Articles: opioid.
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The opioid crisis most likely is the most profound public health crisis our nation has faced. In 2015 alone, 52,000 people died of drug overdoses, with over 30,000 of those people dying from opioid drugs. A recent community forum led by the Cleveland Clinic contrasted this yearly death rate with the loss of 58,000 American lives in 4 years of the Vietnam War. The present review describes the origins of this opioid epidemic and provides context for our present circumstances. ⋯ Alarmingly, the overwhelming majority of opioid abusers begin their addiction with prescription medications, primarily for chronic pain. Chronic postoperative pain, which occurs in 10-50% of surgical patients, is a major concern in many types of surgery. Nationwide, the medical community has made it a priority to ensure that postsurgical analgesia is sufficient to control pain without increasing non-medically appropriate opioid use. The opioid epidemic remains a significant pressing issue and will not resolve easily. Numerous factors, including the inappropriate prescription of opioids, lack of understanding of the potential adverse effects of long-term therapy, opioid misuse, abuse, and dependence, have contributed to the current crisis.
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Curr Pain Headache Rep · Feb 2018
ReviewChronification of Pain: Mechanisms, Current Understanding, and Clinical Implications.
The development of acute to chronic pain involves distinct pathophysiological changes in the peripheral and central nervous systems. This article reviews the mechanisms, etiologies, and management of chronic pain syndromes with updates from recent findings in the literature. ⋯ Chronic post-surgical pain (CPSP) is not limited to major surgeries and can develop after smaller procedures such as hernia repairs. While nerve injury has traditionally been thought to be the culprit for CPSP, it is evident that nerve-sparing surgical techniques are not completely preventative. Regional analgesia and agents such as ketamine, gabapentinoids, and COX-2 inhibitors have also been found to decrease the risks of developing chronic pain to varying degrees. Yet, given the correlation of central sensitization with the development of chronic pain, it is reasonable to utilize aggressive multimodal analgesia whenever possible. Development of chronic pain is typically a result of peripheral and central sensitization, with CPSP being one of the most common presentations. Using minimally invasive surgical techniques may reduce the risk of CPSP. Regional anesthetic techniques and preemptive analgesia should also be utilized when appropriate to reduce the intensity and duration of acute post-operative pain, which has been correlated with higher incidences of chronic pain.
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Randomized Controlled Trial
Effect of sufentanil on bispectral index in the elderly.
We examined the impact of adding sufentanil during anaesthesia induction with propofol on bispectral index values in elderly patients (≥ 65 years). Patients were randomly assigned to receive a target-controlled sufentanil infusion (effect-site concentration of 0.3 ng.ml-1 ) or matching placebo, followed by a target-controlled propofol induction (initial effect-site concentration of 0.5 μg.ml-1 ; step-wise increase of 0.5 μg.ml-1 ) until loss of consciousness defined as an Observer's Assessment of Alertness/Sedation score < 2. Seventy-one patients (sufentanil 35, placebo 36) completed the study. ⋯ At loss of consciousness, mean (SD) bispectral index value was 75.0 (8.6) with sufentanil and 70.0 (8.0) with placebo; mean difference -5.0 (95% confidence interval -8.9 to -1.1), p = 0.013. Post-hoc analyses suggest that the difference was significant in men only (mean difference -7.3 (-11.8 to -2.6), p = 0.003). Sufentanil co-induction with propofol results in higher bispectral index values at loss of consciousness in elderly patients.
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The number of opioids prescribed and used has increased precipitously over the past 2 decades for a number of reasons and has led to increases in long-term dependency, opioid-related deaths, and diversion. Most studies examining the role of prescribing habits have investigated nonoperative providers, although there is some literature describing perioperative opioid prescription and use. There are no studies looking at the number of pills consumed after outpatient foot and ankle surgeries, nor are there guidelines for how many pills providers should prescribe. The purpose of this study was to quantify the number of narcotic pills taken by opioid-naïve patients undergoing outpatient foot and ankle surgeries with regional anesthesia. ⋯ Level II, prospective comparative study.
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Am. J. Obstet. Gynecol. · Feb 2018
ReviewPerioperative pain management: an update for obstetrician-gynecologists.
The opioid epidemic in the United States is unprecedented and continues to worsen. Many opioid abusers obtain their pills through legitimate prescriptions, directly or indirectly, from a medical provider. While practitioners have a responsibility to treat pain, it is now becoming clear that aggressive opioid prescription practices contribute to an epidemic of abuse. ⋯ Therefore, the objective of this publication was to familiarize obstetricians and gynecologists with contemporary concepts in pain management and summarize recent guidelines in a manner that is applicable to our specialty. We focus on perioperative pain management, which is the time period immediately before, during, and after surgery. Topics reviewed include proper risk assessment to evaluate a patient's potential for poor pain control or development of chronic pain or misuse of opioids; multimodal pain management with nonpharmacological, nonopioid alternatives, safe opioid-use strategies; education and documentation; and special considerations for women, veterans, and lactation concerns.