious underlying medical conditions.2.Identify invasive and non-invasive treatment modalities for patients with Ogilive syndrome Acute colonic pseudo-obstruction. (ACPO), also known as Ogilvie Syndrome, is characterized by dilatation of the large intestine in the absence of mechanical obstruction; it usually occurs in adult patients with serious underlying medical conditions and is rarely seen in children. A 16 year-old girl, diagnosed with metastatic small cell osteosarcoma in April 2008, was referred to our quality-of-life service with incurable disease in July 2009. Her illness was complicated by ascites of unknown origin and pain secondary to extensive metastatic disease. Her pain was under reasonable control until the fall of 2010 when she began experiencing abdominal distension, gas retention, and constipation initially treated with metoclopramide and rectal tube. Progressive pain and distension resulted in an extensive evaluation, including colonoscopy, yielding the diagnosis of Ogilvie Syndrome. It is likely that chronic narcotic use, abdominal metastasis, and a paraneoplastic process contributed to development of ACPO in this patient. First line treatment for ACPO is conservative management with bowel rest and mechanical decompression. The case patient failed conservative measures and a trial of pharmacological therapy with neostigmine was undertaken based on efficacy data from the adult literature. Unfortunately, patient experienced a severe anaphylactic reaction with bronchospasm after administration of the first dose precluding future use. We urge clinicians to use caution, such as having anaphylactic medications available, if using this medication in patients with Ogilvie Syndrome and encourage further research in pediatric patients. After thoughtful reflection, the case patient elected to undergo aggressive therapy with a diverting ileostomy and had near immediate relief of her symptoms which persisted for 6 months. This case highlights an infrequent, but important, gastrointestinal complication which can occur in pediatric patients with serious co-morbid disease. It also illustrates the progression of therapies that can be undertaken to treat this disorder in children.