Frequent Use Of Opioids Research Articles

Leser fragen - Experten antworten - Rapid-Sequence-Induction bei Sectio caesarea: Sollte standardmäßig ein Opioid gegeben werden?

The spinal anaesthesia, epidural anaesthesia or combinations of these techniques (combined spinal epidural anaesthesia) so far remain the gold standard to facilitate caesarean section. For some reasons such as refusal by the patients, medical reasons or emergency caesarean section, a general anaesthesia can be necessary. In patients with preeclampsia hypertension during endotracheal intubation has to be avoided. Here the application of an opioid is possible or even necessary to lessen increases of the heart rate and blood pressure. To lessen cardiovascular response, short acting Remifentanil has advantages, e.g. the fast clearance rate in newborns. However, the risk for the newborn from respiratory depression has to be considered and experienced staff to care for the newborn should be present after childbirth. Therefore, an interdisciplinary approach seems to be vital to cope with adverse effects that may arise due to the more frequent use of opioids in conjunction with general anaesthesia for caesarean section.

Pathophysiology of Chronic Migraine and Mode of Action of Preventive Medications

Evidence has accumulated in recent years indicating structural, physiologic, and biochemical alterations in the brain of patients with chronic migraine (CM). Altered pharmacologic responses to opioids and other analgesics have also been reported. Structural or morphologic changes include reduced cortical gray matter of the pain processing areas of the brain and iron accumulation in the periaqueductal gray matter (PAG), red nucleus, and basal ganglia structures. These changes correlate with the duration of migraine disorder and, therefore, are more marked in CM compared to episodic migraine (EM). A dysmodulation of trigeminovascular nociception resulting from changes in PAG may be an important factor in the pathophysiology of CM. Even though the pathophysiology and significance of subcortical white matter lesions and infarct like cerebellar lesions are not fully understood, their occurrence in patients with frequent migraine is further evidence of structural alterations in the brain in CM. Physiologic changes in CM are altered brain metabolism, excitability, and central sensitization of nociceptive pathways. CM is associated with alterations in the brain metabolism confirmed by positron emission tomography (PET) studies. Of special interest is the reversible hypometabolism in the insula, thalamus, anterior cingulate, and parietal lobe and sustained hypometabolism in the orbitofrontal cortex in medication overuse headache. Cortical excitability is increased in CM compared to EM, as confirmed by magnetic suppression of visual accuracy. Cutaneous allodynia, which is more often seen in CM, is a marker of central sensitization. Central sensitization generates free radicals that damage PAG. Cutaneous allodynia is correlated with frequency of migraine attacks and duration of migraine illness. Chronically sensitized central nociceptive neurons may account for CM and its resistance to treatment. Alterations in central glutamate neurotransmission have been reported in the anterior cingulate and insula using magnetic resonance spectroscopy. Medications affecting central glutamatergic neurotransmission may have a potential therapeutic role in CM. Frequent use of opioids and analgesics in EM leads to CM. Opioid-induced hyperalgesia, recognized in recent years, can lead to intractability of migraine. Better understanding of the pathophysiology of CM should lead to better ways to treat these patients. The various effective preventive agents used in migraine prophylaxis, such as topiramate, valproate, β-blockers, and tricyclic antidepressants, appear to have a common effect of suppressing cortical excitability (cortical spreading depression). Suppression of cortical spreading depression by these agents is correlated with the dosages and the duration of treatment. The beneficial effect of botulinum toxin in CM may be due to its antinociceptive effect. Changes in the glutamate and calcitonin gene-related peptide at the peripheral nerve endings reduce peripheral sensitization, which eventually leads to reduced central sensitization.

Doctor, how long?

This study aimed to quantify the average survival time of cancer patients once terminal sedation was started until death and identify potential variables that may influence their survival time on sedation. This is a retrospective cohort analysis of all consecutive terminal cancer patients who died after starting terminal sedation at public tertiary Brazilian Hospital. A total of 532 cancer patients died in Hospital Estadual Mário Covas during this period and 181 out of them who received terminal sedation were included in this analysis. The median survival was 27 h. By multivariate analysis, increase in the dose of sedative drug during sedation (odds ratio 1.576, 95% CI 1.113-2.232), use of opioids alone for sedation (odds ratio 1.438, 95% CI 1.046-1.977) and dyspnoea as cause of sedation (odds ratio 1.564 95% CI 1.045-2.341) were independent risk factors for a shorter survival time after starting terminal sedation. Sedated, terminal cancer patients usually live about 1 day. We identified risk factors for a shorter sedation period. This study is limited by its retrospective design and by the frequent use of opioids as the main sedative medications. Prospective studies must be carried out in order to validate these data.

Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain

Little is known about patients prescribed high doses of opioids to treat chronic non-cancer pain, though these patients may be at higher risk for medication-related complications. We describe the prevalence of high-dose opioid use and associated demographic and clinical characteristics among veterans treated in a VA regional healthcare network. Veterans with chronic non-cancer pain prescribed high doses of opioids (⩾180mg/day morphine equivalent; n=478) for 90+ consecutive days were compared to two groups with chronic pain: Traditional-dose (5–179mg/day; n=500) or no opioid (n=500). High-dose opioid use occurred in 2.4% of all chronic pain patients and in 8.2% of all chronic pain patients prescribed opioids long-term. The average dose in the high-dose group was 324.9 (SD=285.1)mg/day. The only significant demographic difference among groups was race (p=0.03) with black veterans less likely to receive high doses. High-dose patients were more likely to have four or more pain diagnoses and the highest rates of medical, psychiatric, and substance use disorders. After controlling for demographic factors and VA facility, neuropathy, low back pain, and nicotine dependence diagnoses were associated with increased likelihood of high-dose prescriptions. High-dose patients frequently did not receive care consistent with treatment guidelines: there was frequent use of short-acting opioids, urine drug screens were administered to only 25.7% of patients in the prior year, and 32.0% received concurrent benzodiazepine prescriptions, which may increase risk for overdose and death. Further study is needed to identify better predictors of high-dose usage, as well as the efficacy and safety of such dosing.

Nicotine Dependence Predicts Repeated Use of Prescribed Opioids. Prospective Population-based Cohort Study

The aim of this study was to evaluate prospectively smoking dependence as a predictor of repeated use of prescribed opioids in non-cancer patients. We conducted a prospective population-based study cohort of 12,848 men and 15,894 women 30-75 years of age in health surveys in Norway during 2000-2002 with repeated opioid prescriptions (12+, during 2004-2007) recorded in the Norwegian Prescription Database as the outcome measure. Information on history of smoking and potential confounders was obtained at baseline by self-administered questionnaires. For smoking, participants were divided into categories: never; previously heavy (stopped maximum of 5 years earlier; 10+ cigarettes daily); daily not heavy (1-9 cigarettes); dependent daily smokers (10+ cigarettes), and other (previously and/or not daily). Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression. During follow-up, 335 (1.5%) of survey participants were registered with 12+ prescriptions of opioids during the period 2004-2007. The prevalence of repeated prescription frequency of opioids was higher for men and women with a history of smoking. The adjusted OR for prescribed opioids for dependent daily smokers was 3.1 (95% CI: 2.3-4.1), for daily non-heavy smokers 1.8 (1.2-2.7), and for previous heavy smokers 1.8 (1.1-3.0), compared with never-smokers as reference. Results of the study suggest that smoking dependence may predict more frequent use of opioids.

Magnesium and headache after aneurysmal subarachnoid haemorrhage

BackgroundIn patients with aneurysmal subarachnoid haemorrhage (SAH), headache typically is severe and often requires treatment with opioids. Magnesium has analgesic effects in several conditions, but whether it reduces headache after...

Comprehensive Review of Epidemiology, Scope, and Impact of Spinal Pain

Persistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. Chronic pain is defined as, "pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur." In contrast, chronic pain syndrome has been defined as a complex condition with physical, psychological, emotional, and social components. The prevalence of chronic pain in the adult population ranges from 2% to 40%, with a median point prevalence of 15%. Among chronic pain disorders, pain arising from various structures of the spine constitutes the majority of the problems. The lifetime prevalence of spinal pain has been reported as 54% to 80%. Studies of the prevalence of low back pain and neck pain and its impact in general have shown 23% of patients reporting Grade II to IV low back pain (high pain intensity with disability) versus 15% with neck pain. Further, age related prevalence of persistent pain appears to be much more common in the elderly associated with functional limitations and difficulty in performing daily life activities. Chronic persistent low back and neck pain is seen in 25% to 60% of patients, one-year or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Estimates and patterns of productivity losses and direct health care expenditures among individuals with back and neck pain in the United States continue to escalate. Recent studies have shown significant increases in the prevalence of various pain problems including low back pain. Frequent use of opioids in managing chronic non-cancer pain has been a major issue for health care in the United States placing a significant strain on the economy with the majority of patients receiving opioids for chronic pain necessitating an increased production of opioids, and escalating costs of opioid use, even with normal intake. The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist's clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/Evidence-Based Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions.

Doctor, how long?

e20653 Background: In practice it is common to start terminal sedation for patients with advanced cancer who develop physical discomfort not amenable to be treated by other means. We aimed at quantifying the average survival time of terminal cancer patients once sedation was started until death and identify potential variables that may influence their survival time on sedation. Methods: This is a retrospective cohort analysis of all consecutive terminal cancer patients who died after starting terminal sedation at public tertiary brazilian Hospital during 2 years (January 2005 to January 2007). Results: 532 cancer patients died in Hospital Estadual Mário Covas during this period and 181 out of them who received terminal sedation were included in this analysis. The median survival was 27 hours. By multivariate analysis, increase in the dose of sedative drug during sedation (Odds Ratio 1.576, 95% CI 1.113–2.232); use of opioids alone for sedation (Odds Ratio 1.438, 95% CI 1.046–1.977); and dyspnea as cause of sedation (Odds Ratio 1.564 95% CI 1.045–2.341) were independent risk factors for a shorter survival time after starting terminal sedation. Conclusions: Sedated, terminal cancer patients usually live about one day. We identified risk factors for a shorter sedation period. This study is limited by its retrospective design and by the frequent use of opioids as the main sedative medications. Prospective studies must be carried out in order to validate these data in settings in which non-opiods are the main sedative medications. No significant financial relationships to disclose.

Reductions in heroin use are not associated with increases in other drug use: 2-year findings from the Australian Treatment Outcome Study

Aims To determine whether reductions in frequency of heroin use were associated with reductions in the use of other drugs over a 24-month period. Design Longitudinal cohort, with follow-up at 3, 12 and 24 months. Participants Six hundred and fifteen heroin users recruited for the Australian Treatment Outcome Study. Setting New South Wales, Australia. Findings The proportion reporting weekly heroin use declined significantly at 3, 12 and 24 months. Reductions in heroin use were associated with longer periods in both residential rehabilitation (RR) and maintenance treatment (MT). Less frequent use of other opioids, cocaine, amphetamine, cannabis and benzodiazepines were noted over follow-up, with alcohol use remaining stable. Across follow-up, lower frequency heroin use was associated with reduced likelihood of frequent use of other opioids, cocaine, amphetamine and benzodiazepines. Alcohol and cannabis use were unrelated to heroin use. Longer periods spent in RR were associated with declines in the use of all other drug classes, with MT associated with declines in other opioid and alcohol use. Conclusions There was no evidence for drug substitution in the face of reduced heroin use in this cohort of treatment seekers. The fear that a successful reduction in heroin use amongst treatment seekers will precipitate an increase in the use of other drugs appears ill-founded.