Opioid Injections Research Articles

6302057 Comparison of sequential and mixture injections of opioids and hyperbaric bupivacaine for subarachnoid block for lower segment Caeserean section; RCT

6302057 Comparison of sequential and mixture injections of opioids and hyperbaric bupivacaine for subarachnoid block for lower segment Caeserean section; RCT

Comparison of sequential and mixture injections of opioids and hyperbaric bupivacaine for subarachnoid block for lower segment caesarean section: a randomised controlled study.

Opioids are commonly added to local anaesthetic for subarachnoid block for caesarean section due to their synergistic effects. The physiochemical characteristics of opioids suggest premixing with hyperbaric bupivacaine may limit their distribution within the CSF. We studied the effect of a separate injection with a combination of bupivacaine, morphine and fentanyl on block characteristics, haemodynamic changes, postoperative pain and patient satisfaction. Following ethical approval and informed consent, a prospective double-blinded randomised controlled trial was performed in a university hospital. A total of 126 patients undergoing caesarean section were randomised to two groups. In group M, the premixed group, patients received 12mg of hyperbaric bupivacaine, 20 mcg of fentanyl and 100 mcg of morphine injected as a single mixture. In group S, the separate injection group, patients received the same drugs in separate injections. Measurements included haemodynamics, block distribution, intra- and postoperative pain, as well as patient satisfaction. Patients in both groups had similar block height, time to maximum sensory block, time to block regression and motor block. However, haemodynamics were different between the groups. The proportion of systolic hypotension episodes was greater in group S [159/1320 (12.05%)] than group M [113/1452 (7.78%)], with P = 0.0002. Moreover, a greater amount of ephedrine was administered in group S than group M, with values 12.09 (8.1) and 9.09 (8.5) mg respectively (P = 0.001). Additionally, postoperative pain, as measured by the Visual Analogue Scale (VAS), was greater in group M, with a VAS of 4.6 (1.7), vs. group S, which recorded a VAS of 3.8 (2.0) (P = 0.017). Sequential injection of intrathecal opioids and hyperbaric bupivacaine resulted in greater early haemodynamic instability and slightly better postoperative analgesia without any difference in block height or patient satisfaction. NCT04403724.

Associations of hepatitis C virus (HCV) antibody positivity with opioid, stimulant, and polysubstance injection among people who inject drugs (PWID) in rural U.S. communities.

People who inject drugs (PWID) in the rural U.S. often inject stimulants, alone or with opioids. The impact of these substance use patterns may influence HCV risk behaviors. This analysis examines the associations of HCV antibody positivity with injecting only opioids, only stimulants (methamphetamine/cocaine), and opioids and stimulants together among rural PWID. The Rural Opioid Initiative (ROI) consists of eight research sites that enrolled people who use drugs in rural communities in ten U.S. states from 2018 to 2020. This cross-sectional analysis included adult participants who resided in a study area and injected any drug in the past 30 days. The primary outcome was HCV antibody positivity. The exposure of interest was injection drug use classified as only opioids, only stimulants, separate injections of opioids and stimulants, and same-syringe injection of both in the past 30 days. We used multivariable log-binomial regression with generalized linear mixed models to generate prevalence ratios (P.R.) adjusted for demographics, injection history, health insurance, and substance use treatment. Among 3,084 participants enrolled in the ROI, 1,982 met inclusion criteria. Most participants injected opioids and stimulants in the same syringe (34%) or separately (21%), followed by injecting only stimulants (26%), and injecting only opioids (19%). Half (51%) were HCV antibody positive. Compared to people who injected only stimulants, HCV antibody positivity was more prevalent among people who injected opioids alone (aPR=1.62, 95% CI:(1.29-2.03)), injected both opioids and stimulants separately (aPR=1.61, 95% CI:(1.32-1.95)), and in the same syringe (aPR=1.54, 95% CI:(1.28-1.85)). HCV antibody positivity, indicating prior exposure, was highest among those who had recently injected opioids, alone or with stimulants. Additional nucleic acid testing is necessary to confirm active infection. More research is needed to determine the underlying causes of HCV antibody positivity by injection use.

Incidence of postoperative administration of opioids in dogs undergoing a tibial plateau leveling osteotomy after intra-operative liposomal bupivacaine administration with or without morphine epidural

ObjectiveTo determine the influence of two intraoperative pain management protocols on the need for additional opioids in patients receiving an epidural and periarticular liposomal bupivacaine (PLB) vs. PLB alone in the 12–24 h period after undergoing a TPLO.Study designRetrospective study.AnimalsOne hundred seventy-four dogs with cranial cruciate ligament tears presenting for TPLO.MethodsMedical records of dogs presenting for a unilateral or bilateral cranial cruciate ligament tear who had a TPLO performed were reviewed for signalment, weight, body condition score, and peri-operative pain management protocol. Dogs were divided into two groups: those who received an epidural and PLB, and those who received only PLB. Post-operative opioid administration was recorded for each group.ResultsPatients who received an epidural and PLB received fewer postoperative opioids. There were 36% fewer opioid injections administered to dogs who received epidurals compared to dogs who did not receive epidurals (IRR) (95% CI) = 0.64 (0.45–0.92), P = 0.02). BCS was not a significant predictor of the post-operative opioid requirement (IRR (95% CI) = 1.3 (0.75–2.4), P = 0.38). When adjusting for BCS as a possible confounder, there were 39% fewer opioid injections in dogs who received epidurals than dogs without (IRR (95% CI) = 0.61 (0.42–0.88), P = 0.009).ConclusionsThe incidence of postoperative opioid administration was significantly diminished in patients receiving both an epidural and PLB.Clinical significanceAdministration of an epidural in addition to infiltration of PLB significantly decreased the incidence of postoperative opioid administration in dogs undergoing a TPLO.

A Proposed Medical Coordination Model for Pharmaceutical Palliative Care in Community Pharmacies-A Mixed Methods Approach

In recent years, the number of patients undergoing outpatient cancer treatment has been increasing. Community pharmacies, have been increasingly involved in cancer treatment and home palliative care. However, there are several hurdles to overcome, such as logistical support during non-standard working hours (at night or during holidays), emergency visits, and for aseptic dispensing. In this paper, we describe a model of medical coordination for emergency home visits during non-standard working hours in which opioid injections need to be dispensed. The study was conducted using a mixed methods approach. We investigated the need for a medical coordination model in home palliative care as well as the issues that need to be improved upon. We constructed, implemented, and assessed the effectiveness of our medical coordination model in a research setting. The medical coordination model reduced the sense of difficulty for general practitioners and community pharmacists in dealing with patients during non-standard working hours and strengthened the degree of cooperation within the coordination team. The activities of the collaborative team saved patients from emergency hospitalization and enabled them to receive end-of-life care at home in accordance with their wishes. The basic framework of the medical coordination model can be adapted according to regional needs and will help promote home palliative care in the future.

5610845 A PHASE 1 STUDY OF CSL888 (HEMOPEXIN) IN ADULT PATIENTS WITH SICKLE CELL DISEASE

Background: Episodes of vaso-occlusive crisis (VOC) are the primary reason for hospitalization among patients with sickle cell disease (SCD). The release of heme from the breakdown of damaged red blood cells is thought to play an important role in contributing to vaso-occlusion in SCD. Free heme promotes activation of endothelium, expression of endothelial cell adhesion molecules and activation of blood cells (neutrophils, monocytes, and platelets) which “stick” to the blood vessel walls. The net result is blockage of blood circulation, resulting in the characteristic pain of VOC. Hemopexin is a 60 kilodalton (kDa) plasma glycoprotein that is mainly expressed in the liver and belongs to the family of acute-phase proteins whose synthesis is induced after an inflammatory event. Hemopexin binds extracellular heme with the highest known affinity (KD < 1pM) of all plasma proteins. In patients with SCD, hemopexin levels are significantly reduced (approximately 85%) compared to healthy controls due to increased consumption. CSL889 is human plasma-derived hemopexin. It is hypothesized that pharmacological administration of CSL889 may decrease heme toxicity, restore normal blood circulation and therefore have beneficial effects in the management of acute VOC in SCD patients. Translation to the clinic is supported by studies performed in vitro demonstrating protection of heme-mediated endothelial cell damage and in vivo using the Townes mouse model of SCD, in which hemopexin was shown ameliorate vaso-occlusion following hemoglobin or hypoxia/reperfusion challenges (Gentinetta et al. 2022). Preclinical repeat dose toxicity studies in animals have evidenced favorable tolerability up to the highest dose level tested. Methods: We describe the design of a Phase 1, first in human, multicenter, open-label study to evaluate the safety, tolerability, and pharmacokinetics (PK) of CSL889 in adult patients with SCD following single intravenous (IV) doses of CSL889 [NCT04285827]. The study will comprise 2 parts. Part A will include patients with SCD in their usual health (not in VOC) who will receive a single dose of CSL889 at one of up to 6 different dose levels. In Part B, patients with SCD who present in VOC requiring intravenous (IV) opioid injections and admission to hospital for further management, will receive a single dose of CSL889 at a level that has been shown to be safe and tolerable in Part A within 36 hours of in-patient admission. All subjects will be followed up for 32 days post-infusion of CSL889. The range of doses to be studied is based on a translational PK model based on data derived from the study of CSL889 in the Townes mouse model of SCD. Results: The primary objective is to determine the safety and tolerability of single doses of CSL889 given to patients with SCD both without (Part A) and with (Part B) active VOC. The secondary objectives are to determine the PK and immunogenicity of CSL889. Exploratory objectives are to determine changes in biomarkers of target engagement (including changes in cell-free heme) and pharmacodynamic biomarkers related to the mechanism of action. Change in pain scores (as measured by Numeric Rating Scale [NRS]) will be additionally evaluated in Part B. Conclusions: Enrollment is in progress. No serious adverse events considered related to the administration of CSL889 have been reported as of 01-Sep-2022. Disclosures: F Wilson, J Jochems, L Lindqvist, K Jung,T Gentinetta, S Costin and GJ Kato are employed by CSL Reference 1. Gentinetta et al, J Clin Med 2022, 11:630

Changes in pontine and preBötzinger/Bötzinger complex neuronal activity during remifentanil-induced respiratory depression in decerebrate dogs.

Introduction: In vivo studies using selective, localized opioid antagonist injections or localized opioid receptor deletion have identified that systemic opioids dose-dependently depress respiratory output through effects in multiple respiratory-related brainstem areas. Methods: With approval of the subcommittee on animal studies of the Zablocki VA Medical Center, experiments were performed in 53 decerebrate, vagotomized, mechanically ventilated dogs of either sex during isocapnic hyperoxia. We performed single neuron recordings in the Pontine Respiratory Group (PRG, n = 432) and preBötzinger/Bötzinger complex region (preBötC/BötC, n = 213) before and during intravenous remifentanil infusion (0.1-1mcg/kg/min) and then until complete recovery of phrenic nerve activity. A generalized linear mixed model was used to determine changes in Fn with remifentanil and the statistical association between remifentanil-induced changes in Fn and changes in inspiratory and expiratory duration and peak phrenic activity. Analysis was controlled via random effects for animal, run, and neuron type. Results: Remifentanil decreased Fn in most neuron subtypes in the preBötC/BötC as well as in inspiratory (I), inspiratory-expiratory, expiratory (E) decrementing and non-respiratory modulated neurons in the PRG. The decrease in PRG inspiratory and non-respiratory modulated neuronal activity was associated with an increase in inspiratory duration. In the preBötC, the decrease in I-decrementing neuron activity was associated with an increase in expiratory and of E-decrementing activity with an increase in inspiratory duration. In contrast, decreased activity of I-augmenting neurons was associated with a decrease in inspiratory duration. Discussion: While statistical associations do not necessarily imply a causal relationship, our data suggest mechanisms for the opioid-induced increase in expiratory duration in the PRG and preBötC/BötC and how inspiratory failure at high opioid doses may result from a decrease in activity and decrease in slope of the pre-inspiratory ramp-like activity in preBötC/BötC pre-inspiratory neurons combined with a depression of preBötC/BötC I-augmenting neurons. Additional studies must clarify whether the observed changes in neuronal activity are due to direct neuronal inhibition or decreased excitatory inputs.

Behavioral Reaction and c-fos Expression after Opioids Injection into the Pedunculopontine Tegmental Nucleus and Electrical Stimulation of the Ventral Tegmental Area

The pedunculopontine tegmental nucleus (PPN) regulates the activity of dopaminergic cells in the ventral tegmental area (VTA). In this study, the role of opioid receptors (OR) in the PPN on motivated behaviors was investigated by using a model of feeding induced by electrical VTA-stimulation (Es-VTA) in rats (male Wistar; n = 91). We found that the OR excitation by morphine and their blocking by naloxone within the PPN caused a change in the analyzed motivational behavior and neuronal activation. The opioid injections into the PPN resulted in a marked, dose-dependent increase/decrease in latency to feeding response (FR), which corresponded with increased neuronal activity (c-Fos protein), in most of the analyzed brain structures. Morphine dosed at 1.25/1.5 µg into the PPN significantly reduced behavior induced by Es-VTA, whereas morphine dosed at 0.25/0.5 µg into the PPN did not affect this behavior. The opposite effect was observed after the naloxone injection into the PPN, where its lowest doses of 2.5/5.0 μg shortened the FR latency. However, its highest dose of 25.0 μg into the PPN nucleus did not cause FR latency changes. In conclusion, the level of OR arousal in the PPN can modulate the activity of the reward system.

Sexual HIV transmission risk behaviors associated with stimulant drug injection among people who non-medically use gabapentin and opioids

ABSTRACT Background Recent research shows that co-use of stimulants and opioids appears to be increasing and injection of opioids and stimulants carries a risk for HIV transmission. This study examined stimulant injection and sexual HIV risk behaviors among individuals who reported nonmedical use of gabapentin and opioids (n = 62). Methods Comparisons of people who injected stimulants to those who did not were conducted using chi-square and t-tests. Results Compared to those who did not, people who injected stimulants, were less likely to be African American/Black (p < 0.05) and more likely to report sex with another person who injects drugs (p < 0.01), recent injections of prescription and/or illicit opioids (p < .000), and hepatitis C infection (p < 0.01). Condomless intercourse during group sex was more prevalent among stimulant injectors, significant at the trend level (p < 0.1). Conclusions Given the documented association between the use of opioids and nonmedical use of gabapentin and the growing trend of opioid-stimulant co-use, future research must examine whether nonmedical use of gabapentin is an indicator of substance use disorder severity and/or a risk factor for injection drug use. Education and intervention opportunities that address group sex and other sexual risk behaviors are warranted.

An opioid-gated thalamoaccumbal circuit for the suppression of reward seeking in mice

Suppression of dangerous or inappropriate reward-motivated behaviors is critical for survival, whereas therapeutic or recreational opioid use can unleash detrimental behavioral actions and addiction. Nevertheless, the neuronal systems that suppress maladaptive motivated behaviors remain unclear, and whether opioids disengage those systems is unknown. In a mouse model using two-photon calcium imaging in vivo, we identify paraventricular thalamostriatal neuronal ensembles that are inhibited upon sucrose self-administration and seeking, yet these neurons are tonically active when behavior is suppressed by a fear-provoking predator odor, a pharmacological stressor, or inhibitory learning. Electrophysiological, optogenetic, and chemogenetic experiments reveal that thalamostriatal neurons innervate accumbal parvalbumin interneurons through synapses enriched with calcium permeable AMPA receptors, and activity within this circuit is necessary and sufficient for the suppression of sucrose seeking regardless of the behavioral suppressor administered. Furthermore, systemic or intra-accumbal opioid injections rapidly dysregulate thalamostriatal ensemble dynamics, weaken thalamostriatal synaptic innervation of downstream neurons, and unleash reward-seeking behaviors in a manner that is reversed by genetic deletion of thalamic µ-opioid receptors. Overall, our findings reveal a thalamostriatal to parvalbumin interneuron circuit that is both required for the suppression of reward seeking and rapidly disengaged by opioids.

Changes in supervised consumption site use and emergency interventions in Montréal, Canada in the first twelve months of the COVID-19 pandemic: An interrupted time series study.

BackgroundThe COVID-19 pandemic has impacted supervised consumption site (SCS) operations in Montréal, Canada, potentially including changes in SCS visits, on-site emergency interventions, injection of specific drugs, and distribution of harm reduction materials.MethodWe used administrative data from all four Montréal SCS from 1 March 2018 - 28 February 2021 to conduct an interrupted time series study with 13 March 2020 as the intervention point. We employed segmented regression using generalised least squares fit by maximum likelihood. We analysed monthly SCS visits and materials distributed as counts, and emergency interventions and drugs injected as proportions of visits.ResultsSCS visits (level change = -1,286; 95% CI [-1,642, -931]) and the proportion of visits requiring emergency intervention (level = -0.27% [-0.47%, -0.06%]) decreased immediately in March 2020, followed by an increasing trend in emergency interventions (slope change = 0.12% [0.10%, 0.14%]) over the ensuing 12 months. Over the same period, the proportion of injections involving opioids increased (slope = 0.05% [0.03%, 0.07%]), driven by increasing pharmaceutical opioid and novel synthetic opioid injections. Novel synthetic opioids were the drugs most often injected prior to overdose. The proportion of injections involving unregulated amphetamines increased immediately (level = 7.83% [2.93%, 12.73%]), then decreased over the next 12 months (slope = -1.86% [-2.51%, -1.21%]). There was an immediate increase in needle/syringe distribution (level = 16,552.81 [2,373, 30,732]), followed by a decreasing trend (slope = -2,398 [-4,218, -578]). There were no changes in pre-existing increasing trends in naloxone or fentanyl test strip distribution.ConclusionReduced SCS use and increasing emergency interventions at SCS are cause for serious concern. Findings suggest increased availability of novel synthetic opioids in Montréal, heightening overdose risk.

Feeding behavior elicited by mu opioid and GABA receptor activation in the lateral septum

The lateral septum (LS), a brain region typically associated with behaviors involving reward, anxiety-like behavior, learning, and memory, has recently received increased interest due to its potential role in eating behavior. Our current results showed that morphine (5 μg) microinjected into the LS produced a stable feeding response. Specifically, across five days of repeated injections, there was no increase or sensitization effect, nor a decrease in feeding or tolerance. Additionally, we found that pretreatment with the broad-spectrum opioid receptor antagonist naloxone blocked morphine-elicited feeding, further supporting a role for LS opioid receptors in the activation of feeding behaviors. We had previously found that the GABAA receptor agonist muscimol produces a similar increase in feeding when injected into the LS. Given the involvement of the LS in multiple behaviors, we next evaluated whether other behaviors might be co-occurring with feeding in response to opioid or GABAA receptor agonist injection into the LS. We assessed eating, drinking, grooming, sleeping, activity levels and resting behavior for 3 h after injection of aCSF, DAMGO, morphine, or muscimol. We found that morphine and muscimol both decreased the latency to eat, and all drugs tested increased food intake. The feeding occurred within 30 min of muscimol injection but was delayed after opioid injections. The absence of increases in other goal-oriented behavior like drinking or grooming or behavioral hyperactivity supports a primary effect of muscimol and the opioids on LS mechanisms of feeding control. Significance statementThe LS is interesting because of its role in a wide range of behaviors including defensive behaviors, social behaviors, learning, memory, and motivation. Although the LS was discovered to have a role in feeding stimulation over 30 years ago, only recently has major progress begun to reveal the underlying mechanisms. The present paper contributes by suggesting that LS GABAA and μ-opioid receptors elicit eating by inhibiting LS neurons that themselves inhibit eating. Importantly, this work informs lateral septal research which may shed light on disordered eating included binge eating and anorexia.

Gaps in hepatitis C virus prevention and care for HIV-hepatitis C virus co-infected people who inject drugs in Canada.

People who inject drugs (PWID) living with HIV are a priority population for eliminating hepatitis C virus (HCV) as a public health threat. Maximizing access to HCV prevention and treatment strategies are key steps towards elimination. We aimed to evaluate engagement in harm reduction programs and HCV treatment, and to describe injection practices among HIV-HCV co-infected PWID in Canada from 2003 to 2019. We included Canadian Coinfection Cohort study participants who reported injecting drugs between 2003 and 2019 in Quebec, Ontario, Saskatchewan, and British Columbia, Canada. We investigated temporal trends in HCV treatment uptake, efficacy, and effectiveness; injection practices; and engagement in harm reduction programs in three time periods based on HCV treatment availability: 1) interferon/ribavirin (2003-2010); 2) first-generation direct acting antivirals (DAAs) (2011-2013); 3) second-generation DAAs (2014-2019). Harm reduction services assessed included needle and syringe programs (NSP), opioid agonist therapy (OAT), and supervised injection sites (SIS). Median age of participants (N=1,077) at cohort entry was 44 years; 69% were males. Province-specific HCV treatment rates increased among HCV RNA-positive PWID, reaching 16 to 31 per 100 person-years in 2014-2019. Treatment efficacy improved from a 50 to 70% range in 2003-2010 to >90% across provinces in 2014-2019. Drug injecting patterns among active PWID varied by province, with an overall decrease in cocaine injection frequency and increasing opioid injections. In the most recent time period (2014-2019), needle/syringe sharing was reported at 8-22% of visits. Gaps remained in engagement in harm reduction programs: NSP use decreased (58-70% of visits), OAT engagement among opioid users was low (8-26% of visits), and participants rarely used SIS (1-15% of visits). HCV treatment uptake and outcomes have improved among HIV-HCV coinfected PWID. Yet, this population remains exposed to drug-related harms, highlighting the need to tie HCV elimination strategies with enhanced harm reduction programs to improve overall health for this population.

The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial

BackgroundAdherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks.ObjectiveAssess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups.MethodsThis was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs.ResultsOf 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention.ConclusionFactors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process.Trial Registrationclinicaltrials.gov NCT02777983.

One shot to control Pain: Decreasing postoperative opioid use in gynecologic oncology patients with intrathecal opioid injection

ObjectivesTo determine whether regional anesthesia with single-shot intrathecal opioid injections (ITO) reduce postoperative pain and intravenous (IV) opioid use after exploratory laparotomy in major gynecologic surgeries. MethodsA retrospective chart review of 315 consecutive cases of patients who underwent an exploratory laparotomy on the gynecologic oncology service from July 2015 to January 2018 was conducted. Single-shot ITO was offered to all patients undergoing open abdominal surgery. The primary outcomes of interest were IV opioid use in morphine equivalents during the first 48 hours after surgery. Univariate analyses were performed to estimate the effect of ITO on IV opioid use at 0, 6, 12, 24 and 48 hours after surgery. Longitudinal regression analyses were performed to estimate the effect of ITO on changes in outcomes of interest over time, adjusting for potential confounders. Results35% (110/315) received ITO preoperatively. There were no differences in patient age, BMI, previous number of abdominal surgeries, history of opioid dependence, type of gynecologic surgery, or total EBL between the ITO and control groups. Preoperative ITO was associated with a significantly lower IV opioid requirement between 0 and 6 hours after surgery (9.7 ± 8.1 vs 14.3 ± 11.5, p < 0.0001) and between 6 and 12 hours after surgery (2.7 ± 3.8 vs 5.4 ± 9.5, p = 0.0054). There was no statistically significant difference in total hospital stay opioid requirement but median length of stay was increased by 1 day. ConclusionsPreoperative administration of ITO reduced IV opioid requirement in the first 12 hours postoperatively but was associated with median 1 day increase in hospital stay.

Transition from injecting opioids to smoking fentanyl in San Francisco, California

BackgroundThe introduction of illicitly made fentanyl in the United States has slowly replaced heroin. New illicit drugs are often associated with changes in frequency and modes of administration. We assessed changes in injection frequency and smoking fentanyl in the new era of fentanyl availability in San Francisco. MethodsWe used targeted sampling to recruit 395 people who inject drugs (PWID) into an observational cohort study in San Francisco 2018–2020. We assessed changes in injection frequency, opioid injection frequency and fentanyl smoking frequency in four six-month periods. We also conducted qualitative interviews with PWID asking about motivations for injecting and smoking opioids. ResultsThe median number of past-month injections steadily decreased by semi-annual calendar year from 92 injections in July to December 2018 to 17 injections in January to June 2020. The rate of opioid injections reduced by half (Adjusted Incidence Rate Ratio = 0.41; 95 % Confidence Interval = 0.25, 0.70; p < 0.01). The number of days smoking fentanyl was associated with fewer number of injections (X2(2) = 11.0; p < 0.01). Qualitative interviews revealed that PWID’s motivation for switching from injecting tar heroin to smoking fentanyl was related to difficulties accessing veins. After switching to smoking fentanyl, they noticed many benefits including how the drug felt, improved health, fewer financial constraints, and reduced stigma. ConclusionBetween 2018 and 2020, there was a shift from injecting tar heroin to smoking fentanyl in San Francisco. Reductions in injection of illicit drugs may offer public health benefit if it reduces risk of blood-borne viruses, abscesses and soft-tissue infections, and infective endocarditis.

Clinical efficacy of adductor canal block in medial open wedge high tibial osteotomy

BackgroundTo evaluate the effect of adductor canal block (ACB) on short-term postoperative outcomes in patients who underwent medial open-wedge high tibial osteotomy (MOWHTO) compared to that of a placebo. Methods35 patients who underwent unilateral MOWHTO between 2017 and 2019 were prospectively reviewed and randomly divided into two groups: 19 patients who received a single-shot ACB and 16 patients who received a saline injection (a placebo group). Primary outcomes were (1) pain measured using the visual analog scale and range of motion, (2) patient satisfaction, (3) postoperative need for additional opioids, (3) quadriceps strength (the time to straight leg raising [SLR]), (4) clinical outcomes, and (5) complications. ResultsThe pain score was lower in the ACB group than in the placebo group in the first 12 h (p = 0.04). ACB did not exhibit significantly less quadriceps strength weakness postoperatively. There was no statistical difference in the time to SLR (23.5 ± 17.7 h in ACB vs. 27.6 ± 11.4 in placebo, p = 0.520). The opioid consumption rate within postoperative 12 h was significantly decreased after ACB (16.7% in ACB, 70% in placebo, p = 0.017). The proportion of patients with more than 5 opioid injections within 72 h postoperatively was lower in the ACB group (8.3% in ACB, 50% in placebo, p = 0.043). Both groups did not show any localized and systemic complications. ConclusionACB following MOWHTO exhibited better outcomes than a placebo with respect to opioid consumption with no changes in the quadriceps strength and complications. Level of EvidenceII, Prospectively comparative study

Preoperative Intrathecal Opioid Injection on Postoperative Analgesia Requirements in Gynecologic Oncology [37H

INTRODUCTION: Decreasing opioid use during postoperative period is a topic of great ongoing interest. We aimed to determine whether regional anesthesia with single-shot intrathecal opioid injections (ITO) reduced intravenous (IV) opioid use after exploratory laparotomy in gynecologic oncology surgeries. METHODS: A retrospective chart review with institution IRB approval of 314 consecutive gynecologic oncology patients undergoing exploratory laparotomy from July 2015 to January 2018 was conducted. Single-shot ITO was offered to all patients undergoing open abdominal surgery. The primary outcomes of interest were self-reported post-operative pain levels and IV opioid use in morphine equivalents during the first 48 hours after surgery. Univariate analyses were performed to estimate the effect of ITO on IV opioid use at 0, 6, 12, 24 and 48 hours after surgery. The relationship between ITO and primary outcomes of interest were determined using longitudinal regression analysis and adjusted for confounding variables. RESULTS: 34% (107/314) received ITO preoperatively. There were no differences in patient age, BMI, number of prior abdominal surgeries, history of opioid dependence, or EBL between the ITO and control groups. Preoperative ITO was associated with significantly lower IV opioid requirement between 0-6 hours after surgery (9.7±8.1 vs 14.3±11.5, P&lt;.0001) and between 6-12 hours after surgery (2.7±3.8 vs 5.4±9.5, P=.0054). In addition to reduced IV opioid use in ITO group, no differences in self-reported postoperative pain levels were noted in the first 48 hours post-operatively. CONCLUSION: Preoperative ITO reduced postoperative opioid requirement for pain control without negatively affecting patients’ self-reported pain level.

Open cubital and carpal tunnel release using wide-awake technique: reduction of postoperative pain.

PurposeThis study aimed to compare the efficacy of and patient satisfaction with the wide-awake local anesthesia with no tourniquet (WALANT) technique in open cubital and carpal tunnel release surgery.MethodsFrom January 2016 to February 2017, 20 cubital tunnel syndrome (CuTS) patients were in a wide-awake (WA) group and 22 in a general (GA) anesthesia group in . Also, 20 carpal tunnel syndrome (CTS) patients were in a WA group, 22 in a local anesthesia (LA) group, and 20 in a GA group. Injection pain, perioperative pain, and postoperative pain were assessed using a 10-point pain VAS. In CuTS, functional outcome on the “quick” Disabilities of the Arm, Shoulder, and Hand questionnaire were evaluated. In CTS, subjective outcomes were assessed using the Korean version of the Michigan Hand Outcomes Questionnaire.ResultsBoth CuTS and CTS showed significant postoperative pain reduction in group WA. In CuTS, group WA had less pain than group GA up to 48 hours after surgery (P<0.05). Supplemental opioid injections were used on hospitalization day by 12% of group WA and 35% of group GA. In CTS, the postoperative VAS scores in group WA were lower during the first 24 hours than groups LA and GA (P<0.05). Opioid injections were used on hospitalization day by 5% of WA, 18% of LA, and 32% of group GA. There was no difference in postoperative functional outcomes according to anesthesia method in CuTS or CTS.ConclusionCubital and carpal tunnel surgery using the WALANT technique was comparable in function to other anesthesia methods and superior for pain. Immediate postoperative pain was much lower than other groups, which could reduce the use of opioids during hospitalization.

Early experience of laparoscopic assisted right hemicolectomy: a single-center analysis

Background: Laparoscopic colon surgery has been currently accepted as an alternative to open surgery for colon cancer. the laparoscopic approach, also, has been shown to offer clear evidence of benefit when compared to open surgery.Methods: From July 2013 to July 2016, patients admitted via the outpatient clinics of Menofia University Hospital for elective right hemicolectomy of proved malignancy of the cecum, ascending colon, and hepatic flexure of colon were evaluated for eligibility in this study.Results: The study consisted of 22 patients; of them 13 were males (59.1%) and 9 were females (40.9%) patients, with a mean age of 43±9 years (range 25-70 years). mean operative time was 125±14 minutes (range 100-145 minutes). only four (4) intramuscular opioid injections were given as post-operative analgesia. clear fluids were started 48 hours after surgery and soft diet allowed after 72 hours. the mean length of hospital stay was 5.7 days. Only one male patient was converted to conventional surgery due to advanced tumor. two patients developed surgical site infection in the post-operative period that was mild and managed conservatively. there were no cases with intestinal leakage and mortality rate in 30 days postoperative follow up was zero.Conclusions: Laparoscopic assisted right hemicolectomy is safe and feasible technique with a good learning curve