Opioid Pain Medications Research Articles

Text mining and Natural Language Processing on Social Media Data giving Insights for Pharmacovigilance: A Case Study with Fentanyl

In the present Investigation, the contribution of data mining and natural language processing in pharmacovigilance of fentanyl, a synthetic opioid pain medication was evaluated as a case study. The tweets containing fentanyl as keyword were retrieved from Twitter social media. The tweets were preprocessed in order to make them ready for the analysis. The sentiment analysis algorithm labeled 1927 tweets (41.85 %) as negative, 2067 tweets (44.9 %) as neutral and 610 (13.25 %) tweets as positive. Crisis, dead, death, die, dose, drug, heroin, kill, lethal, opioid, overdose and police were some of the words frequently associated with fentanyl. The high correlation and association of fentanyl with these terms identified by association rule algorithms demonstrated fentanyl abuse and aftermaths in the real world. This study could further be extended to study the region- and population-wise fentanyl misuse and side effects by adding location and user demographic information, which possibly could help in developing drug abuse prevention programs.

Patient Perceptions of the Use of Medical Marijuana in the Treatment of Pain After Musculoskeletal Trauma: A Survey of Patients at 2 Trauma Centers in Massachusetts.

To evaluate musculoskeletal trauma patients' beliefs regarding the usefulness of marijuana as a valid medical treatment for postinjury and postoperative pain and anxiety. Prospective survey. Two academic Level 1 trauma centers. Five hundred patients in an orthopedic outpatient clinic. Survey. (1) Do patients believe that marijuana can be used as medicine? (2) Do patients believe that marijuana can help treat postinjury pain? (3) Are patients comfortable speaking with their health care providers about medical marijuana? The majority of patients felt that marijuana could be used to treat pain (78%, 390) and anxiety (62%, 309). Most patients (60%, 302) had used marijuana at least once previously, whereas only 14% reported using marijuana after their injury. Of those who used marijuana during their recovery, 90% (63/70) believed that it reduced symptoms of pain, and 81% (57/70) believed that it reduced the amount of opioid pain medication they used. The majority of patients in this study believed that medical marijuana is a valid treatment and that it does have a role in reducing postinjury and postoperative pain. Those patients who used marijuana during their recovery felt that it alleviated symptoms of pain and reduced their opioid intake. Our results help inform clinicians regarding the perceptions of patients with trauma regarding the usefulness of marijuana in treating pain and support further study into the utility of medical marijuana in this population.

Medication use among pediatric patients with chronic musculoskeletal pain syndromes at initial pain clinic evaluation.

To characterize medication use by adolescents with chronic musculoskeletal pain syndromes before an initial multidisciplinary clinic visit. A cross-sectional sample of 120 adolescents and parents reported on standardized assessment measures, with medication use data extracted from the medical chart and categorized. On average, 3.2 medications were reported; 70% used more than one pain-specific medication including opioids (17%), nonopioids (31%), psychotropics/neuropathics (45%) and other medications (13%). Adolescents with complex regional pain syndrome consistently reported greatest use of opioid, psychotropic/neuropathic and other pain medications. A regression model explained 17% of the variance in pain medication use. Nonpain medication use and disability contributed unique variance - pain duration and intensity did not. Greater attention to factors contributing to prescriptive practices, medication use and long-term outcomes is warranted.

Patterns and predictors of pain following lung transplantation.

Our objective was to examine variability in pain levels following lung transplantation, and examine individual biopsychosocial factors influencing changes in pain. We performed a retrospective study of a cohort of 150 patients transplanted and discharged from Duke University Hospital between January 2015 and September 2016. During hospitalization and at clinic visits up to two months after discharge, subjective pain ratings were obtained using a 0-10 Numeric Rating Scale. Psychiatric diagnoses of anxiety and depression and Center for Epidemiological Studies - Depression (CES-D) scores collected after hospital discharge were examined as predictors of post-surgery pain. Medical and surgical variables were examined as covariates. During hospitalization, pain ratings decreased over time (p<0.001). Predictors of higher pain levels included pre-transplant history of depression (p=0.001) and anxiety (p=0.04), bilateral lung transplant (p=0.03), and lower six-minute walk distance (p=0.02). Two months after discharge, 18% of patients reported continued pain and 34% remained on opioid pain medications. Two months after discharge, more frequent post-operative complications predicted higher pain levels in a univariate analysis (p=0.02) although this relationship was attenuated after adjustment for depression. In a multivariate analysis, elevated CES-D scores (p=0.002), and greater opioid use (p=0.031) predicted higher pain levels 2-months post-discharge. We conclude that patients with psychiatric comorbidities may be at risk for greater pain, and may require additional strategies for more effective pain management.

Effects of opioid medications on cognitive skills among Emergency Department patients

IntroductionTreatment for pain and related conditions has been identified as the most common reason for Emergency Department (ED) visits. Concerns exist regarding the effects of opioid pain medications on cognition and patient ability to consent for procedures, hospital admission, or to refuse recommended medical interventions. This study was undertaken to identify cognitive skills before and after opioid pain medication in the ED setting. MethodsThis was a prospective study comparing performance on the Mini-Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA) before and after administration of opioid pain medications. Eligible participants included ED patients with pain, who received opioid treatment. Participants were randomized to receive either the MMSE before pain medication and the MoCA after medication, or the reverse. MoCA scores were converted to MMSE equivalent scores for comparison. ResultsAmong 65 participants, the median age was 36 and median triage pain score was 8. 35% of patients were considered cognitively impaired based on their MMSE score prior to any opioid medication (MMSE<27). There was a median decrease in pain scores of 1 point following pain medication, p-value<0.001. There was a median decrease in MMSE scores of 1 point following pain medication, p-value=0.003. The range of change in scores (post minus pre) on the MMSE-equivalent was −7 to 3. 35 patients (56%) had a decrease in scores, 6 (10%) had no change, and 21 (34%) had an increase. After medication, 31 (48%) were abnormal (MMSE score<27). No differences in MMSE scores were identified by gender, ethnicity, mode of arrival, insurance, age, triage pain scores, opioid agent given, or ED diagnosis. ConclusionsThere is an association between opioid pain medication and decrease in cognitive performance on the MMSE. Because of the wide range of cognitive performance following opioid pain medication, assessment of individual patients' cognitive function is indicated.

Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures.

We compared the tolerability and efficacy of intranasal subdissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger noninferiority trial that could investigate the potential opioid-sparing effects of intranasal ketamine. This randomized controlled trial compared 1 mg/kg intranasal ketamine to 1.5 μg/kg intranasal fentanyl in children 4 to 17 years old with acute pain from suspected isolated extremity fractures presenting to an urban Level II pediatric trauma center from December 2015 to November 2016. Patients, parents, treating physicians, and outcome assessors were blinded to group allocation. The primary outcome, a tolerability measure, was the frequency of cumulative side effects and adverse events within 60 minutes of drug administration. The secondary outcomes included the difference in mean pain score reduction at 20 minutes, the proportion of patients achieving a clinically significant reduction in pain in 20 minutes, total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the emergency department (ED) stay, and the feasibility of enrolling children presenting to the ED in acute pain into a randomized trial conducted under U.S. regulations. All patients were monitored until 6 hours after their last dose of study drug or until admission to the hospital ward or operating room. Of 629 patients screened, 87 received the study drug and 82 had complete data for the primary outcome (41 patients in each group). The median (interquartile range) age was 8 (6-11) years and 62% were male. Baseline pain scores were similar among patients randomized to receive ketamine (73±26) and fentanyl (69±26; mean difference [95% CI]= 4 [-7 to 15]). The cumulative number of side effects was 2.2 times higher in the ketamine group, but there were no serious adverse events and no patients in either group required intervention. The most common side effects of ketamine were bad taste in the mouth (37; 90.2%), dizziness (30;73.2%), and sleepiness (19; 46.3%). The most common side effects of fentanyl were sleepiness (15; 36.6%), bad taste in the mouth (9; 22%), and itchy nose (9; 22%). No patients experienced respiratory side effects. At 20 minutes, the mean pain scale score reduction was 44±36 for ketamine and 35±29 for fentanyl (mean difference= 9 [95% CI= -4 to 23]). Procedural sedation with ketamine occurred in 28 ketamine patients (65%) and 25 fentanyl patients (57%) prior to completing the study. Intranasal ketamine was associated with more minor side effects than intranasal fentanyl. Pain relief at 20 minutes was similar between groups. Our data support the feasibility of a larger, noninferiority trial to more rigorously evaluate the safety, efficacy, and potential opioid-sparing benefits of intranasal ketamine analgesia for children with acute pain.

Prescriptions Written for Opioid Pain Medication in the Veterans Health Administration Between 2000 and 2016.

The purpose of this study was to identify national opioid pain medication (OPM) prescribing trends within the Veterans Health Administration (VA), and assess the impact of educational campaigns introduced in 2010 and 2013. We created a national cohort that documents more than 21 million patient records and 97 million outpatient OPM prescriptions covering a 17-year period. We examined OPM prescriptions in emergency departments, outpatient clinics, and inpatient settings. The cohort accounted for 2.5 billion outpatient clinic visits, 18.9 million emergency department visits, and 12.4 million hospital admissions. The number of OPM prescriptions peaked in 2011, when they were provided during 5% of all outpatient visits and 15% of all emergency department visits. The morphine milligram equivalents (MMEs) peaked in 2014 at almost 17 billion in outpatient clinics and at 137 million in emergency departments. In 2016, OPM prescriptions were down 37% in outpatient clinics and 23% in emergency departments, and MMEs were down 30% in both settings. Prescriptions for hydrocodone and tramadol increased markedly between 2011 and 2015. OPM doses in inpatient settings continued to rise until 2015. We used a large national cohort to study trends in OPM prescriptions within the VA. Educational efforts to reduce the number of OPM prescriptions coincided with these reductions, but were initially associated with an increase in OPM dosage, an increase in the use of tramadol and hydrocodone, and an increase in the use of OPMs in inpatient settings.

Demographics and disposition of patients in an academic outpatient palliative care practice.

166 Background: Outpatient PC clinics strive to improve value by improving quality of care for patients while reducing cost. Justifying investment in outpatient PC necessitates characterizing the demographics and disposition of the patients whom these clinics serve. We sought to detail our outpatient palliative care practice in an urban academic medical center in the Southeast to serve a model for other institutions building a financial case for outpatient palliative medicine. Methods: A retrospective analysis from 2014-2017 was conducted on clinical and administrative data from the outpatient supportive oncology cohort at an urban Southern academic center. We performed multivariable logistic regression, t-tests, and chi square analyses to assess associations among variables of interest for patients. Results: Of our outpatient palliative care cohort of 3137 patients, 151 identify as white (51%) and 1377 as black (48%). Among whites 140 (9%) expired and 91% went to hospice compared to 151 (11%) nonwhites expired and 89% nonwhites went to hospice. Furthermore, 21% of non-whites were enrolled in commercial insurance while 79% were enrolled in government insurance compared to 28% whites in commercial insurance and 72% enrolled in government insurance. There were significant correlations among race, age, length of stay (LOS), and discharge disposition (p &lt; 0.05) and race and payer mix (X2= 17.67 df=2, p = .0001). White patients and older patients (P &lt; 0.05) were more likely to enter hospice care compared with minority patients (t = -.655, P &lt; 0.0001). Finally, 2942 patients (94%) received opioid pain medications, and over 90% had &gt; 5 readmissions. Conclusions: In our academic outpatient palliative care clinic we found most patients had governmental insurance, most were prescribed opiates, and older patients and white patients had significantly greater LOS and hospice enrollment compared to black patients. These data illustrate the diversity, payer mix, and disposition to expect when building a case to develop an outpatient palliative care practice in an academic urban medical center.

Concurrent Use of Opioids and Benzodiazepines: Evaluation of Prescription Drug Monitoring by a United States Laboratory.

Objectives:Recently, more than 63% of the 52,404 drug overdose deaths in the United States involved heroin and opioid pain medications. More than 30% of opioid-related deaths also involved benzodiazepines. Previous studies examining the extent of concurrent opioid and benzodiazepine use have relied on prescription data. To gain fuller insight into the extent of the concurrent use problem, we analyzed opioid and benzodiazepine prescription patterns in the context of drug testing results.Methods:All specimens from patients that were prescribed at least 1 drug and were tested for both opioids and benzodiazepines by a national reference laboratory were included. This resulted in an analytical set of 231,228 sets of test results from 144,535 patients with diverse demographic factors being tested in a variety of health care settings.Results:Laboratory test results indicated concurrent use of opioids and benzodiazepines in over 25% of patients. In 52% of test results with evidence of concurrent use, 1 drug class was prescribed and the other was non-prescribed. Nearly 1 in 5 specimens (19%) testing positive for prescribed opioids also tested positive for non-prescribed benzodiazepines. Over 15% of specimens with prescribed benzodiazepines also demonstrated non-prescribed opioid use.Conclusions:The extent of concurrent use of benzodiazepines and opioids, particularly non-prescribed use, suggests the need for more effective clinician assessment and intervention. The results support the Centers for Disease Control and Prevention opioid prescribing guidelines that drug testing occur before and periodically throughout opioid use and suggest that this testing should be extended to patients prescribed benzodiazepines as well.

Is There a Role for 5-HT3 Receptor Antagonists in the Treatment of Opioid-Induced Pruritus?

Pruritus is an unpleasant irritation symptom that can be related to various systemic and dermatological conditions. Although underreported, pruritus is a common adverse event noted after use of opioid pain medications. This article reviews the current understanding of the mechanism of opioid-induced pruritus (OIP) and various pharmacological therapies. 5-Hydroxytryptamine 3 (5-HT3) receptor antagonists are potentially effective for treating OIP and may be a valuable treatment option if further controlled studies are encouraging.

Patient Safety and Risk Management in the Treatment of Pain

Treating patients with severe, nonmalignant pain can be challenging, and with so many options for pain management, one should evaluate the risks and benefits of each treatment. Opioid pain medications are very potent analgesics and should be considered for severe pain in certain cases, but it is important to weight the risks and benefits of prescribing and to document this reasoning clearly to avoid confusion and misunderstanding. Opioids carry a risk of abuse and diversion, as well as side effects of respiratory depression, constipation, nausea, and others. There are recommended precautions to take in order to minimize risk when using these high profile drugs. Proper screening practices should be used to determine candidacy for opioid use, including a full history and physical examination, urine drugs screens, and utilizing a state wide prescription monitoring program can help to reduce the risk of misuse, drug seeking behavior. A full patient history, evaluation, and screening for risks of abuse and diversion can help prescribers use opioids more effectively, balance the risks and benefits, and treat pain more appropriately.

Impact of Rescheduling Hydrocodone Combination Products Among Cancer Patients

Many cancer patients experience significant pain requiring the use of an opioid pain medication such as hydrocodone. On October 6, 2014 the DEA rescheduled hydrocodone combination products from Schedule III to Schedule II of the Controlled Substances Act. Schedule II rules are closely enforced by the DEA and caregivers are fined for non-compliance. In addition, mid-level providers and residents are not able to write for schedule II drugs, so this limits the number of providers able to prescribe opioid pain medications. It has been hypothesized that such rescheduling will cause significant delays for patients who require such medications leading to uncontrolled pain, more emergency department visits and increased risk of readmission. The purpose of this study is to investigate what changes physicians and other healthcare providers have made to their prescribing practices as a result of this rescheduling. With IRB approval, prescription and pharmacy pick-up data for Tramadol, Hydrocodone-acetaminophen (Norco) and Tylenol 3 for all patients within a regional safety net health system were obtained. The time-frames in which data was collected were 6 months before the rescheduling date (April 5, 2014 – October 5, 2014) and 6 months after (October 6, 2014 – April 6, 2015). This dataset was then linked with the health system’s cancer database to identify all cancer patients receiving any one of these pain medications. P-values and confidence intervals were calculated using the N-1 chi square test. Total pills dispensed. Among all patients, considering these 3 pain medications, Norco dropped from 50% of the total pills dispensed before the rescheduling to 23.2% after while Tramadol saw a modest increase from 44.3% to 54.0% and Tylenol 3 saw a significant increase from 5.7% to 22.8%. Among cancer patients Norco dropped from 79.3% to 58.1% while Tramadol increased from 16.2% to 23.7% and Tylenol 3 increased from 4.5% to 18.2%. Total pills dispensed, overall saw a 28.5% decrease in all patients from before the rescheduling to after and in cancer patients there was a 24.5% decrease.Abstract 3252TramadolP-valueTylenol 3P-valueNorcoP-valueAll patientsApr 5 2014 – Oct 5 20141277116 (44.3%)163318 (5.7%)1443782 (50.0%)Oct 6 2014 – Apr 6 20141113033 (54.0%)470110 (22.8%)479003 (23.2%)Difference9.69% (CI: 9.61-9.79)<0.00117.13% (CI: 17.07-17.20)<0.00126.83% (CI: 26.75-26.91)<0.001Cancer patientsApr 5 2014 – Oct 5 201470301 (16.2%)19716 (4.5%)344290 (79.3%)Oct 6 2014 – Apr 6 201477859 (23.7%)59605 (18.2%)190570 (58.1%)Difference7.58% (CI: 7.37-7.73)<0.00113.63% (CI: 13.48-13.78)<0.00121.18% (CI: 20.97-21.39)<0.001 Open table in a new tab The rescheduling of hydrocodone products has dramatically changed prescriber patterns in our health system. Further research is warranted to understand the impact on pain scores.

The Impact of an Emergency Department Front-End Redesign on Patient-Reported Satisfaction Survey Results.

IntroductionFor emergency department (ED) patients, delays in care are associated with decreased satisfaction. Our department focused on implementing a front-end vertical patient flow model aimed to decrease delays in care, especially care initiation. The physical space for this new model was termed the Flexible Care Area (FCA). The purpose of this study was to quantify the impact of this intervention on patient satisfaction.MethodsWe conducted a retrospective study of patients discharged from our academic ED over a one-year period (7/1/2013–6/30/2014). Of the 34,083 patients discharged during that period, 14,075 were sent a Press-Ganey survey and 2,358 (16.8%) returned the survey. We subsequently compared these survey responses with clinical information available through our electronic health record (EHR). Responses from the Press-Ganey surveys were dichotomized as being “Very Good” (VG, the highest rating) or “Other” (for all other ratings). Data abstracted from the EHR included demographic information (age, gender) and operational information (e.g. – emergency severity index, length of stay, whether care was delivered entirely in the FCA, utilization of labs or radiology testing, or administration of opioid pain medications). We used Fisher’s exact test to calculate statistical differences in proportions, while the Mantel-Haenszel method was used to report odds ratios.ResultsOf the returned surveys, 62% rated overall care for the visit as VG. However, fewer patients reported their care as VG if they were seen in FCA (53.4% versus 63.2%, p=0.027). Patients seen in FCA were less likely to have advanced imaging performed (12% versus 23.8%, p=0.001) or labs drawn (24.8% vs. 59.1%, p=0.001). Length of stay (FCA mean 159 ±103.5 minutes versus non-FCA 223 ±117 minutes) and acuity were lower for FCA patients than non-FCA patients (p=0.001). There was no statistically significant difference between patient-reported ratings of physicians or nurses when comparing patients seen in FCA vs. those not seen in FCA.ConclusionPatients seen through the FCA reported a lower overall rating of care compared to patients not seen in the FCA. This occurred despite a shorter overall length of stay for these patients, suggesting that other factors have a meaningful impact on patient satisfaction.

Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures

ImportanceThe overprescription of pain medications has been implicated as a driver of the burgeoning opioid epidemic; however, few guidelines exist regarding the appropriateness of opioid pain medication prescriptions after surgery.ObjectivesTo describe patterns of opioid pain medication prescriptions after common surgical procedures and determine the appropriateness of the prescription as indicated by the rate of refills.Design, Setting, and ParticipantsThe Department of Defense Military Health System Data Repository was used to identify opioid-naive individuals 18 to 64 years of age who had undergone 1 of 8 common surgical procedures between January 1, 2005, and September 30, 2014. The adjusted risk of refilling an opioid prescription based on the number of days of initial prescription was modeled using a generalized additive model with spline smoothing.ExposuresLength of initial prescription for opioid pain medication.Main Outcomes and MeasuresNeed for an additional subsequent prescription for opioid pain medication, or a refill.ResultsOf the 215 140 individuals (107 588 women and 107 552 men; mean [SD] age, 40.1 [12.8] years) who underwent a procedure within the study time frame and received and filled at least 1 prescription for opioid pain medication within 14 days of their index procedure, 41 107 (19.1%) received at least 1 refill prescription. The median prescription lengths were 4 days (interquartile range [IQR], 3-5 days) for appendectomy and cholecystectomy, 5 days (IQR, 3-6 days) for inguinal hernia repair, 4 days (IQR, 3-5 days) for hysterectomy, 5 days (IQR, 3-6 days) for mastectomy, 5 days (IQR, 4-8 days) for anterior cruciate ligament repair and rotator cuff repair, and 7 days (IQR, 5-10 days) for discectomy. The early nadir in the probability of refill was at an initial prescription of 9 days for general surgery procedures (probability of refill, 10.7%), 13 days for women’s health procedures (probability of refill, 16.8%), and 15 days for musculoskeletal procedures (probability of refill, 32.5%).Conclusions and RelevanceIdeally, opioid prescriptions after surgery should balance adequate pain management against the duration of treatment. In practice, the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir, or 4 to 9 days for general surgery procedures, 4 to 13 days for women’s health procedures, and 6 to 15 days for musculoskeletal procedures.

Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation – A case report of a 4-year-old girl

Background and purposeThe purpose of this case report is to describe a multimodal pain therapeutic concept including the adjunct use of pregabalin in a 4.5 year-old child after forefoot amputation.Phantom limb pain and sensation is a complex pain syndrome that is difficult to treat and prevent. 70–75% of all children develop such a pain syndrome after amputation. We describe here a paediatric patient who underwent forefoot amputation following traumatic foot injury and received multimodal pain therapy including pregabalin. MethodsA 4.5 year-old otherwise healthy girl suffered severe injuries of the right foot and lower leg during a motor vehicle accident. Due to development of severe necrosis, forefoot amputation had to be performed during the hospital stay. ResultsInitial pain therapy included paracetamol, ibuprofen, metamizol, morphine and fentanyl. With mounting pain and anxiety, regional anaesthesia of the distal sciatic nerve was administered in combination with a ketamine and morphine patient controlled analgesia pump (PCA). The peripheral blockade of the distal sciatic nerve was placed with the guidance of ultrasound and nerve stimulator. The PCA concept included a continuous basal rate combined with a bolus function. Although the regional anaesthesia was well positioned and functioning, there was inadequate pain control. The pain was described by the patient as short, highly intense and sharp sensations with intensity on the visual analogue scale (VAS) of 10 (out of 10). Furthermore, she suffered from anxiety episodes and sleep disturbance. The medical team decided to treat with pregabalin to resolve these issues while awaiting amputation (Lisfranc line). She received psychological counselling as adjunct treatment. This multimodal concept enabled an early and efficient pain reduction pre- and post-amputation and allowed for the possibility of a hospital discharge without any opioid pain medication. ConclusionThe multimodal pain therapy including pregabalin was well tolerated, safe and highly effective in this case of traumatic limb injury and subsequent amputation. The use of pregabalin allowed significant pain and anxiety reduction for the patient. ImplicationsPregabalin is frequently used in adult patients for severe complex pain syndromes. There are only few reports of such adjunct medication (pregabalin) in paediatric pain syndromes. These reports focus mainly on the paediatric oncologic population. The case reported here encourages physicians to consider adjunct medications when treating complex pain, which are well established in the adult population. The benefits of such therapy in complex pain and anxiety can be extended to the paediatric population in select cases. Of course, one must always take into account that many routine medications used in children are well established but are off-label use. The authors are well aware of this problem and have conducted a critical literature review prior to pregabalin administration, including the search for randomized trials examining safety and tolerability. The parents or legal guardians of a minor must be thoroughly informed and consent to such a constellation of medical treatment.

Safe Opioid Prescription: A SMART on FHIR Approach to Clinical Decision Support.

Prescription opioid pain medication overuse, misuse and abuse has been a significant contributing factor in the opioid epidemic. The rising death rates from opioid overdose has caused healthcare practitioners and researchers to work on optimizing pain therapy and limiting the prescriptions for pain medications. The state of New York has implemented a prescription drug monitoring program(PDMP), amended public health law to limit the prescription of opioids for acute pain and utilized the resources of the state and county health departments to help in curbing this epidemic. The recent publication of guidelines for prescription opioids from CDC [2] and ASIPP (American Society of Interventional pain practitioners) [4] have independently reviewed literature and found good evidence of limiting opioid prescription for acute and chronic non cancer pain.MethodClinical Decision Support Systems (CDSS) have been developed over the last decade to help in the work flow of healthcare providers since advanced technology is increasing the complexity of electronic health records systems. There are several systematics reviews on the effectivity and utility of CDSSs. The common consensus seems to be that commercially and locally developed CDSS are effective in improving patient measures while actual workload improvement and efficient cost cutting measure are not significantly improved by CDSS. Patient provider involvement in developing CDSS is a determinant of its success and utilization rates. In this light, a plug and play form of CDSS which is independent of the vendors of Electronic Health Records and can be implemented from an external platform through secure channels would be more effective.The Health Level Seven’s (HL7) open licensed interoperability standard called Fast Health Interoperability Resources (FHIR) has a platform, Substitutable Medical Applications and Reusable Technologies (SMART) for CDSS app development by a third party. (Mandl and Kohane) [13] We adopted these open source standard to develop an app for proper implementation of the recently published guidelines for management of pain with opioid pain medications.The goal for this CDSS tool would be to achieve proper monitoring of prescription drugs, patients’ medication list and potential interactive medications, surveillance for abuse/ misuse, patient involvement in alternative therapy, reporting problems and obtaining adequate pain control.

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Liposomal Bupivacaine versus Continuous Popliteal Nerve Block in Total Ankle Arthroplasty

Category: Ankle, Ankle Arthritis Introduction/Purpose: The use of liposomal bupivacaine (LB) has recently gained popularity in joint arthroplasty. Despite it’s proven safety and efficacy, there is little reported on the use of LB in foot and ankle surgery. Catheter placement for a continuous popliteal sciatic nerve block (CPSNB) has an excellent track record for pain relief, and is commonly used by our group for major foot and ankle reconstructions. The purpose of this study was to compare the use of intraoperative LB injection to CPSNB as a regional anesthetic for total ankle arthroplasty (TAA), with attention to postoperative pain scores, narcotic use, and complications. Methods: Retrospective review of TAA patients treated by two fellowship-trained orthopedic foot and ankle surgeons was performed. Patient demographic data, operative, and postoperative details were collected, including type of regional anesthetic used. Patient’s received either preoperative single-shot popliteal sciatic nerve block with 0.25% bupivacaine followed by intraoperative injection of LB, or preoperative CPSNB alone. Outcomes examined were VAS pain score at 8 hours, 24 hours, 1 week, and 3 weeks following surgery, need for opioid pain medication refill, physician office notification for pain issues or other adverse events, and complications within the first 90 days following surgery. Standard statistical analysis was performed and p &lt; 0.05 was considered significant. Results: 75 patients were identified who underwent TAA and met inclusion criteria. 41 received LB and 34 received CPSNB. No statistical difference was seen between groups with regard to complications, emergency department visits, readmissions, reoperations, VAS pain score at any time point, physician office contacts, and narcotic refills. Mean VAS with LB use was 1.8, 3.5, 2.6, and 2.2 at 8 hours, 24 hours, 1 week, and 3 weeks respectively, compared with mean VAS 2.1, 3.2, 2.2, and 1.9 at similar time points for CPSNB (p=0.59, 0.65, 0.27, and 0.40, respectively). 16 of 41 LB patients needed narcotic refills, versus 12 of 34 CPSNB patients (p=0.81). 3 of 41 LB patients had a complication postoperatively, versus 4 of 34 CPSNB patients. Conclusion: This is the first study evaluating the use of LB for total ankle arthroplasty. LB was both safe and effective for postoperative pain control, with comparable results to CPSNB. As LB gains more widespread use in foot and ankle surgery, further investigation is warranted to determine potential unseen complications and cost-effectiveness.

Opioid Medications in the Management of Chronic Abdominal Pain.

Chronic abdominal pain is a complex medical condition. The causes of chronic abdominal pain are extremely diverse ranging from chronic pancreatitis, Crohn's disease, to chronic pain with no clear etiology. Treatment of chronic abdominal pain remains a challenge in our clinical practice. While current interventions with celiac plexus blocks and pain medications provide some relief for these patients, but these treatments are typically less efficacious and limited by various adverse effects. Opioid medications are commonly used to manage chronic pain syndromes that are refectory to other pain management interventions. The potential problems related to opioids include misuse, abuse, constipation, nausea pruritus, et al. Moreover, according to the recent centers for disease (CDC) control report, opioid abuse has reached epidemic proportions in the USA (LJ P. Centers for Disease Control and Prevention. 2016) and accounted for 28,000 deaths in 2014. Rudd et al. (MMWR Morb Mortal Wkly Rep 64(50-51):1378-82, 2016) Given this current situation, it is apparent that a careful review of clinical evidences supporting the use of opioid medications is necessary to guide our treatment approaches in the management of complex chronic abdominal pain patients. This review is set out to analyze efficacy of opioid medications for chronic abdominal pain. The literature referenced was obtained via a computer search with Google Scholar, Pubmed, Medline, and EMbase. The search terms used included Opioid, Oxycodone, Buprenorphine, Morphine, Fentanyl, Oxymorphone, Hydromorphone, chronic abdominal pain, Crohn's disease, and pancreatitis. All studies were considered eligible for inclusion if they were clinical studies evaluating the efficacy of opioid medications for chronic abdominal pain. Two studies were found according to these criteria. Chronic abdominal pain is a challenging medical condition in our daily practice. This condition often requires opioid medications when other treatments fail. This review provided very limited clinical evidence to support long-term opioid use for chronic abdominal pain. Given recent CDC report of opioid epidemic, it is prudent to use the best medical practice with appropriate evaluation of psychological comorbidities, urine drug screening, prescription drug monitor, and opioid treatment agreements to minimize adverse side effects related to opioids. Furthermore, well-designed clinical trials are needed to evaluate the effectiveness of long-term use of opioid medications, and more clinical research on which opioid medication is more effective for chronic abdominal pain.

Advances in the delivery of buprenorphine for opioid dependence.

Opioid use disorders (OUDs) have long been a global problem, but the prevalence rates have increased over 20 years to epidemic proportions in the US, with concomitant increases in morbidity and all-cause mortality, but especially opioid overdose. These increases are in part attributable to a several-fold expansion in the prescription of opioid pain medications over the same time period. Opioid detoxification and psychosocial treatments alone have each not yielded sufficient efficacy for OUD, but μ-opioid receptor agonist, partial agonist, and antagonist medications have demonstrated the greatest overall benefit in OUD treatment. Buprenorphine, a μ-opioid receptor partial agonist, has been used successfully on an international basis for several decades in sublingual tablet and film preparations for the treatment of OUD, but the nature of formulation, which is typically self-administered, renders it susceptible to nonadherence, diversion, and accidental exposure. This article reviews the clinical trial data for novel buprenorphine delivery systems in the form of subcutaneous depot injections, transdermal patches, and subdermal implants for the treatment of OUD and discusses both the clinical efficacy of longer-acting formulations through increasing consistent medication exposure and their potential utility in reducing diversion. These new delivery systems also offer new dosing opportunities for buprenorphine and strategies for dosing intervals in the treatment of OUD.