Articles: opioid.
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The United States underwent massive expansion in opioid prescribing from 1990-2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. ⋯ Key messagesAlthough opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised. Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny. Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.
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Cystic fibrosis (CF) is a rare genetic multisystemic disorder with progressive abdominal and pulmonary involvement. Pain is still an underestimated symptom in CF patients. ⋯ Pain management in CF requires meticulous monitoring as well as an interdisciplinary approach and should be implemented in the German CF guidelines. The authors also want to suggest recommendations for the treatment of thoracic pain in CF. The range and severity of organ involvement complicates the use both of opioids and non-opioids. Especially opioid treatment carries the risk of hypoxia and opioid-induced constipation (OIC) and needs close medical supervision.
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Also in ambulatory surgery, there will usually be a need for analgesic medication to deal with postoperative pain. Even so, a significant proportion of ambulatory surgery patients have unacceptable postoperative pain, and there is a need for better education in how to provide proper prophylaxis and treatment. ⋯ Multimodal analgesia should start pre or per-operatively and include paracetamol, nonsteroidal anti-inflammatory drug (NSAID), dexamethasone (or alternative glucocorticoid) and local anaesthetic wound infiltration, unless contraindicated in the individual case. Paracetamol and NSAID should be continued postoperatively, supplemented with opioid on top as needed. Extra analgesia may be considered when appropriate and needed. First-line options include nerve blocks or interfascial plane blocks and i.v. lidocaine infusion. In addition, gabapentinnoids, dexmedetomidine, ketamine infusion and clonidine may be used, but adverse effects of sedation, dizziness and hypotension must be carefully considered in the ambulatory setting.
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Drug misuse is a global problem. Markets that supply illegal drugs often span international borders. However, each country has different primary drugs of use, populations that are using and consequences of use. ⋯ Key MessagesWhile the primary approach to addressing drug use has focussed resources on law enforcement for over 100 years, many countries are adopting elements of a public health approach including prevention and treatment of the harms of drug use including substance use disorders. There is a growing global movement to make policy towards drugs and drug users more humane and evidence-based. Donor nation resources can be applied in a variety of combinations to improve care and outcomes for people who use drugs in low- and middle-income countries.
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Curr Pain Headache Rep · Nov 2022
ReviewUltrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain.
Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies. ⋯ In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.