Opioid-related Adverse Events Research Articles

Incidence of and predictors for serious opioid-related adverse drug events.

To determine the incidence of and predictors for serious opioid-related adverse drug events (ORADEs) in postoperative inpatients. A retrospective cohort study design of serious ORADEs in surgical inpatients between 2015 and 2017, who were abstracted from the electronic health record, in an 800-bed academic medical health center. A total of 27,942 surgery patients met the inclusion criteria. Of those, 25,208 patients (90%) were exposed to opioids after surgery. A total of 25,133 (99.7%) patients exposed to opioids did not experience a serious ORADE while 75 (0.3%) patients did experience a serious ORADE and required naloxone. The predictors for ORADEs include age (OR = 1.040, P-value < .0001); gender (OR = 0.394, P-value = .0006); psychiatric disorder (OR = 4.440, CI: 2.435, 8.095); morphine level with respect to hydrocodone-acetaminophen (OR = 5.841, P-value = .0384); and were almost six times more likely to experience a serious ORADE when morphine is prescribed and 4.44 times more likely in patients with a psychiatric disorder (P-value < .0001). Once a baseline incidence is known, predictors for serious ORADEs in surgical inpatients are useful in guiding medical-surgical nurses' opioid safety practices, with more frequent focused respiratory assessments before opioid dosing and closer monitoring when opioids are prescribed postoperatively, especially in higher-risk surgical inpatients.

Association of injury after prescription opioid initiation with risk for opioid-related adverse events among older Medicare beneficiaries in the United States: A nested case-control study.

BackgroundInjury, prevalent and potentially associated with prescription opioid use among older adults, has been implicated as a warning sign of serious opioid-related adverse events (ORAEs) including opioid misuse, dependence, and poisoning, but this association has not been empirically tested. The study aims to examine the association between incident injury after prescription opioid initiation and subsequent risk of ORAEs and to assess whether the association differs by recency of injury among older patients.Methods and findingsThis nested case-control study was conducted within a cohort of 126,752 individuals aged 65 years or older selected from a 5% sample of Medicare beneficiaries in the United States between 2011 and 2018. Cohort participants were newly prescribed opioid users with chronic noncancer pain who had no injury or ORAEs in the year before opioid initiation, had 30 days or more of observation, and had at least 1 additional opioid prescription dispensed during follow-up. We identified ORAE cases as patients who had an inpatient or outpatient encounter with diagnosis codes for opioid misuse, dependence, or poisoning. During a mean follow-up of 1.8 years, we identified 2,734 patients who were newly diagnosed with ORAEs and 10,936 controls matched on the year of cohort entry date and a disease risk score (DRS), a summary score derived from the probability of an ORAE outcome based on covariates measured prior to cohort entry and in the absence of injury. Multivariate conditional logistic regression was used to estimate ORAE risk associated with any and recency of injury, defined based on the primary diagnosis code of inpatient and outpatient encounters. Among the cases and controls, 68.0% (n = 1,859 for cases and n = 7,436 for controls) were women and the mean (SD) age was 74.5 (6.9) years. Overall, 54.0% (n = 1,475) of cases and 46.0% (n = 1,259) of controls experienced incident injury after opioid initiation. Patients with (versus without) injury after opioid therapy had higher risk of ORAEs after adjustment for time-varying confounders, including diagnosis of tobacco or alcohol use disorder, drug use disorder, chronic pain diagnosis, mental health disorder, pain-related comorbidities, frailty index, emergency department visit, skilled nursing facility stay, anticonvulsant use, and patterns of prescription opioid use (adjusted odds ratio [aOR] = 1.4; 95% confidence interval (CI) 1.2 to 1.5; P < 0.001). Increased risk of ORAEs was associated with current (≤30 days) injury (aOR = 2.8; 95% CI 2.3 to 3.4; P < 0.001), whereas risk of ORAEs was not significantly associated with recent (31 to 90 days; aOR = 0.93; 95% CI 0.73 to 1.17; P = 0.48), past (91 to 180 days; aOR = 1.08; 95% CI 0.88 to 1.33; P = 0.51), and remote (181 to 365 days; aOR = 0.88; 95% CI 0.73 to 1.1; P = 0.18) injury preceding the incident diagnosis of ORAE or matched date. Patients with injury and prescription opioid use versus those with neither in the month before the ORAE or matched date were at greater risk of ORAEs (aOR = 5.0; 95% CI 4.1 to 6.1; P < 0.001). Major limitations are that the study findings can only be generalized to older Medicare fee-for-service beneficiaries and that unknown or unmeasured confounders have the potential to bias the observed association toward or away from the null.ConclusionsIn this study, we observed that incident diagnosis of injury following opioid initiation was associated with subsequent increased risk of ORAEs, and the risk was only significant among patients with injury in the month before the index date. Regular monitoring for injury may help identify older opioid users at high risk for ORAEs.

Opioid-free total intravenous anesthesia for thyroid and parathyroid surgery: Protocol for a randomized, double-blind, controlled trial.

BackgroundOpioid-free anesthesia (OFA) may improve postoperative outcomes by reducing opioid-related adverse effects. This study aims to evaluate the effects of OFA on postoperative nausea and vomiting (PONV), postoperative pain, and 30-day outcomes after thyroid and parathyroid surgery.MethodsThis two-center, randomized, double-blind, controlled trial will include 400 adult patients scheduled for thyroid and parathyroid surgery. Patients will be randomly assigned, 1:1 and stratified by sex and site, to an OFA group (esketamine, lidocaine, and dexmedetomidine) or a control group (opioid-based anesthesia with sufentanil). All patients will receive propofol-based total intravenous anesthesia and PONV prophylaxis with dexamethasone and ondansetron. The primary outcome is the incidence of PONV (defined as experiencing any event of nausea, retching, or vomiting) during the first 48 h postoperatively. The secondary outcomes include the severity of PONV, antiemetic rescue therapy, pain scores at rest and while coughing, need for rescue analgesia, perioperative adverse effects related to anesthetics or analgesics (hypotension, bradycardia, hypertension, tachycardia, desaturation, dizziness, headache, hallucination, and nightmare), time to extubation, length of post-anesthesia care unit stay, length of postoperative hospital stay, patient satisfaction, and a composite of 30-day major adverse events (myocardial infarction, cardiac arrest, cerebrovascular accident, coma, acute renal failure, pulmonary embolism, sepsis, septic shock, deep neck space infection, reintubation, reoperation, blood transfusion, failure to wean off ventilator, and death). Analyses will be performed in the modified intention-to-treat population.DiscussionWe hypothesize that our OFA regimen reduces PONV after thyroid and parathyroid surgery. We will also investigate whether OFA leads to improvements in postoperative pain and major adverse events. Our results will offer evidence for optimizing anesthesia regimens in patients who undergo thyroid and parathyroid surgical procedures.Clinical trial registrationhttp://www.chictr.org.cn, identifier: ChiCTR2200059656.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Pectus Excavatum Surgery: A Retrospective Propensity-Score Study

Pectus excavatum (PE) repair is burdened by severe postoperative pain. This retrospective study aimed to determine whether the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) plus standard intravenous analgesia (SIVA) might be superior to SIVA alone in pain control after PE surgical repair via Ravitch or Nuss technique. A retrospective cohort study. At a university hospital. All participants were scheduled for surgical repair of PE. From January 2017 to December 2019, all patients who received ESPB plus SIVA or SIVA alone were investigated retrospectively. A 2:1 propensity-score matching analysis considering preoperative variables was used to compare analgesia efficacy in 2 groups. All patients received a 24-hour continuous infusion of tramadol, 0.1 mg/kg/h, and ketorolac, 0.05 mg/kg/h, via elastomeric pump, and morphine, 2 mg, intravenously as a rescue drug. The ESPB group received preoperative bilateral ESPB block. Postoperative pain, reported using a numerical rating scale at 1, 12, 24, and 48 hours after surgery; the number of required rescue doses; total postoperative morphine milligram equivalents consumption; and the incidence of postoperative nausea and vomit were analyzed. A total of 105 patients were identified for analysis. Propensity-score matching resulted in 38 patients in the SIVA group and 19 patients in the ESPB group. Postoperative pain, the number of rescue doses, and postoperative nausea and vomit incidences were lower in the ESPB group (p < 0.005). Erector spinae plane block may be an effective option for pain management after surgical repair of PE as part of a multimodal approach. This study showed good perioperative analgesia, opioid sparing, and reduced opioid-related adverse effects.

Randomized Trial of Transversus Abdominis Plane Block With Liposomal Bupivacaine After Cesarean Delivery With or Without Intrathecal Morphine

(J Clin Anesth. 2021;75:110527. doi: 10.1016/j.jclinane.2021.110527) Intrathecal morphine (ITM) is regularly used for analgesia following cesarean delivery (CD), although there is no standardized dose. Employed as part of a multimodal analgesia system, recommended ITM dosing ranges from 50 to 150 µg. Dose-dependent opioid-related adverse events including vomiting, nausea, pruritus, and respiratory depression call for investigation into alternate methods that provide effective analgesia with fewer opioid-related adverse events. Previous studies of transverse abdominis plane (TAP) block with long-acting liposomal bupivacaine (LB) combined with ITM suggest enhanced analgesia compared to LB TAP or ITM alone. The comparison of efficacy and safety of LB TAP block with or without ITM (LB and LB + ITM) versus ITM alone has not been previously undertaken. The adequacy of analgesia including pain scores and postsurgical opioid consumption was studied for the 3 intervention groups (LB and LB + ITM, vs. ITM) with noninferiority tested before superiority.

Pericapsular nerve group (PENG) block for hip arthroscopy: a randomized, double-blinded, placebo-controlled trial

IntroductionArthroscopic hip surgery is associated with significant postoperative pain. Femoral nerve blocks have been shown to improve postoperative analgesia at the expense of quadriceps weakness. The pericapsular nerve group (PENG)...

Impact of an Enhanced Recovery after Surgery Protocol on Postoperative Outcomes in Cardiac Surgery

Background: Enhanced recovery after surgery (ERAS) protocols are perioperative care pathways designed to achieve early recovery after procedures. ERAS protocols have shown shortened recovery time, and lower opioid utilization and postoperative complication rates. Evidence to support the use of ERAS protocols is robust, however, minimal data exists in cardiac surgery patients. Methods: This observational cohort compared adults receiving post-operative care after coronary artery bypass or valve procedures who received an ERAS protocol containing acetaminophen, gabapentin, and methocarbamol to historical controls. The primary outcome of this study was postoperative opioid use during the first 72-hours following cardiac surgery. Secondary outcomes included length of stay, average pain scores 72-hours postoperatively, and incidence of opioid-related complications. Results: Total cumulative 72-hour post-operative opioid consumption showed a trend toward reduction in opioid use in patients who received the ERAS protocol vs the historic control group [75.8 mg vs 105.4 mg oral morphine equivalents (P = .09)]. Median postoperative lengths of stay and pain scores were similar between groups. Opioid related complications including constipation and respiratory depression occurred more frequently in the control group compared to the ERAS group [47.7% vs 60.5% (P < .05) and 57.1% vs 62.7% (P < .05) respectively]. Conclusions: Use of an ERAS protocol shows a promising trend toward less postoperative opioid use in cardiac surgery patients. Lower rates of opioid-related adverse events, including constipation and respiratory depression, were observed in the ERAS protocol group. This study indicates that ERAS protocols have a potential role for cardiac surgery patients postoperatively.

An analgesic peptide H-20 attenuates chronic pain via the PD-1 pathway with few adverse effects

The lack of effective and safe analgesics for chronic pain management has been a health problem associated with people's livelihoods for many years. Analgesic peptides have recently shown significant therapeutic potential, as they are devoid of opioid-related adverse effects. Programmed cell death protein 1 (PD-1) is widely expressed in neurons. Activation of PD-1 by PD-L1 modulates neuronal excitability and evokes significant analgesic effects, making it a promising target for pain treatment. However, the research and development of small molecule analgesic peptides targeting PD-1 have not been reported. Here, we screened the peptide H-20 using high-throughput screening. The invitro data demonstrated that H-20 binds to PD-1 with micromolar affinity, evokes Src homology 2 domain-containing tyrosine phosphatase 1 (SHP-1) phosphorylation, and diminishes nociceptive signals in dorsal root ganglion (DRG) neurons. Preemptive treatment with H-20 effectively attenuates perceived pain in naïve WT mice. Spinal H-20 administration displayed effective and longer-lasting analgesia in multiple preclinical pain models with a reduction in or absence of tolerance, abuse liability, constipation, itch, and motor coordination impairment. In summary, our findings reveal that H-20 is a promising candidate drug that ameliorates chronic pain in the clinic.

Association of Postsurgical Opioid Refills for Patients With Risk of Opioid Misuse and Chronic Opioid Use Among Family Members

The US health care system is experiencing a sharp increase in opioid-related adverse events and spending, and opioid overprescription may be a key factor in this crisis. Ambient opioid exposure within households is one of the known major dangers of overprescription. To quantify the association between the postsurgical initiation of prescription opioid use in opioid-naive patients and the subsequent prescription opioid misuse and chronic opioid use among opioid-naive family members. This cohort study was conducted using administrative data from the database of a US commercial insurance provider with more than 35 million covered individuals. Participants included pairs of patients who underwent surgery from January 1, 2008, to December 31, 2016, and their family members within the same household. Data were analyzed from January 1 to November 30, 2018. Duration of opioid exposure and refills of opioid prescriptions received by patients after surgery. Risk of opioid misuse and chronic opioid use in family members were calculated using inverse probability weighted Cox proportional hazards regression models. The final cohort included 843 531 pairs of patients and family members. Most pairs included female patients (445 456 [52.8%]) and male family members (442 992 [52.5%]), and a plurality of pairs included patients in the 45 to 54 years age group (249 369 [29.6%]) and family members in the 15 to 24 years age group (313 707 [37.2%]). A total of 3894 opioid misuse events (0.5%) and 7485 chronic opioid use events (0.9%) occurred in family members. In adjusted models, each additional opioid prescription refill for the patient was associated with a 19.2% (95% CI, 14.5%-24.0%) increase in hazard of opioid misuse in family members. The risk of opioid misuse appeared to increase only in households in which the patient obtained refills. Family members in households with any refill had a 32.9% (95% CI, 22.7%-43.8%) increased adjusted hazard of opioid misuse. When patients became chronic opioid users, the hazard ratio for opioid misuse among family members was 2.52 (95% CI, 1.68-3.80), and similar patterns were found for chronic opioid use. This cohort study found that opioid exposure was a household risk. Family members of a patient who received opioid prescription refills after surgery had an increased risk of opioid misuse and chronic opioid use.

Shifting practice in pediatric prescription opioid use in the emergency department for fractures

ObjectivesJudicious opioid use is important for balancing patient comfort and safety. Although opioid use is well studied in adult populations, pediatric opioid prescription practices are less understood and there are very few guidelines regarding its usage. The purpose of this study was to investigate pediatric opioid prescription trends by emergency medicine physicians over the last ten years, including assessing proxies for the adequacy of pain control and risk of any opioid-related adverse events including overdose. MethodsA retrospective analysis was performed of all patients age 0 to 18 who presented to an urban county hospital emergency department (ED) between 2007 and 2017 for acute fracture care. Data collected included age, opioids given in the ED, opioid prescriptions from the ED, adverse events, and secondary opioid prescriptions. Opioid prescription quantities were assessed in morphine equivalents (Meqs). ResultsOut of 4713 patients diagnosed with acute fracture, opioid prescriptions from the ED were given to 1772 patients (37.6%), with a mean quantity of 107.0 Meqs (SD = 69.1). Over the ten-year period studied, prescription rates declined from 54.8% in 2007 to 13.6% in 2017. Although 201 (4.3%) fracture patients had a second fracture-related ED visit, only 27 visits (0.57%) were for inadequate pain control, with no significant differences in year-to-year analysis. During the ten-year study period, there were zero opioid overdoses reported among pediatric fracture patients. ConclusionsA major shift has occurred in the last ten years, as emergency medicine physicians now favor non-opioid pain management regimens over opioids for the majority of pediatric fracture patients. There was no increase in the rate of inadequate pain control requiring a return to the ED, even as opioid prescription rates declined during the study period.

Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use

BackgroundFascia iliaca compartment block (FICB) has become a keystone technique for acute pain management in patients with hip and proximal femur fractures. ObjectivesTo demonstrate that administering FICB preoperatively to patients with hip or proximal femur fractures in the emergency department (ED) is likely to reduce opioid use and related complications, and to decrease hospital length of stay (LOS). MethodsAn unblinded study of adult patients with hip and proximal femur fractures who consented to receive an FICB with 30 cc of bupivacaine with epinephrine administered in the ED. We compared this group with a contemporaneous group of controls who only received systemic opioids. Over the course of approximately 6 months, main outcome measured between the two groups was amount of morphine equivalents given from block administration until 8 h after. We also compared complications such as delirium, constipation, and bleeding rates (oozing from injection site or hematoma formation). ResultsA total of 166 patients with hip and proximal femur fractures from August 12, 2018 to April 25, 2021; 81 received FICB plus systemic opioids, and 85 received only systemic opioids. Among the FICB group, morphine equivalents were reduced by 0.6 mg/h with no significant difference in LOS. A statistically significant difference in opioid-related adverse outcomes was found between the anticoagulated group vs. the no anticoagulation group. ConclusionsFICB is a safe and effective preoperative technique for initial pain management in patients with hip and proximal femur fractures, as it can also be used with additional systemic opioids. FICB administration may reduce systemic opioid use preoperatively, thus reducing opioid-related adverse effects with no significant impact on hospital LOS.

Association between opioid therapy trajectories and potential opioid-related adverse health events.

We identified associations between membership in seven group-based trajectories based on supply of filled opioid prescriptions and potential opioid-related adverse health events over a 720-day window. We identified two veteran cohorts with chronic non-cancer pain who initiated treatment with long-term opioid therapy between 2008 and 2015, excluding those with prior substance use disorder (n=373 941) or non-SUD, opioid-related adverse outcome (n=405 631) diagnoses. Outcomes of interest included opioid use disorder, non-opioid drug use disorder, and alcohol use disorder for the first cohort; or accidents resulting in wounds or injuries, self-inflicted injuries, opioid-related accidents and overdoses, alcohol and non-opioid drug-related accidents and overdoses, and violence-related injuries for the second cohort. Using a cross-sectional design, Veterans were followed until the specific outcome of interest was diagnosed, they died, the study ended, or they were lost to follow up. Accelerated failure time models were estimated for each outcome. Membership in persistent moderate days covered and persistent modest days covered trajectories was associated with decreased risk of opioid use disorder (Moderate: θ=0.59, 95%CI:0.54, 0.64; Modest: θ=0.54, 95%CI:0.50, 0.59) and opioid overdose (Moderate: θ=0.67,95%CI: 0.57, 0.79; Modest: θ=0.72, 95%CI:0.61, 0.85) versus higher-utilizing persistent users. Rapid discontinuation was associated with decreased risk of opioid use disorder (θ=0.86, 95% CI:0.77, 0.95) and opioid overdose (θ=0.54, 95%CI:0.41, 0.71), but increased risk of alcohol use disorder (θ=1.07, 95%CI:1.00, 1.15) and other substance use disorders. Delayed discontinuation or delayed reduction was associated with increased risk for most opioid related adverse health events. Persistent use trajectories with low levels of opioid utilization were associated with lower risks of potential opioid-related adverse health events.

SA32 Continuity of Opioid Prescribing Among Older Adults on Long-Term Opioids

Previous research shows fragmentation of care among older adults maybe associated with high-risk opioid prescriptions. This project aims to describe the continuity of opioid prescribing and prescriber characteristics among older adults with chronic non-cancer pain (CNCP) who are on long-term opioid therapy (LTOT) and to evaluate the association of continuity of opioid prescribing and prescriber characteristics with the risk of opioid-related adverse events (ORAEs).

HSD125 Geographic Variation of High-Risk Prescription Opioid Use Measures Among Disabled Medicare Beneficiaries, 2011-2018

To curb opioid-related adverse events, the Centers for Medicare and Medicaid Services (CMS) endorsed several quality measures of high-risk opioid use: 1)high-dose use, 2)multiple providers, and 3)concurrent benzodiazepine use. We examined geographic patterns of high-risk opioid use among disabled Medicare beneficiaries given their high prevalence of musculoskeletal disorders and opioid use.

Randomized Policy Evaluation of the Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM).

The Veterans Health Administration (VHA) developed a dashboard Stratification Tool for Opioid Risk Mitigation (STROM) to guide clinical practice interventions. VHA released a policy mandating that high-risk patients of an adverse event based on the STORM dashboard are to be reviewed by an interdisciplinary team of clinicians. Randomized program evaluation to evaluate if patients in the oversight arm had a lower risk of opioid-related serious adverse events (SAEs) or death compared to those in the non-oversight arm. One-hundred and forty VHA facilities (aka medical centers) were randomly assigned to two groups: oversight and non-oversight arms. VHA patients who were prescribed opioids between April 18, 2018, and November 8, 2019, were included in the cohort. We hypothesized that patients cared for by VHA facilities that received the policy with the oversight accountability language would achieve lower opioid-related SAEs or death. We did not observe a relationship between the oversight arm and opioid-related SAEs or death. Patients in the non-oversight arm had a significantly higher chance of receiving a case review compared to those in the oversight arm. Even though our findings were unexpected, the STORM policy overall was likely successful in focusing the provider's attention on very high-risk patients.

Early Initiation of Sub-Anesthetic Ketamine Infusion in Adults with Vaso-Occlusive Crises Is Associated with Greater Reduction in Sickle Cell Pain Intensity: A Single Center's Experience.

Recurrent, severely painful episodes, known as vaso-occlusive crises (VOCs) are the hallmark of sickle cell disease (SCD) and the primary reason for hospitalization. Opioids have been the gold standard for VOC treatment without significant improvement pain outcomes. To aid analgesia and combat opioid related adverse effects (ORAEs), some SCD clinicians have trialed infusions of sub-anesthetic ketamine along with opioids to treat VOCs. In this retrospective analysis, we compared adult SCD patients who received early vs late adjunctive sub-anesthetic ketamine infusions for VOCs. We identified adult SCD patients (age 18-50 years) who presented to Duke University with a VOC and received sub-anesthetic ketamine infusions from July 2015 to June 2019. We assessed both daily opioid consumption (measured as oral morphine milligram equivalents (MME)) and self-reported 0-10 numeric pain ratings (NPR) at 1, 2, and 3 days after infusion initiation, as well as 1 day after discontinuation. A total of 56 patients were identified with a median age of 30 years. Compared to late administration, early infusion of sub-anesthetic ketamine was associated with a 24.5% (P = .0003) and 25.9% (P = .0006) reduction, respectively, in median NPR at 1 day and 2 days after infusion initiation but did not persist at 3 days following initiation of the infusion. A statistically significant reduction in MME was not observed. In a nonrandomized study of sickle cell patients with VOCs, early sub-anesthetic ketamine infusion led to greater reduction in subjective pain intensity than late initiation of the infusion. Randomized studies should further explore whether early vs late ketamine infusion improves management of acute SCD pain.

Budget Impact and Cost-Effectiveness of Intravenous Meloxicam to Treat Moderate-Severe Postoperative Pain.

This study assesses the budget impact and cost-effectiveness of intravenous meloxicam (MIV) to treat moderate-severe acute postoperative pain in adults. A two-part Markov cohort model captured the pharmacoeconomic impact of MIV versus non-opioid intravenous analgesics (acetaminophen, ibuprofen, ketorolac) among a hypothetical adult cohort undergoing selected inpatient procedures and experiencing moderate-severe acute postoperative pain: Part1 (postoperative hour0 to discharge, cycled hourly), health states were defined by pain level. Pain transition rates, adverse event probabilities, and concomitant opioid utilization were derived from a network meta-analysis. Part2 (discharge to week52, cycled weekly), health states were defined by the presence/absence of pain-related readmission and opioid use disorder as determined by literature-based inputs relating to pain control outcomes. Healthcare utilization and direct medical costs were derived from an administrative claims database analysis. Primary outcomes were the incremental cost per member per month (PMPM) and cost per quality-adjusted life year (QALY) gained. Scenario, univariate, and probabilistic sensitivity analyses were conducted. The model assumed a private payer perspective in the USA (no discounting, 2019 US$). Modeled outcomes indicated MIV was associated with lower accumulated postoperative pain, fewer adverse events, and less opioid utilization for most procedures and comparators, with longer-term outcomes also generally favoring MIV. The budget impact of MIV was - $0.028PMPM. From a cost-effectiveness perspective, MIV had lower costs and better outcomes for all comparisons except against ketorolac in orthopedic procedures where the former was cost-effective but not cost saving ($95,925/QALY). Scenario and sensitivity analyses indicated that modeled outcomes were robust to alternative inputs and underlying input uncertainty. Differences in direct medical costs were driven by reduced costs attributable to length of stay and opioid-related adverse drug events. MIV was associated with modeled clinical and economic benefits compared to commonly used non-opioid intravenous analgesics.

Opioids in advanced lung malignancy: a clinical audit of opioid prescription, patient education and safeguarding

Opioids have an important role in symptom management for people with advanced cancer. Clinical guidelines recommend patient education to ensure the safe use of opioids; however, no Australian studies have explored current education and safeguarding practices when opioids are initiated to advanced cancer patients. To investigate risk assessment, safeguarding and education practices when opioids are first prescribed to advanced lung cancer patients. A retrospective medical record audit of outpatients with advanced non-small cell lung cancer seen at a tertiary Australian hospital between 1 January 2015 and 31 December 2019 and prescribed strong opioids for cancer-related symptoms. Of 1022 patients attending the lung cancer clinic, 205 were newly initiated on an opioid. Opioid-related risks including previous recreational drug use (28; 13.6%) and history of falls (16; 7.9%) were infrequently documented. Opioid-related safeguards and adverse effects management were variably instituted: written general practitioner correspondence at opioid initiation (62; 30%), clinic follow up (186; 91%) and laxative co-prescription (55; 26.8%). Most patients (137; 66.8%) received no documented opioid education on drug initiation. There was no association between age (P = 0.653), number of comorbidities (P = 0.569) or chronic alcohol use (P = 0.263) and the provision of education on opioid initiation. Palliative care doctors or nurse practitioners were eight times more likely to document opioid education than medical oncologists (odds ratio=8.5; confidence interval=2.9-24.8; P < 0.0001). Guideline-recommended risk assessment, safeguards and patient education were infrequently documented when opioids were initiated. Clinician training, decision-assist prompts in electronic prescribing software and written education resources for patients may address these gaps in care.

A critical review of oliceridine injection as an IV opioid analgesic for the management of severe acute pain

ABSTRACT Introduction Oliceridine is a G protein-selective (biased) agonist at the μ-opioid receptor, with less recruitment of β-arrestin-2, a signaling pathway associated with opioid-related adverse events. Nonclinical evidence showed that oliceridine elicits a rapid systemic analgesic effect while attenuating opioid-related adverse events. Areas covered Three pivotal studies in patients with moderate-to-severe acute pain, including two randomized, double-blind, placebo- and morphine-controlled efficacy studies following either orthopedic surgery-bunionectomy or plastic surgery-abdominoplasty; and an open-label safety study following a surgical procedure or due to a medical condition. Expert opinion Poorly controlled acute postoperative pain is associated with poorer recovery, longer hospitalization, increased complications, and worse healthcare outcomes. Recently, oliceridine intravenous injection was approved for use in adults for the management of acute pain severe enough to require an intravenous opioid analgesic and for whom alternative treatments are inadequate. Introduction of this new IV opioid provides a valuable option to manage postoperative pain.

Caudal epidural morphine versus intravenous morphine for postoperative analgesia in pediatric cardiac surgery

Background &amp; objective: Traditionally, analgesia after heart surgery is obtained with the use of intravenous opioids (particularly morphine). Continuous infusion of narcotic analgesics results in a more constant level of analgesia, but slow accumulation may cause excessive sedation. The caudal epidural narcotics, alone or with local anesthetics have been advocated following lower abdominal and thoracic surgery in children. We compared the analgesic effect and safety of caudal epidural morphine (CEM) after heart surgery with intravenous morphine infusion.&#x0D; Methodology: Sixty children, aged 6 months to 5 y, undergoing elective cardiac surgery under general anesthesia were enrolled in the study. The patients were randomly allocated to one of the two groups to receive either 0.06 mg/kg CEM at induction of anesthesia (study group or CEM group) or postoperative morphine infusion at a rate of 0.025 mg/kg/h intravenously (control group or PIVM group). Postoperative pain scores were assessed according to the COMFORT behavior scale. Two patients were excluded from the study after randomization and 58 patients completed the study.&#x0D; Results: Time from pediatric intensive care unit (PICU) admission to the need of intravenous morphine boluses was significantly longer in the CEM group compared with the control group (16-20 h vs 38 min; P &lt; 0.0001). In CEM group, 68.97% of patients did not require additional morphine and the total intravenous morphine consumption over the 48 h postoperatively was lower (P &lt; 0.0001). Moreover, the use of CEM resulted in earlier extubation and earlier discharge from the PICU (P = 0.011). Over-sedation was recorded in the control group on the first postoperative day. The incidence of adverse events was low in both groups. Respiratory depression was not seen in CEM group patients.&#x0D; Conclusion: A single dose of morphine 0.06 mg/kg in caudal epidural, preoperatively in pediatric cardiac surgery, had a significant intravenous morphine sparing effect as compared to a postoperative morphine infusion at a rate of 0.025 mg/kg/h, and was associated with a low incidence of adverse events after pediatric cardiac surgery. Effective analgesia was achieved for 16-20 h after surgery.&#x0D; Key words: Caudal epidural morphine; COMFORT behavior scale; Opioid–related adverse events; Pediatric cardiac surgery; Analgesia, Postoperative&#x0D; Citation: Nguyen TD, Ngo D, Pham NH, Jantzen T. Caudal epidural morphine versus intravenous morphine for postoperative analgesia in pediatric cardiac surgery. Anaesth. pain intensive care 2022;26(4):514-522.&#x0D; DOI: 10.35975/apic.v26i4.1959&#x0D; Received: August 15, 2022; Reviewed: January 02, 2022; Accepted: July 07, 2022