Chronic Opioid Users Research Articles

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

Trajectories of Prescription Opioid Utilization During Pregnancy Among Prepregnancy Chronic Users and Risk of Neonatal Opioid Withdrawal Syndrome

Little is known about the impact of dose, duration, and timing of prenatal prescription opioid exposure on the risk of neonatal opioid withdrawal syndrome (NOWS). Using a cohort of 18,869 prepregnancy chronic opioid users nested within the 2000-2014 Medicaid Analytic eXtract, we assessed average opioid dosage within biweekly gestational age intervals, created group-based trajectory models, and evaluated the association between trajectory groups and NOWS risk. Women were grouped into 6 distinct opioid use trajectories which, based on observed patterns, were categorized as 1) continuous very low-dose use, 2) continuous low-dose use, 3) initial moderate-dose use with a gradual decrease to very low-dose/no use, 4) initial high-dose use with a gradual decrease to very low-dose use, 5) continuous moderate-dose use, and 6) continuous high-dose use. Absolute risk of NOWS per 1,000 infants was 7.7 for group 1 (reference group), 28.8 for group 2 (relative risk (RR)=3.7, 95% confidence interval (CI): 2.8, 5.0), 16.5 for group 3 (RR=2.1, 95% CI: 1.5, 3.1), 64.9 for group 4 (RR=8.4, 95% CI: 5.6, 12.6), 77.3 for group 5 (RR=10.0, 95% CI: 7.5, 13.5), and 172.4 for group 6 (RR=22.4, 95% CI: 16.1, 31.2). Trajectory models-which capture information on dose, duration, and timing of exposure-are useful for gaining insight into clinically relevant groupings to evaluate the risk of prenatal opioid exposure.

S406 Patterns of Esophageal Dysmotility Among Chronic Opioid Users and Non-Opioid Users

S406 Patterns of Esophageal Dysmotility Among Chronic Opioid Users and Non-Opioid Users

S3576 Oddity of an Opiated Oddi: A Case of Sphincter of Oddi Dysfunction

Introduction: We present a case of recurrent right upper quadrant (RUQ) pain resulting from Sphincter of Oddi Dysfunction (SOD) in the setting of chronic opioid use. SOD is a functional gastrointestinal disorder that presents similarly to other disorders of the biliary tree. Understanding features of this disorder and its etiologies can streamline evaluation and treatment. Case Description/Methods: Our patient is a 77-year-old male, chronic opioid user, who had multiple Emergency Department (ED) visits and hospital admissions for RUQ pain in the setting of significantly elevated liver associated enzymes (LAEs). However, repeated imaging of the RUQ with CT, Ultrasound, and MRCP remained largely unremarkable. On a subsequent presentation, the patient experienced severe increase in pain after administration of morphine. Lab investigation showed an abrupt increase in LAEs and lipase after administration of morphine. Imaging was obtained, and was again inconsistent with cholecystitis. Interestingly, he attained analgesia with meperidine on admission. During a following ED visit, RUQ imaging showed non-specific gallbladder inflammation, and a Hepatobiliary Iminodiacetic Acid (HIDA) scan showed low gallbladder ejection fraction (GBEF). These findings suggested Functional Gallbladder Disorder and laparoscopic cholecystectomy was performed. Unfortunately, ten days later the patient had worsening RUQ pain with no signs of obstruction. With diagnostic criteria for SOD met and other etiologies ruled out, our patient was referred for sphincterotomy. Discussion: Opiate-induced SOD is theoretically well known, but there have been only few reported cases in literature. Furthermore, SOD is difficult to diagnose, as providers must first rule out other hepatobiliary disease. ROME IV Diagnostic Criteria for Functional Gastrointestinal Disorders was used in review of our case. Biliary pain, absence of bile duct stones or other structural abnormalities, and elevated LAEs fulfilled the criteria for this disorder. This case highlights the clinical evaluation and care of SOD. While all opioids have been shown to contract the Sphincter of Oddi (SO), morphine has been shown to strongly cause this contraction, and is one of the earliest reported causes of SOD in literature. Meperidine has been shown to have minimal effect on the SO contraction and is the ideal opioid to treat pain of biliary or pancreatic source.

Full Opioid Agonists and Tramadol: Pharmacological and Clinical Considerations.

Opioids are mu receptor agonists and have been an important part of pain treatment for thousands of years. In order to use these drugs appropriately and successfully in patients, whether to control pain, to treat opiate-induced side effects, or opiate withdrawal syndromes, a solid understanding of the pharmacology of such drugs is crucial. The most recognized full agonist opioids are heroin, morphine, codeine, oxycodone, meperidine, and fentanyl. Phenanthrenes refer to a naturally occurring plant-based compound that includes three or more fused rings. The opioids derived from the opium plant are phenanthrene derivatives, whereas most synthetic opioids are simpler molecules that do not have multiple rings. Methadone acts as a synthetic opioid analgesic similar to morphine in both quality and quantity; however, methadone lasts longer and in oral form, has higher efficacy, and is considered a diphenylheptane. Fentanyl is a strong synthetic phenylpiperdine derivative that exhibits activity as a mu-selective opioid agonist approximately 50 to 100 times more potent than morphine. Meperidine is another medication which is a phenylpiperdine. Tramadol is considered a mixed-mechanism opioid drug, as it is a centrally acting analgesic that exerts its effects via binding mu receptors and blocking the reuptake of monoamines. Some of the most common adverse effects shared among all opioids are nausea, vomiting, pruritus, addiction, respiratory depression, constipation, sphincter of Oddi spasm, and miosis (except in the case of meperidine). Chronic opioid usage has also established a relationship to opioid-induced hypogonadism and adrenal suppression. Physicians must be stewards of opioid use and use opioids only when necessary.

Increasing Chronic Opioid Usage Despite Reduced Prescriptions After Vascular Surgery

Perioperative narcotics confer an increased risk of chronic opioid use (COU), but optimal prescribing in vascular surgery is undefined. The study goal was to identify current practices in perioperative opioid prescription and COU in opioid-naïve patients undergoing vascular surgery. The Optum Clinformatics Data Mart is a deidentified commercial and Medicare Advantage claims database with beneficiaries across the United States. From 2004 to 2018, adult patients undergoing vascular surgery within a 3-year continuous enrollment period were queried. Common procedural terminology codes for amputation, thoracic and abdominal endovascular aortic repair, arteriovenous fistula, carotid endarterectomy, supra- and infra-inguinal bypass, open abdominal aortic repair, peripheral endovascular intervention, and venous procedures were used. Opioid-related definitions were derived from prior literature: patients were considered opioid-naïve if they did not fill a narcotic prescription within 1 year to 14 days prior to surgery. Perioperative prescriptions were those filled between 14 days prior and 7 days after surgery, and chronic opioid use was defined as filling 10 prescriptions or a 120-day supply within the postoperative year. Morphine milligram equivalents (MME) were calculated, with perioperative totals exceeding 50 MME/day as an indicator of increased overdose risk. Multivariate logistic regression was performed to identify patient factors associated with COU. Of 119,491 patients, 66,637 (53.3%) were female, with a mean age of 64.0 ± 14.2 years. Procedures were most commonly venous (44.6%), followed by peripheral endovascular interventions (14.7%) and carotid endarterectomy (14.0%). Perioperative MME/day varied significantly by procedure (P < .0001), ranging from 40.0 in supra-inguinal bypass to 23.8 MME/day in venous procedures (Fig 1A). Rates of postoperative COU varied significantly by procedure (P < .0001) and were highest following amputation (7.62%), peripheral endovascular intervention (6.95%), and infra-inguinal bypass (6.94%) (Fig 1A). Although the percentage of perioperative prescriptions greater than 50 MME/day decreased from 2004 to 2018 (27.11% to 13.98%; P < .0001), rates of COU increased (2% to 5.8%; P < .0001) (Fig 1B). In a multivariate logistic regression for factors associated with chronic opioid use, increased age (P < .001), prior substance abuse (P < .001), and a history of diabetes (P = .002) were independently associated with COU. Supra-inguinal bypass, infra-inguinal bypass, and amputations are associated with increased perioperative opioid prescriptions and postoperative COU. Despite reductions in perioperative opioid prescriptions, the incidence of COU following vascular surgery in opioid-naïve patients has increased in the last 15 years. Comorbidities including increased age, prior substance abuse, and diabetic history are independently associated with COU risk.

The effects of diabetes mellitus on gastric emptying: A prospective observational cohort study

Study objectiveOur goal was to evaluate the effect of diabetic severity and duration on preoperative residual gastric volume. Secondarily we compared ultrasonic estimates of residual gastric volume with actual volume determined by aspiration during endoscopy. DesignThis was a prospective, observational cohort study that included adults with a history of diabetes mellitus and/or opioid use scheduled for gastrointestinal endoscopic procedures. SettingEndoscopy unit at Cleveland Clinic Main Campus from 2017 to 2019. ParticipantAdults scheduled for upper endoscopy with or without colonoscopy. Intervention and measurementsResidual gastric volumes were primarily determined by aspiration during endoscopy, and secondarily estimated with ultrasound. We evaluated the relationship between gastric residual volume and preoperative HBA1C concentration and duration of diabetes. Secondarily, we conducted an agreement analysis between the two gastric volume measurement techniques. Main resultsAmong 145 enrolled patients, 131 were diabetic and 17 were chronic opioid users. Among 131 diabetic patients, the mean ± SD HbA1c was 7.2 ± 1.5% and the median (Q1, Q3) duration of diabetes was 8.5 (3, 15) years. Neither HbA1c nor duration of diabetes was associated with residual gastric volume. The adjusted mean ratio of residual gastric volume was 1.07 (98.3% CI: 0.89, 1.28; P = 0.38) for 1% increase in HbA1c concentration, and 0.84 (98.3% CI: 0.63, 1.14; P = 0.17) for each 10-year increase induration of diabetes. The median [Q1–Q3] absolute difference between gastric ultrasound measurement and endoscopic measurement was 25 [15, 65] ml. ConclusionsIn this prospective observational cohort study, neither the duration nor severity of diabetes influenced preoperative residual gastric volume. Gastric ultrasound can help identify patients who have excessive residual volumes despite overnight fasting.

Preoperative chronic opioid use and its impact on early complicationsin bariatric surgery: a Swedish nationwide cohort study of 56,183 patients.

The association between severe obesity and chronic pain makes opioid use common among bariatric patients. Preoperative opioid use has been identified as a risk factor in other surgical procedures. To examine the impact of preoperative opioid use on complications after primary bariatric surgery. Sweden. All primary laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) patients from 2007-2017 were identified in the Scandinavian Obesity Surgery Register. Prescriptions for opioids within 90 days prior to surgery were retrieved from the Swedish Prescribed Drug Register and converted into oral morphine equivalents (OMEs). Patients with ≥2 prescription of opioids within 90 days prior to surgery were defined as chronic opioid users. Generalized linear regression was used to adjust for age, sex, body mass index, procedure type, year of operation, and co-morbidities. Of the 56,183 patients who had undergone primary LRYGB (n = 49,615) or LSG (n = 6568), 17.5% (n = 9825) had at least 1 prescription of opioids prior to surgery, of which 4.3% (n = 2390) weredefined as chronic opioid users. Chronic opioid use was associated with a higher risk of severe complications (Clavien Dindo grade ≥ 3b; odds ratio [OR], 1.67; 95% confidence interval [CI], 1.37-2.04), increased lengths of stay (relative risk, 1.11; 95% CI, 1.08-1.14), and higher rates of readmission(OR, 1.70; 95% CI, 1.49-1.94) and reoperation (OR, 1.87; 95% CI, 1.53-2.27; all P values< .001). Furthermore, higher OME exposure was associated with stepwise higher risks. Preoperative opioid use was an independent risk factor for severe complications, as well as prolonged lengths of stay, readmission, and reoperation after primary bariatric surgery.

Effects of opioids on respiration assessed by a contact-free unconstraint respiratory monitor with load cells under the bed in patients with advanced cancer.

Nocturnal periodic breathing of chronic opioid users has been predominantly documented by the use of polysomnography. No previous studies have assessed the opioid effects of respiratory rhythms throughout the day without the use of physical restraint. We recently developed a contact-free unconstraint vital sign monitoring system with four load cells placed under the bed legs, which allows continuous measurements of respiratory change at the center of gravity on the bed. We aimed to reveal details of the patient's 24-h respiratory status under a monitoring system and to test the hypothesis that respiratory rhythm abnormalities are opioid dose-dependent and worsen during the night time. Continuous 48-h respiratory measurements were successfully performed in 51 patients with advanced cancer (12 opioid-free patients and 39 opioid-receiving patients). Medians of respiratory variables with minimal body movement artifacts were calculated for each 8-h split time period. Compared with opioid-free patients, opioid-receiving patients had slower respiratory rate with higher respiratory rate irregularity without changing tidal centroid shift regardless of the time period. Irregular ataxic breathing was only identified in opioid-receiving patients (33%, P = 0.023) whereas incidence rate of periodic breathing did not differ between the groups. Multivariate regression analyses revealed that opioid dose was an independent risk factor for occurrence of irregular breathing [odds ratio 1.81 (95% CI: 1.39-2.36), P < 0.001], and ataxic breathing [odds ratio 2.08 (95% CI: 1.60-2.71), P < 0.001]. Females developed the ataxic breathing at lower opioid dose compared with males. We conclude that respiratory rhythm irregularity is a predominant specific feature of opioid dose-dependent respiratory depression particularly in female patients with advanced cancer.NEW & NOTEWORTHY Through usage of a novel contact-free unconstraint vital sign monitoring system with four load cells placed under the bed legs allowing continuous measurements of respiratory changes of center of gravity on the bed, this study is the first to assess detailed respiratory characteristics throughout day and night periods without interference of daily activities in patients with advanced cancer receiving opioids. Respiratory rhythm irregularity is a predominant specific feature of opioid dose-dependent respiratory depression particularly in female patients with advanced cancer.

The protective effect of zinc on morphine-induced testicular toxicity via p53 and Akt pathways: An in vitro and in vivo approach

BackgroundChronic use of morphine is associated with reproductive complications, such as hypogonadism and infertility. While the side effects of morphine have been extensively studied in the testis, much less is known regarding the effects of morphine on Sertoli cells and the effects of zinc on morphine-induced testicular injury as well as their underlying mechanisms. Therefore, the purpose of this study was to investigate the effect of morphine (alone and co-administered with zinc) on cell viability and apoptosis of the testicular (Sertoli) cells as well as the tumor suppressor p53 and phosphorylated-protein kinase B (p-Akt) protein levels in both in vitro and in vivo models. MethodsCultured Sertoli cells were exposed to morphine (23 μM), zinc (8 μM), and zinc prior to morphine and their effects on Sertoli cell viability and apoptosis were investigated. Morphine (3 mg/kg) and zinc (5 mg/kg, 1 h before morphine) were also injected intraperitoneally to rats and then the apoptotic changes in the testis were evaluated. ResultsCell viability and p-Akt protein levels decreased in morphine-treated cells, while apoptosis and p53 protein expression increased in these cells. Pretreatment with zinc recovered morphine-induced apoptotic effects, as well as over-expression of p53 and down-regulation of p-Akt. These findings were supported by a subsequent animal study. ConclusionThe present data indicated the protective effect of zinc against morphine-induced testicular (Sertoli) cell toxicity via p53/Akt pathways in both in vivo and in vitro models and suggested the clinical importance of zinc on infertility among chronic opioid users and addicted men.

Opioid use and social disadvantage in patients with chronic musculoskeletal pain.

Historically, marginalized patients were prescribed less opioid medication than affluent, white patients. However, because of persistent differential access to nonopioid pain treatments, this direction of disparity in opioid prescribing may have reversed. To compare social disadvantage and health in patients with chronic pain who were managed with versus without chronic opioid therapy. It was hypothesized that patients routinely prescribed opioids would be more likely to live in socially disadvantaged communities and report worse health. Cross-sectional analysis of a retrospective cohort defined from medical records from 2000 to 2019. Single tertiary safety net medical center. Adult patients with chronic musculoskeletal pain who were managed longitudinally by a physiatric group practice from at least 2011 to 2015 (n=1173), subgrouped by chronic (≥4 years) adherent opioid usage (n=356) versus no chronic opioid usage (n=817). Not applicable. The primary outcome was the unadjusted between-group difference in social disadvantage, defined by living in the worst national quartile of the Area Deprivation Index (ADI). An adjusted effect size was also calculated using logistic regression, with age, sex, race, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Physical Function scores as covariates. Secondary outcomes included adjusted differences in health by chronic opioid use (measured by PROMIS). Patients managed with chronic opioid therapy were more likely to live in a zip code within the most socially disadvantaged national quartile (34.9%; 95% confidence interval [CI] 29.9-39.9%; vs. 24.9%; 95% CI 21.9-28.0%; P < .001), and social disadvantage was independently associated with chronic opioid use (odds ratio [OR] 1.01 per ADI percentile [1.01-1.02]). Opioid use was also associated with meaningfully worse PROMIS Depression (3.8 points [2.4-5.1]), Anxiety (3.0 [1.4-4.5]), and Pain Interference (2.6 [1.7-3.5]) scores. Patients prescribed chronic opioid treatment were more likely to live in socially disadvantaged neighborhoods, and chronic opioid use was independently associated with worse behavioral health. Improving access to multidisciplinary, nonopioid treatments for chronic pain may be key to successfully overcoming the opioid crisis.

An Overlooked Sequela of Long-Term Opioid Analgesic Use: A Case Report on Central Adrenal Insufficiency

Background: Opioid use began to surge since late 1990s and has evolved into a full-fledge opioid epidemic. 2 million Americans aged 12 or older are estimated to have opioid use disorder. We hereby present a case of opioid-induced adrenal insufficiency (OIAI), an overlooked endocrinopathy in which chronic opioid use suppresses the hypothalamic-pituitary-adrenal axis. Clinical Case: A 53-year-old African American female with past medical history of chronic pain syndrome presented with worsening fatigue and generalized weakness for a week, to the extent that she required full assistance to ambulate at home. Upon further inquiry, she also suffered from postprandial eipgastric pain and non-bloody diarrhea for several months. She has a 2-year use of Norco 10 mg/325 mg three times daily to manage her chronic pain. Her blood pressure was running low at 85/57 mmHg with no other abnormal vitals. Our first visual impression of her was a debilitated lady with low voice and slow body movements. Adrenal insufficiency was suspected and subsequently confirmed with low morning cortisol level (1.1 mcg/dL), low DHEAS level (25.3 mcg/dL) and subnormal response of cortisol (16.8 mcg/dL) to the cosyntropin stimulation test. Her ACTH level was less than 3 pg/mL. These laboratory findings were consistent with central adrenal insufficiency. Chronic steroid use, the most common culprit for adrenal insufficiency, was not found in her home medication list or prescription records. To further evaluate the underlying etiologies, we checked the pituitary hormones and found normal levels of LH, FSH, TSH, prolactin and IGF-1. Head CT 2 years prior was negative for any discernible mass. The suspicion for pituitary mass that markedly suppresses ACTH secretion only was reasonably low. The diagnosis of OIAI was made by excluding other causes. Endocrinology was consulted for the dosing of hydrocortisone. She improved physically after receiving hydrocortisone replacement therapy. Collaborative efforts were made to cut down her opioid dose. Conclusions: OIAI is a longstanding overlooked condition in chronic opioid users of which clinicians should raise their awareness. The estimated prevalence of OIAI ranges from 9% to 29% depending on the daily dosage and total duration of opioid use. The case reports of OIAI, however, are only a few. Patients with OIAI could present with fatigue, weight loss, gastrointestinal symptoms, headache or muscular aches. Not only does OIAI impair patients’ quality of life and potentially escalate their opioid dosage by inexperienced prescribers, it also leads to catastrophic adrenal crisis following acute insults. The challenge clinicians face is to uncover the clinical clues suggesting OIAI, which are often hidden in a myriad of symptoms caused by chronic pain and other co-morbidities. Timely diagnosing OIAI is thus never more important in the midst of the unprecedented opioid epidemic.

Opioid use in medical cannabis authorization adult patients from 2013 to 2018: Alberta, Canada

BackgroundThe opioid overdose epidemic in Canada and the United States has become a public health crisis - with exponential increases in opioid-related morbidity and mortality. Recently, there has been an increasing body of evidence focusing on the opioid-sparing effects of medical cannabis use (reduction of opioid use and reliance), and medical cannabis as a potential alternative treatment for chronic pain. The objective of this study is to assess the effect of medical cannabis authorization on opioid use (oral morphine equivalent; OME) between 2013 and 2018 in Alberta, Canada.MethodsAll adult patients defined as chronic opioid users who were authorized medical cannabis by their health care provider in Alberta, Canada from 2013 to 2018 were propensity score matched to non-authorized chronic opioid using controls. A total of 5373 medical cannabis patients were matched to controls, who were all chronic opioid users. The change in the weekly average OME of opioid drugs for medical cannabis patients relative to controls was measured. Interrupted time series (ITS) analyses was used to assess the trend change in OME during the 26 weeks (6 months) before and 52 weeks (1 year) after the authorization of medical cannabis among adult chronic opioid users.ResultsAverage age was 52 years and 54% were female. Patients on low dose opioids (< 50 OME) had an increase in their weekly OME per week (absolute increase of 112.1 OME, 95% CI: 104.1 to 120.3); whereas higher dose users (OME > 100), showed a significant decrease over 6 months (− 435.5, 95% CI: − 596.8 to − 274.2) compared to controls.ConclusionsThis short-term study found that medical cannabis authorization showed intermediate effects on opioid use, which was dependent on initial opioid use. Greater observations of changes in OME appear to be in those patients who were on a high dosage of opioids (OME > 100); however, continued surveillance of patients utilizing both opioids and medical cannabis is warranted by clinicians to understand the long-term potential benefits and any harms of ongoing use.

Removal of prior authorization for medication-assisted treatment: impact on opioid use and policy implications in a Medicare Advantage population.

BACKGROUND: More than 30% of Medicare beneficiaries and 40% of patients dually eligible for Medicare and Medicaid use opioids. With an estimated 8%-12% of patients developing an opioid use disorder (OUD) after initiating opioids, opioid misuse is a significant public health challenge, especially among high-risk Medicare populations. Medication-assisted treatment (MAT) is the use of medications for the treatment of OUD and to prevent relapse to opioid use. MAT is the most effective treatment for OUD. There are a variety of barriers to MAT therapy that may delay access to treatment. OBJECTIVE: To study the impact of the removal of prior authorization requirements for MAT medications on MAT utilization, opioid utilization, and clinical outcomes, including emergency department visits, inpatient admission, relapse rates, behavioral health services, and nonopioid pain medication utilization, among opioid-using individuals with Medicare Advantage Prescription Drug (MAPD) coverage. METHODS: This retrospective, cross-sectional study used administrative medical, pharmacy, and enrollment data to identify chronic opioid users and a subset cohort initiating MAT use in 2017, when prior authorization requirements were in effect, and 2018 after removal of prior authorization requirements. Opioid and MAT utilization and clinical outcomes from emergency department visits were also examined before and after prior authorization requirements. A logistic regression analysis was conducted to examine the impact of the policy change on relapse rates, comparing relapse rates in 2017 and 2018, after controlling for potentially confounding demographic and clinical factors. RESULTS: This policy change was followed by a decrease in opioid utilization, an increase in MAT initiation, and a 4% decline in relapse rates. Patients initiating MAT after removal of prior authorizations had a 19% decrease in likelihood of relapse, and those with an OUD diagnosis were 47% less likely to relapse. The majority of MAT recipients were aged younger than 65 years, had a mental or behavioral health disorder diagnosis, and initially used relatively low doses (< 90 MME) of prescription opioids. There were no statistically significant differences in the use of behavioral health services or the use of nonopioid medications from 2017 to 2018. CONCLUSIONS: Utilization management policies should ensure appropriate MAT use, while minimizing impediments to access. Providing patients with evidence-based therapy effective for the treatment of OUD is essential to patient recovery and combating the consequences of the opioid epidemic. Further strides are needed to eliminate additional obstacles to OUD care. DISCLOSURES: No outside funding supported this study. All authors are or were employees of Humana, Inc., at the time of the study and have no other potential conflicts of interest to disclose.

Risk factors of chronic opioid use after surgical procedures in noncancer patients: A nationwide case-control study.

Surgery is an indication for opioid prescription in noncancer patients, and chronic use of opioids is associated with overdose and abuse. We aimed to evaluate the prevalence and risk factors associated with chronic opioid use (COU) following surgery among noncancer patients. A nationwide case-control study. Retrospective analysis of the annual national patient sample data from 2012 to 2018 in South Korea. Adults without cancer who had undergone surgery and received noninjectable opioids during hospital stay. COU during 3 months following surgery. A total of 15 543 participants were included, and the prevalence overall and in opioid-naïve users was 8.1 and 5.7%, respectively. Prior exposure patterns of opioids [intermittent user, adjusted odds ratio (aOR) 2.35; 95% CI, 2.00 to 2.77, and continuous user, aOR 8.58; 95% CI, 6.54 to 11.24] and concomitant use of benzodiazepine (in continuous user, aOR 18.60; 95% CI 11.70 to 29.55) were strongly associated with COU compared with naïve users. Morphine milligram equivalent, type of opioid strength at discharge and prescription of nonopioid analgesics at discharge were also associated with COU. Compared with minor surgery, knee (aOR 1.49; 95% CI 1.17 to 1.89), spine (aOR 1.65; 95% CI 1.33 to 2.06) and shoulder (aOR 2.54; 95% CI 1.97 to 3.27) procedures showed a significantly positive association with COU. Sensitivity analysis in opioid-naïve patients showed similar results. About 8.1% of noncancer patients who had undergone surgery and were prescribed noninjectable opioids became chronic opioid users in Korea. Identified risk factors could be used to derive strategies for safe opioid use in noncancer patients in the future.

Risk of chronic opioid use after simultaneous versus staged bilateral knee arthroplasty

BackgroundSeveral studies have identified excess risk associated with undergoing simultaneous (compared with unilateral or staged) bilateral total knee arthroplasty (BTKA). However, few have addressed subsequent chronic opioid use. Given the...

Burden of preoperative opioid use and its impact on healthcare utilization after primary single level lumbar discectomy

Background ContextThe complication profile and higher cost of care associated with preoperative opioid use and spinal fusion is well described. However, the burden of opioid use and its impact in patients undergoing lumbar discectomy is not known. Knowledge of this, especially for a relatively benign and predictable procedure will be important in bundled and value-based payment models. PurposeTo study the burden of pre-operative opioid use and its effect on postoperative healthcare utilization, cost, and opioid use in patients undergoing primary single level lumbar discectomy. Study DesignRetrospective cohort study. Patient SampleA 29,745 patients undergoing primary single level lumbar discectomy from the IBM MarketScan (2000-2018) database. Outcome MeasuresNinety-day and 1-year utilization of lumbar epidural steroid injections, emergency department (ED) services, lumbar magnetic resonance imaging, hospital readmission, and revision lumbar surgery. Continued opioid use beyond 3-months postoperatively until 1-year was also studied. We have reported costs associated with healthcare utilization among opioid groups. MethodsPatients were categorized in opioid use groups based on the duration and number of oral prescriptions before discectomy (opioid naïve, < 3-months opioid use, chronic preoperative use, chronic preoperative opioid use with 3-month gap before surgery, and other). The risk of association of preoperative opioid use with outcome measures was studied using multivariable logistic regression analysis with adjustment for various demographic and clinical variables. ResultsA total of 29,745 patients with mean age of 45.3±9.6 years were studied. Pre-operatively, 29.0% were opioid naïve, 35.0% had < 3-months use and 12.0% were chronic opioid users. There was a significantly higher rate of post-operative lumbar epidural steroid injections, magnetic resonance imaging , ED visits, readmission and revision surgery within 90-days and 1-year after surgery in chronic pre-operative opioid users as compared with patients with < 3-months use and opioid naïve patients (p<.001). Chronic post-operative opioid use was present in 62.6% of the preoperative chronic opioid users as compared with 5.6% of patients with < 3-months opioid use. A 3-month prescription free period before surgery in chronic pre-operative opioid users cut the incidence of chronic post-operative opioid use by more than half, at 25.7%. Cost of care and adjusted analysis of risk have been described. ConclusionChronic preoperative opioid use was present in 12% of a national cohort of lumbar discectomy patients. Such opioid use was associated with significantly higher post-operative healthcare utilization, risk of revision surgery, and costs at 90-days and 1-year postoperatively. Two-third of chronic preoperative opioid users had continued long-term postoperative opioid use. However, a 3-month prescription free period before surgery in chronic opioid users reduces the risk of long-term postoperative use. This data will be useful for patient education, pre-operative opioid use optimization, and risk-adjustment in value-based payment models.

Chronic Opioid Use and Central Sleep Apnea, Where Are We Now and Where To Go? A State of the Art Review.

Opioids are commonly used for pain management, perioperative procedures, and addiction treatment. There is a current opioid epidemic in North America that is paralleled by a marked increase in related deaths. Since 2000, chronic opioid users have been recognized to have significant central sleep apnea (CSA). After heart failure-related Cheyne-Stokes breathing (CSB), opioid-induced CSA is now the second most commonly seen CSA. It occurs in around 24% of chronic opioid users, typically after opioids have been used for more than 2 months, and usually corresponds in magnitude to opioid dose/plasma concentration. Opioid-induced CSA events often mix with episodes of ataxic breathing. The pathophysiology of opioid-induced CSA is based on dysfunction in respiratory rhythm generation and ventilatory chemoreflexes. Opioids have a paradoxical effect on different brain regions, which result in irregular respiratory rhythm. Regarding ventilatory chemoreflexes, chronic opioid use induces hypoxia that appears to stimulate an augmented hypoxic ventilatory response (high loop gain) and cause a narrow CO2 reserve, a combination that promotes respiratory instability. To date, no direct evidence has shown any major clinical consequence from CSA in chronic opioid users. A line of evidence suggested increased morbidity and mortality in overall chronic opioid users. CSA in chronic opioid users is likely to be a compensatory mechanism to avoid opioid injury and is potentially beneficial. The current treatments of CSA in chronic opioid users mainly focus on continuous positive airway pressure (CPAP) and adaptive servo-ventilation (ASV) or adding oxygen. ASV is more effective in reducing CSA events than CPAP. However, a recent ASV trial suggested an increased all-cause and cardiovascular mortality with the removal of CSA/CSB in cardiac failure patients. A major reason could be counteracting of a compensatory mechanism. No similar trial has been conducted for chronic opioid-related CSA. Future studies should focus on (1) investigating the phenotypes and genotypes of opioid-induced CSA that may have different clinical outcomes; (2) determining if CSA in chronic opioid users is beneficial or detrimental; and (3) assessing clinical consequences on different treatment options on opioid-induced CSA.

Rare but relevant: a systematic review of stercoral perforation.

Knowledge of the aetiologies of large bowel perforation are fundamental to its management. Stercoral perforation is a rare cause associated with high mortality. Owing to the paucity of coverage of this condition in the literature, this review raises awareness of stercoral perforation among clinicians. A literature search of PubMed, Embase, MEDLINE, CINAHL, Ovid and Cochrane was performed. Key search terms included 'stercoral, perforation', 'perforated', 'perforat*' and 'stercoral perforation'. Only literature published between December 2011 and July 2020 was included to avoid duplication. Twenty-nine papers were obtained giving an overall cohort of 58 patients. The median age was 58 years (range 2-83 years) and 72.4% (n=42) were female. Constipation was reported in 69% (n=40) and 20.7% (n=12) reported chronic opioid use. A computed tomography scan was performed in 94.8% (n=55) of cases and typically a Hartmann's procedure (n=40, 72.2%) was performed. The mortality rate was 17.2% (n=10). The median age of patients with stercoral perforation has decreased from that found in previous studies and the mortality rate has improved. Chronic opioid users have also emerged as an important cohort. Early recognition, diligent decision making and focused perioperative care form the backbone of the definitive management of stercoral perforation.

Can a novel opioid-free protocol following total knee arthroplasty prevent chronic opioid addiction? A follow-up study of 386 patients.

Background: Studies have shown that there is an approximately 8.2% risk of chronic addiction after total knee arthroplasty (TKA) using conventional methods to recover from surgery in patients who are opioid-naive (1). A previous study by the authors found that a novel multimodal protocol significantly reduced the use of postoperative TKA opioids in the first 90 days post-op (2). The present study sought to ascertain whether the protocol had persistent effects which led to a lower risk of chronic addiction than that which is currently published. Methods: All 386 patients from the previous study who underwent TKA were identified through a HIPPA-compliant portal and searched on the New York State Internet System for Tracking Over-Prescribing (NYS I-STOP) database. Patients who had received one or more opioid prescriptions in the 12 months preceding the I-STOP search were noted and then individually contacted to ascertain the reason for the prescription. Results: Overall, 88 patients received an opioid prescription within 12 months of searching I-STOP, 73 of which were opioid-naive. Of the opioid-naive patients, 10 were defined as chronic opioid users post-TKA, but only one patient named the TKA as the reason for using opioids. This study found that there was a 0.28% (1/356) chance for opioid-naive patients to become chronically addicted to opioids as a direct result of the TKA. The overall risk of becoming a chronic opioid user for any reason (including TKA) was 2.81% (10/356). The overall risk of an opioid-naive patient receiving at least one or more opioid prescriptions outside of the 90 day window after TKA for any reason was 20.5% (73/356). Conclusions: Following the previously published novel multimodal protocol led to a significant reduction in post-operative risk for converting to chronic opioid use in patients who were opioid-naive prior to surgery as directly related to the TKA. This study suggests that querying large databases for opioid use after TKA may not capture the actual reason for post-surgical opioid prescriptions and further study is warranted to determine the actual frequency with which TKA is responsible for chronic opioid use.