Opioid Group Research Articles

The Efficacy of Transverse Abdominis Plane Block for Postoperative Analgesia in Laparoscopic Hysterectomy: A Randomized Prospective Study.

Postoperative pain is an inevitable acute pain for which a multimodal analgesic approach is required. The aim of this study was to quantify and compare the efficacy of transverse abdominis plane (TAP) block as a postoperative analgesic for patients undergoing laparoscopic hysterectomies versus intravenous opioid analgesics. Sixtyfemale patients were enrolled and randomized into two groups following a computer-generated sequence of numbers. In group T (n=30) patients received an ultrasound-guided bilateral TAP block with 20 of 0.375% levobupivacaine on each side immediately after surgery. Patients in group O (opioid group, n = 30) received intravenous (i.v.) tramadol (100mg) immediately after surgery.Rescue analgesic (inj. tramadol 50mg) i.v. bolus given in both groups if visual analog scale (VAS) >4. In the postanesthesia care unit (PACU), the vital signs, episodes of nausea, vomiting, and VAS score of each patient were recorded every two hours for the first 24 hours. Total consumption of rescue analgesic (inj. tramadol 50 mg i.v.) during the first 24 hours was significantly higher in group O (186.47+37.48mg) than in group T (107.28+26.34mg). No significant difference was observed in intraoperative vital parameters (HR, NIBP, SPO2). The VAS scores were significantly low in group T.Incidence of postoperative nausea and vomiting (PONV) was significantly higher in group O (13 out of 28 patients) than in group T (five out of 28 patients) with P value =0.043. Our study indicated bilateral ultrasound-guided TAP block is a good alternative to opioids for postoperative analgesia.

Opioid versus Nonopioid Analgesia for Craniotomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Despite the use of intraoperative opioid analgesia, postoperative pain is often reported by patients undergoing craniotomies. Opioids also cause undesirable side effects in neurosurgical patients. Hence, the role of nonopioid analgesia has been explored for craniotomies in recent years. This systematic review evaluated evidence from randomized controlled trials (RCTs) comparing opioid and nonopioid analgesia during craniotomies regarding postoperative pain, recovery, and adverse events. Of the 10,459 records obtained by searching MEDLINE, Embase, and Web of Science databases, 6 RCTs were included. No difference was observed in pain scores between opioid and nonopioid analgesia at 1 and 24 hours after surgery: mean difference (MD), 1.11 units; 95% confidence interval [CI],-0.16 to 2.38, P= 0.09 and MD,-0.06 units; 95% CI,-1.14 to 1.01, P= 0.91, respectively. The time for first postoperative analgesic requirement was shorter with opioids but was not statistically significant (MD,-84.77 minutes; 95% CI,-254.65 to 85.11; P= 0.33). Postoperative nausea and vomiting (relative risk= 1.60; 95% CI, 0.96-2.66; P= 0.07) was similar but shivering (relative risk= 2.01; 95% CI, 1.09-3.71; P= 0.03) was greater in the opioid group than nonopioid group. There were no important differences in clinical outcomes between the groups in our review. The GRADE certainty of evidence was rated low for most outcomes. Available evidence does not suggest superiority of intraoperative nonopioid over opioid analgesia for postoperative pain in patients undergoing craniotomy. More studies are needed to firmly establish the role of nonopioid intraoperative analgesics as an alternative to opioids in this population.

Treating Prehospital Pain in Children: A Retrospective Chart Review Comparing the Safety and Efficacy of Prehospital Pediatric Ketamine and Opioid Analgesia

Prior to 2020, pain management in the Washtenaw/Livingston County Medical Control Authority (W/L MCA) Emergency Medical Service (EMS) system in Southeast Michigan was limited to morphine, fentanyl, ketorolac, and acetaminophen. Based on the increasing evidence describing its safety and efficacy, ketamine was added to local protocols for pain management. This study aimed to evaluate differences in pain management and adverse effects of ketamine and opioid administration. Data from pediatric patients who received ketamine or an opioid in the W/L MCA EMS system from October 2019 to March 2021 were analyzed. The primary outcome was the difference in pain score, and the secondary outcome was adverse effects observed after analgesic administration. The decrease in pain scores was greater among ketamine patients (mean: 5.2) compared to opioid patients (mean: 2.9), p < 0.001. The prevalence of adverse effects was higher among patients in the ketamine group (28.6%) compared to patients in the opioid group (2.4%, p < 0.001). Of 14 patients who received ketamine, one 17-year-old male experienced mild anxiety (7.1%), two teenage females experienced mild dissociation (14.3%), and one 20-year-old female experienced mild nausea (7.1%). Overall, ketamine is a safe and effective option compared to opioids for pediatric patients experiencing moderate to severe prehospital pain.

The Cost of Multimodal vs Opioid Postoperative Pain Regimens for the Foot &amp; Ankle Surgical Patient

Category: Other; Other Introduction/ Purpose: Orthopedic surgeons are one of the highest prescribing specialties of opioids in medicine. To address the ongoing opioid crisis in the United States, many surgeons have adopted multimodal regimens for post-operative pain control to decrease the need for opioids. Recent studies have demonstrated the effectiveness of opioid-sparing multimodal pain management therapies when compared to opioid inclusive therapies. However, to date there are no published studies analyzing the cost of multimodal vs opioid postoperative pain regimens for the elective foot &amp; ankle surgical post-surgical patient. Methods: A secondary analysis of data collected from two studies that evaluated pain control after elective forefoot surgery was analyzed. The index study examined the number of opioid pills consumed post-operatively. A follow-up then examined the clinical utility of the non-opioid pain regimen for pain control post-operatively. Medications in the non-opioid multimodal regimen included cyclobenzaprine, ketorolac, meloxicam, pregabalin, and acetaminophen. Using information collected during these two studies, deidentified patient profiles were constructed using the patient’s insurance carrier and preferred pharmacy to determine the cost of each patient’s post-operative regimen (narcotics vs multimodal). All patients, 40 patients from the multimodal pain pathway study and 59 from the opioid pain control study, were included in this analysis and their prescription costs were totaled and analyzed. Results: A box plot was constructed to visualize data and identify outliers to be removed for data analysis. Prescriptions in the opioid group had an average cost of $8.92 (SD=$5.74) while the multimodal group had an average cost of $25.60 (SD=$10.49), p Conclusion: Patients whose post-operative pain was managed by an opioid-free multimodal regimen had statistically significant higher prescription costs than with opioid monotherapy regardless of health insurance type. However, the difference may not be clinically significant as on average it was $17. As more studies demonstrate the effectiveness of opioid-free post-operative pain management, it may be reassuring to surgeons that despite a greater number of medications with the multimodal protocol the average cost difference was only about $17. This information may allow surgeons to prescribe this regimen to all patients regardless of socioeconomic status and continue to decrease post-operative opioid prescriptions.

Postpartum Care Visit Attendance Within 60Days of Delivery Among Women With and Without Opioid Use During Pregnancy: An Analysis of Commercial Insurance Data.

Postpartum care (PPC) is a key component of maternal health, particularly for people who use opioids during pregnancy. Little is known about the prevalence and correlates of PPC visit attendance among those using opioids compared with nonusers in a privately insured population. A retrospective cohort study was conducted using nationwide private insurance claims between 2011 and 2017 (N=1,291,352 women) comparing the following opioid use groups: nonusers, nonchronic prescription users, chronic prescription users, and women with opioid use disorder (OUD). Multivariable logistic and linear regressions evaluated the odds of PPC attendance and the mean time to an initial PPC visit for each user group. Stratified models identified factors associated with PPC attendance by opioid use type. Overall, 45% of the cohort attended a PPC visit and nearly 10% had any opioid use during pregnancy. More women in the three opioid use categories attended PPC than nonusers (50-56% vs. 45%). Opioid use regardless of type was associated with higher odds and earlier PPC visitation than women with no opioid use; nonchronic and chronic users had 17% and 40% greater odds of PPC than nonusers (adjusted odds ratio [aOR]: 1.17; 95% confidence interval [CI]: 1.16-1.19; aOR: 1.40, 95% CI: 1.34-1.46), whereas women with OUD had 7% higher odds (aOR: 1.07; 95% CI: 1.00-1.13). Antenatal care and psychiatric, hypertensive, and pain conditions were most strongly associated with higher odds of attending PPC; older maternal age was negatively associated with PPC. Stratified analysis showed opioid correlates varied similarly across user groups. PPC use was generally low in this study cohort of privately insured women. Women who used opioids and those with chronic conditions had greater odds of attending PPC. Improved efforts are needed to engage people in PPC, as well as service integration and coordination for people who use opioids during pregnancy.

Increased lung weight in fatal intoxications is not unique to opioid drugs.

Fatal intoxications with opioids are known to be associated with an increased lung weight, as well as with brain and pulmonary edema and urinary retention. However, there is evidence to suggest that fatal intoxications with non-opioid substances are also associated with increased lung weight; however, the latter aspect has not been comprehensively analyzed. To determine to what extent opioid and non-opioid substances are associated with increased lung and brain weight, we studied these organs in cases where the cause of death was attributed to intoxication with a single agent. Using data from cases autopsied at the National Board of Forensic Medicine (NBFM) in Sweden from 2009 through 2019 where the cause of death was attributed to a single substance, we created models of combined lung weight and brain weight. The models used age and sex as predictors as well as nested varying effects for the specific intoxicant and category of intoxicant. Suicidal hanging with negative toxicology cases served as controls. The population majority was male among both intoxications (68%) and controls (83%). The most common single substance group was opioids. All tested substances were associated with heavier lungs than controls, with the largest effect in the opioid group. Our findings show that several substances are associated with increased lung weight and that among intoxication deaths there is no difference in expected brain weight between substances. Hence, heavy lungs, without a reasonable explanation, should prompt a broad toxicological screening.

Does Preoperative Opioid Consumption Influence Patient Satisfaction following Total Knee Arthroplasty?

Chronic opioid use prior to total knee arthroplasty (TKA) has been implicated in adverse outcomes. The purpose of this study was to evaluate clinical outcome measures and patient satisfaction in patients with a history of preoperative chronic opioid use undergoing primary TKA. A retrospective cohort study was performed on 296 consecutive patients undergoing primary TKA. Seventy-four (25%) patients were identified with chronic preoperative opioid use (study group; 22 males, 52 females). A 3:1 matched cohort ratio of control versus study group was utilized resulting in a control group consisting of 222 patients (97 males, 125 females) without chronic opioid use prior to surgery. There was no statistically significant difference in age, BMI, or follow-up. Average follow-up was 23.4 months in the control group and 23.6 months in the study group (p = 0.87). Clinical data including patient satisfaction (Likert score), Knee Society (KS) Knee scores, KS Function scores, Forgotten Joint Score (FJS), length of stay (LOS), and complications were evaluated. Patient satisfaction at the most recent visit was 92.8% in the control group versus 83.8% in the chronic opioid group (p = 0.0016). Differences in patient-reported outcomes measures comparing the control and study cohorts included KS Function Score of 83.23 versus 75.31 (p = 0.0034). The FJS of 63.7 versus 58 (p = 0.1883) and the KS Knee Score of 89.5 versus 88.1 (p = 0.4075) were not significant. Postoperative opioid usage for the control versus the study group was 62/222 (27.9%) versus 56/74 (75.7%) at 4 to 8 weeks (p <0.0001), and 4/222 (1.80%) versus 27/74 (36.5%) at 12 months (p <0.0001). Overall complication occurrence was 18.9% in the study group versus 11.3% in the control group (p = 0.11). Patients with history of chronic preoperative opioid use had significantly lower patient satisfaction and KS Function scores and increased postoperative opioid usage at 12 months compared with patients without a history of opioid use prior to TKA.

Comparison of Pregnancy Complication Rates: Does Opioid Agonist Pharmacotherapy Make A Difference?

Background: Over the past decade, the prevalence of opioid use disorder (OUD) in pregnant patients has increased by 131% with an associated increase in pregnancy complications. Opioid agonist pharmacotherapy (OAP) with methadone or buprenorphine is recommended by ACOG for the management of OUD. The objectives of our study are to compare the incidence of pregnancy complications among patients who at the time of their delivery used OAP, OAP plus any additional substance (OAP+), illicit or prescribed opioids, and no opioids. Methods: We conducted a retrospective cohort study at Berkshire Medical Center in Pittsfield, MA, between January 1, 2018, through December 31, 2020, to compare the incidence of nine pregnancy complications in patients who at the time of their delivery were using OAP, OAP+, illicit or prescribed opioids, and no opioids. The data was analyzed with Chi-squared tests and a Bonferroni correction of the p-value was used to adjust for comparison of the rates. The significance level used was p ≤ 0.025. Results: There were 1979 deliveries during the 3-year study period with a total complication incidence of 23%. The complication incidence was 11% for OAP, 15% for OAP+, 42% for illicit or prescribed opioids, and 24% for no opioids. The incidence of complications in the OAP group was significantly lower than the incidence in the no opioids group (11% vs 24%, p = 0.01). There was no significant difference in the comparisons between other groups. Discussion: Our study investigated nine pregnancy complications; no other single study included all of these complications. Patients who used OAP had a significantly lower incidence of pregnancy complications compared to those who used no opioids. A multisite cohort study showed a low incidence of placental abruption in patients using methadone (3%), which was a similar outcome to the MOTHER study (2.3%) and our study (1.4%). The results of this research could assist providers in counseling their patients on the use of OAP in pregnancy.

Survival Outcomes Associated With the Size of Opioid Prescriptions in the Management of Chronic Pain Related to Advanced Nasopharyngeal Carcinoma.

Patients with advanced nasopharyngeal carcinoma (ANC) often experience chronic pain. Opioids are generally recommended to treat tumor-related pain, but increased opioid use may lead to detrimental aftereffects, particularly with respect to tumor progression, resulting in reduced quality of life and increased risk of death. Our objective was to investigate whether the high size of opioid prescriptions is associated with poor overall survival (OS) in patients with ANC. A consecutive cohort of patients with newly diagnosed ANC who underwent high or low opioid prescription size treatment during 2012-2019 was retrospectively identified from our medical institutions. Survival was estimated with the Kaplan-Meier method with a log-rank test. Multivariate binary logistic regression was used to assess the association between opioid use and OS, adjusting for age, sex, body mass index (BMI), Eastern Collaborative Oncology Group performance status (ECOG PS), and ANC histology. The criterion to distinguish between the high opioid prescription size group [HD] and the low opioid prescription size group [LD] was 5mg of oral morphine equivalents (OME) per 24hours. The cohort consisted of 244 consecutive patients (HD: n = 120, median age = 66 years [range, 40-81 years]; LD: n = 124, median age = 65 years [40-82years]. Patients who underwent treatment with a high opioid prescription size had a worse median OS than those who underwent treatment with a low opioid prescription size (5.1 vs 6.6 months), and the high opioid prescription size was associated with a remarkable 48% higher risk of death than the low opioid prescription size (HR 1.48, 95% CI 1.11-1.98; P = .005). The cumulative dose of opioids greater than or equal to 500mg of OME was associated with a higher risk of death, adjusted for age, sex, BMI, ECOG PS, and ANC histology. In patients with newly diagnosed ANC experiencing palliative care, a high opioid prescription size may be associated with shorter OS than a low opioid prescription size.

Prevalence and impact of opioid use in patients undergoing peroral endoscopic myotomy

Chronic narcotic use may cause opioid-induced esophageal dysfunction and associated type III achalasia, hypercontractile esophagus (HE), diffuse esophageal spasm (DES), and esophagogastric junction outflow obstruction (EGJOO). The frequency of opioid use and its impact on peroral endoscopic myotomy (POEM) in these patients is unknown. Consecutive patients between April 2017 and September 2021 who underwent POEM for type III achalasia, EGJOO, DES, or HE with≥6 months follow-up were identified. Baseline evaluation was done with EGD, esophageal high-resolution manometry (HRM), and functional lumen impedance planimetry (FLIP) of the esophagogastric junction (EGJ). Eckardt scores (ESs) were calculated at baseline and follow-up at 6 to 12 months after POEM for opioid users and nonusers. Clinical response was defined as ES≤3, EGJ distensibility index >2.8mm2/mm Hg, maximum EGJ diameter >14mm, and integrated relaxation pressure (IRP)<15mm Hg. Opioid use before baseline HRM was assessed. One hundred twenty-six patients underwent POEM, and 89 had≥6 months of follow-up. Daily opioid use was present in 18 of 89 patients (20%). Baseline demographics, FLIP metrics, IRP, distribution of motility disorders, and POEM characteristics were similar between both groups. At 6 to 12 months after POEM, clinical response and frequency of GERD, esophagitis, and proton pump inhibitor use were similar between opioid users and nonusers. Heartburn was more frequent in the opioid group (82.4% vs 38.6%, P= .002). In this single-center study of 89 patients with type III achalasia, EGJOO, DES, or HE treated with POEM, daily opioid use was present in 20%. Response to POEM and post-POEM GERD were similar between opioid users and nonusers. (Clinical trial registration number: NCT02770859.).

Reduced Narcotic Utilization in Total Joint Arthroplasty Patients in an Urban Tertiary Care Center.

Opioid use after total joint arthroplasty must be balanced against the risks of opioid dependence and diversion. This study sought to define the baseline patient characteristics and discharge opioid use after the initiation of a preoperative and postoperative institutional opioid prescription protocol in a population with a high prevalence of opioid dependence and substance use. Data on 1004 patients undergoing total joint arthroplasties from July 1, 2017, to June 30, 2019, were retrospectively reviewed. Demographics were collected, and data were grouped into high- and low-discharge opioid groups based on 1 standard deviation above or below the mean. Patient characteristics of the high and low groups were compared using one-way analysis of variance and Pearson chi-square test. The prevalence of preoperative opioid dependence was 21.8%. The mean discharge opioid prescription was 264 morphine milligram equivalents (MMEs). The cutoffs of high- and low-use groups were above 424 MMEs and below 104.5 MMEs. The high-discharge opioid group was more likely to be male, younger, to have a history of preoperative opioid use, to undergo general anesthesia, and to be uninsured. The lower-discharge opioid group was more likely to be older, female, to have Medicare, and to stay approximately 1day longer in the hospital. Body mass index, intraoperative opioid requirement, American Society of Anesthesiologists Classification score, race, total knee vs total hip arthroplasty, or surgical approach for total hip arthroplasty did not affect discharge opioid prescriptions. Reduction of opioid prescriptions at discharge in total joint arthroplasty patients may be possible with the use of preoperative and postoperative protocols, optimizing patient risk factors for opioid use and utilizing a patient-specific opioid taper regimen.

Opioid versus non-opioid analgesia for spine surgery: a systematic review and meta-analysis of randomized controlled trials.

Opioids are the primary analgesics used in patients undergoing spine surgery. Postoperative pain is common despite their liberal use and so are opioid-associated side effects. Non-opioid analgesics are gaining popularity as alternative to opioids in spine surgery. This systematic review evaluated current evidence regarding opioid and non-opioid intraoperative analgesia and their influence on immediate postoperative pain and adverse events in spine surgery. A total of 10,459 records were obtained by searching Medline, EMBASE and Web of Science databases and six randomized controlled trials were included. Differences in postoperative pain scores between opioid and non-opioid groups were not significant at 1h: 4 studies, mean difference (MD) = 0.65 units, 95% confidence intervals (CI) [-0.12 to 1.41], p = 0.10, but favored non-opioid at 24h after surgery: 3 studies, MD = 0.75 units, 95%CI [0.03 to 1.46], p = 0.04. The time for first postoperative analgesic requirement was shorter (MD = -45.06min, 95%CI [-72.50 to -17.62], p = 0.001), and morphine consumption during first 24h after surgery was higher in opioid compared to non-opioid group (MD = 4.54mg, 95%CI [3.26 to 5.82], p < 0.00001). Adverse effects of postoperative nausea and vomiting (Relative risk (RR) = 2.15, 95%CI [1.37 to 3.38], p = 0.0009) and shivering (RR = 2.52, 95%CI [1.08 to 5.89], p = 0.03) were higher and bradycardia was lower (RR = 0.35, 95%CI [0.17 to 0.71], p = 0.004) with opioid analgesia. The certainty of evidence on GRADE assessment is low for studied outcomes. Available evidence supports intraoperative non-opioid analgesia for overall postoperative pain outcomes in spine surgery. More research is needed to find the best drug combination and dosing regimen. Prospero Registration: CRD42020209042.

Morbidity through 3 Years of Age in Children of Women Using Methamphetamine during Pregnancy: A National Registry Study

Background: There is a lack of studies on methamphetamine (MA) exposure and morbidity in children beyond the perinatal period. Objectives: We compared morbidity in children (0–3 years) with prenatal MA exposure to opioid-exposed and to non-exposed children. Methods: We used data from a Czech nationwide, registry-based cohort study (2000–2014). Children, who reached 3 years of age, of mothers hospitalized with (i) MA use disorder during pregnancy (MA; n = 194), (ii) opioid use disorder during pregnancy (opioids; n = 166), and (iii) general population (GP; n = 1,294,349) with no recorded history of substance use disorder (SUD). Information on inpatient contacts, length of stay, and diagnoses (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10]) were assessed. Crude and adjusted odds ratios (aOR), 95% confidence interval (CI) for the risk of hospitalization, and for getting diagnosis from the ICD-10 diagnosis chapters were calculated using binary logistic regression. A stratified analysis on hospitalizations with SUD of mothers was performed. Results: No significant differences were found in the measures of hospitalization between the MA and opioid groups. Children prenatally exposed to MA and opioids had higher numbers of hospitalizations and diagnoses and longer stays in hospital than children in the GP. Increased risks of certain infectious and parasitic diseases were found in both MA (aOR = 1.6; CI: 1.1–2.3) and opioid (aOR = 1.9; 1.3–2.8) groups as compared to the GP group. The most pronounced difference in stratified analysis on maternal hospitalizations related to SUD after birth was observed for injury, poisoning, and certain other consequences of external causes in the strata of the MA group who had hospitalized mothers (aOR 6.3, 1.6–24.6) compared to the strata without maternal hospitalizations (aOR 1.4, 0.9–2.3). Conclusion: This study suggests that children born to mothers using MA during pregnancy have similar morbidity during the first 3 years of life but higher than the GP. The excess of risk was primarily due to infections and injuries in the MA group.

Effect of Opioids on Survival in Patients with Cancer.

Opioids are commonly used for pain management in patients with cancer. They have a range of unwanted effects, including some that potentially influence cancer growth. This article reviews the data assessing the effects of opioids on survival in patients with cancer. Many studies assessing this show an association between opioids and decreased survival. This effect is present even at very low doses of opioids. These studies do not assess causality, so it is not known if it is a direct effect of opioids on survival. As the control groups are not matched to the opioid group it might be that opioids are being used to control pain and patients receiving opioids have more aggressive cancers and it is the underlying cancer which is causing the decreased survival. Furthermore, although some studies allude to different opioids having different effects on survival, often all opioids are pooled in analysis. Future work needs to try to ascertain causality and differentiate between different opioids, pain, and cancer-mediated effects on survival in specific cancer types. Until then, opioids should continue to be used in patients with cancer as part of measures to optimise comfort and quality of life.

Opioid Use Among Medicare Beneficiaries With Knee Osteoarthritis: Prevalence and Correlates of Chronic Use.

To determine the prevalence of chronic and occasional opioid use and identify risk factors of opioid use among persons with knee osteoarthritis (OA). We used the Medicare Current Beneficiary Survey to select a knee OA cohort. We obtained data on demographics characteristics, marital status, comorbidities, insurance, and prescription medication coverage from survey data and linked Medicare claims. We included all prescribed medication records classified as opioid under the First Databank therapeutic antiarthritics or analgesics categories. We stratified individuals with knee OA into 3 opioid use groups: 1) nonusers (0 prescriptions/year), 2) occasional users (1-5 prescriptions/year), and 3) chronic users (6+ prescriptions/year). We built multivariable logistic regression models using a generalized estimating equation to determine correlates of chronic opioid use. Among 3,549 Medicare beneficiaries with knee OA and a mean ± SD age of 78 ± 7 years, 68% were female, 9% were chronic users, and 21% used opioids occasionally. Multivariable analysis showed that non-Hispanic ethnicity (odds ratio [OR] 4.8, 95% confidence interval [95% CI] 2.2-10.2), divorced status (vs. married; OR 2.3, 95% CI 1.5-3.5), Medicaid eligibility (OR 1.9, 95% CI 1.3-2.7), depression (OR 1.9, 95% CI 1.5-2.5), chronic obstructive pulmonary disease (OR 1.9, 95% CI 1.4-2.5), and inability to walk without assistive devices (vs. no difficulty walking; OR 2.4, 95% CI 1.5-3.7) were independently associated with chronic opioid use. A total of 9% of persons with knee OA use opioids chronically. Efforts to find nonopioid regimens for treating knee OA pain should be tailored to patients at high risk for chronic use.

ODP346 Prevalence and Predictors of Endocrinopathies Amongst Patients on Chronic Opioid Use for Non-Cancer Pain

Abstract Introduction Opioids are increasingly used for non-cancer pain control. Studies in cancer patients have shown that chronic opioid use could lead to secondary hypocortisolism and hypogonadism of varying degree. We seek to determine this association in an Asian cohort of patients with non-cancer pain and also examine the effect of opioids on other pituitary hormones comparing them to patients who are on non-opioid analgesia. Methods This is a cross-sectional study of patients recruited from pain clinic. Inclusion criteria were patients aged between 18-75 with non-cancer pain on opioids (morphine/oxycodone/fentanyl/tramadol) for more than 3 months. Patients with active cancer or intracranial pathology, who were already on hormone replacement and on long term glucocorticoids or had intra-muscular or intra-articular steroids in the preceding 3 months were excluded. Controls were age and sex matched. All recruited patients had a renal profile, albumin, cortisol, ACTH, fT4, TSH, FSH, LH, IGF-1, prolactin, testosterone (male) and oestrogen (female) drawn at 8am in a fasting state. Demographic data, menstrual history, pain type and pain score, opioid type and duration of use, were collected. Results Forty eight patients (28 opioid group and 20 controls), 52% men, 31%postmenopausal women, mean age: 55 ±13 years and mean BMI: 27±5 kg/m 2, were recruited. Opioid group had significantly higher pain score (6±2 vs 5±2, p=0. 09) and duration of pain (6.16 ± 5.87 vs 3.56 ± 3.35 years, p=0. 07) compared to controls. 75% of patents were on short acting opioids with a morphine equivalent daily dose (MEDD) of 31 ± 16 mg. There was a higher prevalence of hypocortisolism in the opioid group (50%) compared to control (30%). Of note, 14% of the opioid group had AM cortisol of &amp;lt;100nmol/L, which required replacement. The MEDD of more than 25mg was the only independent predictor of hypocortisolism with OR: 20.4 (95% CI: 1.1-39. 0, p=0. 04). 11% of patients (3 men, 2 post-menopausal women) had secondary hypogonadism. Pain score was significantly higher (7.8±1.5 vs 5.6±2.1, p=0. 03) and the duration of opioid was significantly longer (7.6±3 vs 3.2±4, p=0. 02) in the hypogonadism group. However, there was no independent predictive factor for hypogonadism. The was no sodium abnormality or other pituitary axes involvement in both groups. Conclusion With the increasing use of opioids for non-cancer pain, the prevalence of opioid endocrinopathies are expected to rise. Development of hypocortisolism is independently associated with a higher MEDD. Gonadal axis involvement was more common amongst men and postmenopausal women. Higher use of short acting opioids in our cohort may explain the lower prevalence of hypogonadism compared to previous studies. Further long term studies are needed to examine the need for and effects of hormone replacement in this group of patients. Presentation: No date and time listed

Postoperative Nausea and Vomiting in Opioid-Free Anesthesia Versus Opioid Based Anesthesia in Laparoscopic Cholecystectomy.

Background: Postoperative nausea and vomiting (PONV) is a usual complication in patients undergoing laparoscopic cholecystectomy. Minimized opioid use due to surgery has been shown to have a better effect on patient recovery after surgery. In this study we evaluate the effect of opioid free anesthesia for postoperative nausea and vomiting in laparoscopic cholecystectomy. Materials and methods: 80 patients aged 20-65 years old were included in this randomized, clinical and prospective trial. The patients belonged to the ASA classifications 1 and 2 and were scheduled for laparoscopic cholecystectomy. Patients were classified into two groups: group 1 (fentanyl group- FG), which included 40 patients who received opioid anesthesia, and group 2 (opioid free anesthesia group-OFAG) which included 40 patients who received opioid free anesthesia. In patients from group 1 (fentanyl group -FG) introduction to general anesthesia consisted of giving midazolam at 0.04 mg/kg, fentanyl at 0.002 mg/kg, 2 mg/kg of propofol and 0.6 mg/kg of rocuronium bromide. These patients received fractionated bolus doses of fentanyl during surgery. Prior to general anesthesia these patients did not receive dexamethasone. The patients from group 2 (opioid free anesthesia group - OFAG) received dexamethasone at 0.1 mg/kg and 1 g of paracetamol before introduction to anesthesia as a pre-emptive analgesia. Introduction to anesthesia consisted of giving midazolam at 0.04 mg/kg, lidocaine at 1 mg/kg, propofol at 2 mg/kg, ketamine at 0.5 mg/kg, and 0.6 mg/kg of rocuronium bromide. Immediately after intubation, continuous intravenous infusion with lidocaine at 2 mg/kg/h and magnesium sulfate at 1.5 g/h was given. In this group, fentanyl was not given either during the introduction of anesthesia or during the intraoperative period. Immediately after extraction of the gallbladder patients from group 2 (OFAG) received 2.5 g of metamizole intravenously. PONV were recorded in the postoperative period of 24 hours after surgery. Results: There was no significant difference with respect to age, weight, sex, duration of surgery, and anesthesia time. PONV at different time intervals were statistically not significant at all postoperative time points - 1 hr, 4 hr, 8 hr, 12 hr and 24 hr after surgery in fentanyl group compared to opioid free anesthesia group. Even not statistically significant, PONV have occurred more often in patients who received opioid anesthesia. Conclusion: Postoperative nausea and vomiting occurs more often in patients who received opioids during laparoscopic cholecystectomy compared to patients who received opioid free anesthesia, but without statistical significance.

Characterization of Opioid Use in the Intensive Care Unit and Its Impact Across Care Transitions: A Prospective Study

Purpose: The objective of this study is to characterize opioid intensity in the intensive care unit (ICU) and its association with opioid utilization across care transitions. Methods: This is a prospective cohort study. Medically ill ICU patients with complete medication histories who survived to discharge were included. Opioid intensity was characterized based on IV morphine milligram equivalents (IV MME). Primary outcomes were opioid prescribing upon ICU and hospital discharge. Results: Opioids were prescribed to 34.1% and 31.1% of patients upon ICU and hospital discharge. Within the ≥50 mean IV MME/ICU day cohort, 64.7% of patients received opioids after ICU discharge compared to 45.8% and 13.6% in the 1-49 mean IV MME/ICU day and no opioid groups (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 70.6% of patients were prescribed opioids after hospitalization compared to 37.3% and 13.6% of patients who received less or no opioids. (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 29.4% of patients were opioid naïve and discharged with an opioid, which is over double compared to patients with lower opioid requirements (P < .05). Conclusion: Patients with higher mean daily ICU opioid requirements had increased opioid prescribing across care transitions despite preadmission opioid use.

Economic burden of opioid misuse focused on direct medical costs.

Background: Since their development, synthetic opioids have been used to control pain. With increased opioid use, problematic opioid prescription has also increased, resulting in a growing economic burden. However, there is a paucity of research studies on the economic burden of prescription opioid misuse in Asia, especially South Korea. Objectives: To estimate the incremental economic burden of prescription opioid misuse for the South Korean population. Methods: The National Health Insurance Service-National Sample Cohort database, covering 2% of the South Korean population between 2010 and 2015, was analyzed. Outpatients aged 18 or older who took one or more prescription opioids were selected. Based on their opioid prescription patterns, patients were classified into opioid misuse and non-misuse groups. The direct medical costs per person per year (PPPY) and the incremental economic burden of the opioid misuse group were explored using an exponential conditional model with a suitable distribution and log link function. All analyses were performed using SAS® Enterprise Guide version 9.4, and p < 0.05 was considered statistically significant. Results: The number of patients who had ≥1 opioid prescription was 345,020 including 84,648 (24.53%) in the opioid misuse group and 260,372 (75.47%) in the non-misuse group. The adjusted mean direct medical costs PPPY were estimated to be USD 401 for the opioid misuse group, which is 1.49 times significantly higher than that for the non-misuse group (p < 0.0001). The incremental economic burden of the opioid misuse group in the South Korean population was estimated to be approximately USD 0.52 billion for the period 2010-2015. Conclusion: Prescription opioid misuse was significantly associated with the increased economic burden. Along with proper policies for using opioids, it is necessary to monitor opioid prescription patterns to prevent opioid misuse and reduce the related economic burden.

Sex Differences in Oxycodone/Naloxone vs. Tapentadol in Chronic Non-Cancer Pain: An Observational Real-World Study.

Despite the large body of research on sex differences in pain, there is a lack of translation to real-world pain management. Our aim was to analyse the sex differences in the analgesic response to oxycodone/naloxone (OXN) and tapentadol (TAP), in comparison with other opioids (OPO) commonly prescribed for chronic non-cancer pain (CNCP). An observational and cross-sectional study was conducted on ambulatory CNCP patients (n = 571). Sociodemographic, clinical (pain intensity, relief, and quality of life), safety (adverse events (AEs), adverse drug reactions), hospital frequentations and pharmacological (morphine equivalent daily dose (MEDD)) variables were collected. Multiple linear regressions were carried out to assess the association between sex and outcomes. Sex differences were observed, with lower female tolerability and higher hospital frequentation, especially in the OXN group (OR AEs report = 2.8 [1.8–4.4], p < 0.001). Here, females showed higher hospital use (23% hospital admission, 30% prescription change, p < 0.05), requiring a higher MEDD (127 ± 103 mg/day, p < 0.05), compared to OXN men. Regardless of the opioid group, CNCP women were significantly older than men (three years), with significantly higher benzodiazepine use (OR = 1.6 [1.1–2.3]), more constipation (OR = 1.34 [0.93–1.90]) and headache (OR = 1.45 [0.99–2.13]) AEs, than men who were more likely to refer sexual dysfunction (OR = 2.77 [1.53–5.01]), and loss of libido (OR = 1.93 [1.22–3.04]). Sex-differences were found related to poorer female drug tolerability and higher hospital resources, even worst in OXN female users. Other differences related to older female ages and benzodiazepine prescription, need to be further analysed from a gender perspective.