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Publications American Journal of Disaster Medicine Opioid Management
Society Journal of Neurodegeneration & Regeneration Activities Directors' Quarterly for Alzheimer's & Other Dementia Patients American Journal of Recreation Therapy |
January/February 2009; pages 7-9
January/February 2009; pages 10-10
January/February 2009; pages 11-21 Abstract Objective: This study aimed to describe intensity and treatment of symptoms other than pain in European palliative care units. Patients: A total of 3,030 patients, including 2,064 that used an opioid, were included from 143 palliative care centers, in 21 European countries. Results: Pain was treated with analgesics corresponding to the WHO pain ladder step I (n = 374), II (n = 497), and III (n = 1,567). Frequencies of symptoms observed as moderate or severe were for generalized weakness (50 percent), fatigue (48 percent), anxiety (28 percent), anorexia (26 percent), constipation (18 percent), focal weakness (18 percent), depression (18 percent), and dyspnoea (15 percent). When comparing WHO-groups, cancer diagnoses, metastasis sites, countries, and genders, we found that some of the symptom intensities and treatments differed significantly between subgroups. A majority of patients used drugs for symptom management. Still, more than one-third of patients assessed to have moderate or severe constipation did not receive any treatment. The corresponding numbers for depression, confusion, nausea, vomiting, or anxiety were approaching 40 percent and for poor sleep about 50 percent. Prescription practice of antiemetics, laxatives, and psychotropic drugs varied widely between countries both in terms of preparation and percent of patients receiving a specific treatment. Conclusions: This survey shows that clinically relevant symptoms are frequent and that one-third to half of the patients with a symptom observed as moderate or severe do not receive any treatment aimed to reduce the symptom intensity. Several symptoms and treatments differed between WHO-groups, cancer diagnoses, metastasis locations, countries, and genders. Prescription practice varied between countries both in terms of medication administered and percent of patients receiving specific treatment. Key words: cancer, palliative care, opioid, adverse effects, signs and symptoms
January/February 2009; pages 23-26 Abstract Objective: To evaluate the efficacy and safety of inhaled morphine delivered in patients experiencing severe acute pain in an emergency setting. Patients and Methods: Patients were eligible for inclusion if they were aged 18 years or older, with a severe acute pain defined by a numerical rating scale (NRS) score of 60/100 or higher. The intervention involved administering a single dose of 0.2 mg/kg morphine nebulized using a Misty-Neb nebulizer system. NRSs were recorded and were repeated at 1, 3, 5, and 10 minute after the end of inhalation (T10). The protocol-defined primary outcome measure was pain relief (defined by an NRS score of 30/100 or lower) at T10. Secondary outcomes included differences between pain scores at baseline and at T10 and incidence of adverse events. Results: A total of 28 patients were included in this study. No patient experienced pain relief 10 minutes after the end of inhalation, and no adverse effects were recorded. Respective initial and final median NRS scores were 80 (70-90) and 70 (60-80), p < 0.0001. Despite achieving statistical significance, the value of this point estimate is less than the 14 NRS difference that was defined a priori as representing a minimum clinically significant difference in pain severity. Conclusion: 0.2 mg/kg nebulized morphine is not effective in managing acute pain in an emergency setting. In spite of the potential advantages of the pulmonary route of administration, opioids should be intravenous prescribed at short fixed intervals to control severe acute pain in an emergency setting. Key words: morphine, nebulization, acute pain, opioids, emergency medicine
January/February 2009; pages 27-37 Abstract Objective: To evaluate the features and modes of adaptation to aging among Methadone Maintenance Treatment (MMT) enrollees. Setting: Beth Israel Medical Center in New York City. Participants: A sample of 156 MMT enrollees (103/66 percent males and 53/34 percent females) age 24-68 years. Twenty-nine percent of participants were aged 55 or older. Design: A cross-sectional, multivariate, correlational design. Outcome Measures: Participants were administered the MMSE, ASI, BSI, as well as measures of impulsiveness and quality of life (QOL). Results: Older adults were more likely to have had longer periods of treatment (p < 0.01), less likely to report current heroin use (p < 0.05) and overall drug use (p < 0.05), but were more likely to have a history of comorbid alcohol misuse (p < 0.01). Advanced age was also associated with less impulsiveness, hostility, paranoia, and interpersonal sensitivity (p < 0.01), more chronic medical problems (p < 0.05), greater use of medication for medical problems (p < 0.05), and more liberal take home medicine schedules (p < 0.01). However, no differences were found between older and younger participants with respect to their scores on the Overall Social Support scale (p > 0.05), the Personal Well-Being Index (p > 0.05) and the Satisfaction with Life Scale (p > 0.05), suggesting comparable levels of QOL. Furthermore, the rate of contact for older participants with medical professionals did not differ significantly from that of younger participants (p > 0.05). Only 7.1 percent of older participants reported regular contact with a primary care physician; a rate that is slightly lower than the rate in the overall population. Conclusions: The findings from the present study highlight at least two underappreciated challenges that clinicians are increasingly likely encounter in their work with the aging MMT population. These challenges are: (1) that despite numerous medical and psychiatric complaints, only a small proportion of MMT patients have regular contact with a primary care physician and the rate of contact does not appear to increase with age and (2) even with age-related declines in psychiatric comorbidity and illicit substance use, the suboptimal level of QOL that is characteristic of the MMT population as a whole does not improve with aging and length of tenure in MMT. Key words: methadone maintenance, aging
January/February 2009; pages 39-45 Abstract Although most extended-release morphine formulations are indicated for use once-daily (q24h) or twicedaily (q12h), KADIAN® (morphine sulfate extended-release) capsules, which contain polymer-coated, extended-release morphine sulfate pellets, are indicated for q24h and q12h dosing. This analysis identified factors that might impact decisions to choose q24h or q12h regimens for patients with chronic, nonmalignant pain. Data were obtained from a supplemental analysis of the KRONUS-MSP trial, a community-based, open-label, 4-week study in which patients with chronic, nonmalignant pain (N = 1,428) were randomized to KADIAN q24h dosed either AM or PM. At week 2, investigators could switch to q12h dosing if indicated. For this analysis, demographics, baseline pain features, efficacy outcomes (changes in pain intensity, sleep interference, quality of life [SF-36v2 Health Survey], and Patient and Clinician Global Assessments of Therapy) were compared between patients who remained on q24h regimens and those who switched to q12h. By week 4 (n = 1,042), 56.8 percent of patients reporting were on q24h dosing, and 43.2 percent were dosing q12h. Older patients remained on q24h regimens more frequently than did younger patients. There were no differences in dosing regimen based on sex or race. Mean daily KADIAN doses and baseline pain scores were lower in patients who remained on q24h compared with those who switched to q12h. Patients who switched to q12h had higher pain scores at baseline and week 2 compared with patients who remained on q24h dosing. They demonstrated a smaller degree of change on the other efficacy outcomes than those who remained on q24h dosing at the week 2 visit. However, once switched to q12h, improvements in efficacy measures at week 4 were comparable between the two schedules; Patient and Clinician Global Assessments of Therapy scores also increased compared with previous therapy. Results were significant versus baseline for all outcomes. Adverse event rates were similar for the two groups; the most common adverse events were constipation and nausea. Results demonstrate that KADIAN was effective in relieving pain and improving sleep and quality-of-life scores, regardless of whether patients dosed q24h or q12h, and that dosing decisions can be made, based on individual factors, within the first few weeks of therapy. Key words: KADIAN, morphine, opioid, extended-release opioid, pain, chronic pain, long-acting opioid
January/February 2009; pages 47-55 Abstract The infant exposed to opioids in utero frequently presents a challenge to the neonatal care provider in the assessment and treatment of symptoms of Neonatal Abstinence Syndrome (NAS) after birth. This review is intended to provide the healthcare professional with a brief review of current evidence and practical guidelines for optimal evaluation and pharmacologic management of the opioid-exposed newborn. Key words: neonatal abstinence syndrome, methadone, opioids, infant, substance abuse
January/February 2009; pages 59-64 Abstract A significant breakthrough in the treatment of opioid addiction occurred with the passage of the Data Addiction Treatment Act of 2000 (DATA 2000),1 signed into law by President Clinton, which allowed physicians for the first time in more than eight decades to prescribe opioid medications for the treatment of opioid addiction in the normal course of their practice. Two years later, on October 8, 2002, Suboxone (Buprenorphine/Naloxone) and Subutex (Buprenorphine) received FDA approval for the treatment of opioid addiction. Prior to DATA 2000, opioid maintenance treatment was available through highly regulated methadone clinics. This article discusses opioid addiction in the United States today and the principles of buprenorphine therapy. Key words: buprenorphine, maintenance therapy, opioid addiction, opioid withdrawal Journal of Opioid Management March/April 2009, Volume 5, Number 2
March/April 2009; pages 71-73
March/April 2009; pages 75-80 Abstract Objective: To evaluate the safety and efficacy of a single dose of 2 mg IV hydromorphone administered to emergency department patients in acute severe pain. Design: Prospective interventional. Setting: Urban academic emergency department. Patient, participants: Nonelderly adults (21-64 years old) with acute severe pain and baseline oxygen saturation (SO2) _95 percent. Interventions: Two milligrams IV hydromorphone administered over 2-3 minutes. Main outcome measures: The primary outcome was use of naloxone as a reversal agent. Secondary outcomes included degree of pain relief as measured on a numerical rating scale, frequency of oxygen desaturation (SO2 < 95 percent), and side effects. Results: Of the 269 patients, none received IV naloxone. Median pain scores fell from 10 (worst pain possible) at baseline to 1 within 5 minutes and to 0 (no pain) at 30 minutes. SO2 was = 95 percent at all time points in 68 percent of patients (95 percent CI 62-73 percent), while 26 percent (95 percent CI 21-32 percent) had one or more SO2 levels between 90-94 percent, and 6 percent (95 percent CI 4-10 percent) had SO2 values below 90 percent at one or more time points. The lowest SO2 was 82 percent. The incidence of nausea and vomiting were 16 percent and 7 percent, respectively. Conclusions: Two milligrams IV hydromorphone provides efficacious and rapid pain relief in nonelderly adults presenting to the ED with acute severe pain. However, oxygen desaturation below 95 percent occurred in about one third of patients. Although no noticeable clinical signs of hypoxemia occurred, a conservative interpretation of this finding suggests that 2 mg IV hydromorphone is too much opioid to be given routinely to patients in pain as a single initial dose. Key words: acute, pain, hydromorphone, emergency department, efficacy, safety
March/April 2009; pages 81-87 Abstract Generic drugs account for half of all prescription drug purchases in the United States. Although they are bioequivalent to their branded counterparts, they are typically sold at substantial discounts from the branded price. Given this, the purpose of this analysis is to examine the impact of the introduction of generic forms of selected opioids on their diversion to the illicit marketplace. The analgesics in this analysis include oxycodone ER (extended release), and the fentanyl transdermal patch. The data were collected through a postmarketing surveillance initiative supported by the Researched Abuse Diversion and Addiction-Related Surveillance (RADARS®) System risk management program, gathered on a quarterly basis from a national sample of police and regulatory agencies. The results indicate that with oxycodone ER and the fentanyl transdermal patch, the diversion of their generic formulations occurs less often than that of the branded products, and that the introduction of the generic formulations did not significantly increase the overall levels of diversion during the period covered by this analysis. Although diversion did not increase in the short-term, the need for longer term monitoring appears warranted. Key words: diversion, oxycodone, opioids, generics, fentanyl
March/April 2009; pages 89-96 Abstract Pain is one of the most common symptoms experienced by cancer patients during the course of their illness. It can negatively impact patients’ quality of life, functional status, and progress during rehabilitation. Despite the widespread availability of analgesic therapies, cancer pain remains undertreated. Developing knowledge and skills on cancer pain management is of extreme importance for healthcare providers dealing with cancer patients. The goal of this article is to review the principles of pharmacological therapy of cancer pain, to describe the basic pathophysiological mechanisms and etiologies of cancer pain, and to highlight the elements of a thorough pain assessment. Key words: opioids, cancer, pain
March/April 2009; pages 97-105 Abstract Objective: To assess the safety and efficacy of long-term repeated dosing of OROS® hydromorphone in chronic pain patients. Design: This multicenter, open-label extension trial enrolled patients from three short-term OROS® hydromorphone trials. Setting: Fifty-six centers in the United States and Canada. Patients: Adults with chronic cancer pain or chronic nonmalignant pain who were receiving stable doses of OROS® hydromorphone (= 8 mg/day). Three hundred and eighty-eight patients were enrolled, 106 patients completed at least 12 months of therapy. Interventions: OROS® hydromorphone (individualized doses) was administered once daily. Main outcome measures: Safety and efficacy (Brief Pain Inventory and patient and investigator global evaluations) were assessed at monthly visits. Results: The median duration of extended OROS® hydromorphone therapy was 274 days. The median daily dose of study medication was 32.0 mg at extension-study baseline, 40.0 mg at month 3, and 48.0 mg at months 6, 9, and 12, respectively. The most frequently reported adverse events were nausea (n = 93, 24.0 percent) and constipation (n = 75, 19.3 percent). The analgesic effects of OROS® hydromorphone, assessed using the Brief Pain Inventory, were maintained throughout the extension. At 12 months, 72.4 percent of patients and 75.9 percent of investigators rated overall treatment as good, very good, or excellent. Conclusions: Once-daily OROS® hydromorphone is an osmotically driven, controlled-release preparation that may be particularly well suited to long-term use, because it provides consistent plasma concentrations and sustained around-the-clock analgesia. In this study, the benefits of OROS® hydromorphone attained in short-term studies were maintained in the long-term when daily administration was continued. Key words: chronic pain, long-term management, hydromorphone, safety, tolerability, efficacy
March/April 2009; pages 107-114 Abstract Background: Limited case reports have suggested a role for methadone as an analgesic for chronic pain in patients maintained on methadone for treatment of opiate addiction. Patients with HIV are disproportionately represented in this population and often have severe, debilitating chronic pain syndromes of multiple etiologies, including cancer-related pain syndromes. Objective: This study evaluated the safety and efficacy of initiating and maintaining additional methadone for chronic pain in HIV-positive patients with ongoing treatment for opiate addiction in methadone maintenance treatment programs (MMTPs). Methods: We performed a retrospective chart review of 53 HIV/AIDS patients (36 male, 17 female; 24 with cancer) with diverse chronic pain syndromes who were followed in an HIV Pain Clinic and were currently enrolled in an MMTP. The outcome measure was pain, assessed using a numeric rating scale (0-10). Incidence of heroin use was also measured. Results: The mean methadone dose initially prescribed for analgesia was approximately equal to 67 percent of the methadone dose used in the MMTP for addiction. Over the 12-month retrospective observation period, methadone was titrated to approximately 200 percent of the methadone maintenance dose. The mean pain score at initial visit to the Pain Clinic was 9.4 + 1.03. After methadone for analgesia has been administered for 1 month, the mean pain score decreased to 5.35 ± 1.7 (p < 0.001), at 3 months, 4.8 ± 1.3 (p < 0.001), at 6 months, 4.2 ± 1.7 (p < 0.001), and at 12 months, 4.2 ± 1.4 (p < 0.001). No serious adverse events or side effects were observed with methadone therapy for analgesia. Conclusion: HIV/AIDS patients with chronic pain enrolled in MMTPs achieved improved analgesia with no serious side effects when additional methadone was administered for pain relief. Further controlled studies are needed to confirm our findings and to establish the safety and efficacy of methadone therapy for chronic pain in this population. Key words: methadone, addiction, pain, methadone maintenance treatment program
March/April 2009; pages 115-122 Abstract Background: Prehospital emergency physicians (EP) are often confronted with the acute care of palliative care patients. Dyspnoea is a frequent acute symptom and its causes often differ from the generally known emergency medical causes. Till now, there have been no relevant concepts for emergency care of palliative care patients for their specific symptoms. Methods: Over a 24-month period, the authors retrospectively investigated all out-of-hospital emergency medical services for palliative care patients with acute dyspnoea at four emergency physician support points. The evaluation of these services was followed retrospectively on the basis of the therapy carried out by the EP (Group 1: therapy with morphine and oxygen; Group 2: therapy with morphine, bronchodilator effective drugs and oxygen; Group 3: therapy with bronchodilator effective drugs and oxygen; Group 4: therapy with oxygen; Group 5: no medical treatment). Moreover, EPs were interviewed about their actions and their uncertainties in the treatment of palliative care patients. Results: The diagnosis of acute dyspnoea in palliative care patients occurred 121 times (116 patients were integrated in the present investigation) within the defined period. In total, 116 patients were included (Group 1: 21, Group 2: 29, Group 3: 31, Group 4: 28, and Group 5: 7). Dyspnoea was satisfactorily treated in 41 percent of the patients (Group 1: 67 percent, Group 2: 52 percent, Group 3: 22 percent, Group 4: 18 percent, and Group 5: 71 percent). Most EPs (70 percent) revealed uncertainties in emergency medical therapy for patients at the end of life. Conclusions: The current investigation showed a significant relief of acute dyspnoea when using opioids, in contrast with the established out-of-hospital emergency medical therapy for acute dyspnoea. Therefore, opioids should be recommended for emergency medical therapy of dyspnoea in palliative care patients. Clinical studies that recommend the use of effective opioids for the treatment of dyspnoea in palliative care patients are supported by the current retrospective study. Most EPs felt uncertain in the treatment of palliative care patients. Therefore, advanced training in palliative care medicine and end-of-life care should be integrated into emergency medical training. Key words: palliative emergency, prehospital emergency care, dyspnoea, symptom control, respiratory depression Journal of Opioid Management May/June 2009, Volume 5, Number 3
May/June 2009; pages 131-133
May/June 2009; pages 134-134
May/June 2009; pages 137-140 Abstract Objective: To characterize the impact of opioid-induced constipation (OIC) on healthcare resource use, work productivity, and health-related quality of life (HRQOL) in patients receiving chronic opioid therapy. Design: Data were collected via Internet questionnaires during the international National Health and Wellness Survey (NHWS) 2004 from individuals aged >/= 18 years who reported taking opioids for >/= 6 months. Healthcare resource utilization, Work Productivity, and Activity Impairment, and Short-Form 8 (SF-8) questionnaire responses were compared between those who did or did not report OIC. Results: Data were available from 2,430 individuals receiving opioids, of whom 359 reported OIC. Participants with OIC reported significantly more physician visits (mean difference 3.84 visits; p < 0.05) and alternative care provider visits (mean difference 1.73 visits; p < 0.05) over the previous 6 months than those without OIC; however, no significant differences in emergency room visits or number of days of hospitalization were observed. Respondents with OIC also reported significantly greater time missed from work, impairment while working, overall work impairment, and activity impairment (p < 0.05 for all comparisons). HRQOL scores were significantly lower in the OIC group than those without OIC on both the physical and mental components of the SF-8 questionnaire (p _ 0.05 for both comparisons). Conclusions: The survey results reflect a negative impact of OIC on individuals’ HRQOL and on society in terms of healthcare resource use and work productivity beyond that imposed by patients’ pain conditions. These findings indicate a need for effective treatment for opioid-induced constipation in patients receiving chronic opioid therapy. Key words: constipation, opioid, quality-of-life, productivity, pain management
May/June 2009; pages 145-151 Abstract Opioids are the mainstay of management for patients with cancer-related pain. Although the analgesic efficacy of opioid therapy is well documented, the recent European Pain in Cancer survey demonstrated that the management of moderate-to-severe pain in patients with cancer is far from optimal. Bowel dysfunction, and importantly constipation, is a common side effect and has a significant impact on the patient’s morbidity and quality of life. Nonpharmacological strategies and laxatives are often not effective in the management of opioid-induced constipation (OIC), making it necessary to search for new strategies for the treatment of opioid-induced bowel dysfunction. One promising strategy is the prevention of OIC with peripherally acting opioid antagonists that specifically target the underlying cause of this condition, without affecting centrally mediated analgesia. In recent studies, the novel combination of prolonged-release oral oxycodone and prolonged-release oral naloxone provided effective analgesia with improved bowel function in patients suffering from severe cancer-related and noncancer- related pain. The combination has the potential to improve the quality of pain management significantly in these patients. Key words: cancer, constipation, naloxone, opioid, oxycodone, pain
May/June 2009; pages 153-168 Abstract Cannabis (marijuana) has been used for medicinal purposes for millennia, said to be first noted by the Chinese in c. 2737 BCE. Medicinal cannabis arrived in the United States much later, burdened with a remarkably checkered, yet colorful, history. Despite early robust use, after the advent of opioids and aspirin, medicinal cannabis use faded. Cannabis was criminalized in the United States in 1937, against the advice of the American Medical Association submitted on record to Congress. The past few decades have seen renewed interest in medicinal cannabis, with the National Institutes of Health, the Institute of Medicine, and the American College of Physicians, all issuing statements of support for further research and development. The recently discovered endocannabinoid system has greatly increased our understanding of the actions of exogenous cannabis. Endocannabinoids appear to control pain, muscle tone, mood state, appetite, and inflammation, among other effects. Cannabis contains more than 100 different cannabinoids and has the capacity for analgesia through neuromodulation in ascending and descending pain pathways, neuroprotection, and anti-inflammatory mechanisms. This article reviews the current and emerging research on the physiological mechanisms of cannabinoids and their applications in managing chronic pain, muscle spasticity, cachexia, and other debilitating problems. Key words: cannabinoids, cannabis, marijuana, chronic pain, opioids, opiates, botanical medicine
May/June 2009; pages 169-174 Abstract Objective: To assess awareness of existing pain management guidelines and compare physicians’ confidence versus competence in selected pain management skills. Design: Prospective survey study. Setting: A large urban tertiary medical center. Patients, participants: All Department of Medicine interns, senior residents, and attending physicians were sent a questionnaire; the overall response rate was 30 percent (91/304). Interventions: The questionnaire assessed physicians’ awareness of the institution’s pain management guidelines, their self-reported comfort level (confidence) with, and a knowledge assessment (competence) of three pain management skills (managing chronic-continuous pain, equianalgesic dose conversion, and managing breakthrough pain) using validated, standardized case vignettes. Main outcome measures: A comparison of physicians’ confidence with their competence in these pain management skills. Results: A total of 23 percent (21/91) of the respondents reported an awareness of the institution’s pain management guidelines. Interns were significantly less confident than senior residents in all three pain management skills (p < 0.001, 0.006, 0.02) but nonsignificantly more competent in two of three skills (chronic-continuous pain, dose conversion). Attendings were generally more confident and nonsignificantly more competent than senior residents in all three pain management skills. Conclusions: The underutilization of the pain management guidelines illustrates that the mere existence of these resources as a means of ensuring optimal pain management is insufficient. Creative pain management educational initiatives are needed to address the disparity between physician confidence and competence. Key words: pain management, physician knowledge, physician confidence
May/June 2009; pages 175-179 Abstract Buprenorphine is a partial agonist/antagonist used for the outpatient management of pain and addiction. It avidly binds to the opioid receptors and has a long and varied half-life. Its effects can impair the efficacy of opioids used for postoperative pain. The authors present a case of a patient managed with buprenorphine as an outpatient who presented for revision spine surgery and had significant postoperative pain that was successfully treated with hydromorphone and dexmedetomidine. This is the first reported use of dexmedetomidine for postoperative pain in a patient treated with buprenorphine. Key words: opioid, Precedex, Suboxone, Subutex Journal of Opioid Management July/August 2009, Volume 5, Number 4
July/August 2009; pages 187-187
July/August 2009; pages 189-195 Abstract Purpose: Epidural morphine has been associated with a significant incidence of postoperative nausea and vomiting (PONV). The authors have evaluated the prophylactic effects of midazolam in preventing nausea and vomiting following epidural morphine for postoperative pain control. Methods: The authors studied 80 women (n = 40 in each group) undergoing total abdominal hysterectomy under epidural anesthesia, in a randomized, double-blind, placebo-controlled study. At the end of the surgery, all patients received epidural morphine 3 mg for postoperative pain. Before morphine injection, the midazolam group received lowdose midazolam infusion (1 mg bolus followed by 1 mg h-1), while the placebo group received IV saline. Results: Patients in the midazolam group reported a lower incidence of total PONV, and a lower frequency of rescue antiemetic request than those in the placebo group (p < 0.05). In addition, midazolam was associated with a reduced incidence of pruritus following epidural morphine (p < 0.05). Conclusion: The authors conclude that low-dose midazolam infusion is effective in the prevention of nausea, vomiting, and pruritus following epidural morphine for postoperative pain control. Key words: midazolam, nausea, vomiting
July/August 2009; pages 197-202 Abstract Subarachnoid block is a widely used technique for cesarean section. Opioids adding to the local anesthetics can improve its quality. In this prospective, randomized, double blind, controlled trial, we compared the effects of coadministration of intrathecal sufentanil and morphine with intrathecal sufentanil and a single administration of subcutaneous morphine. Sixty-four pregnant women scheduled for elective cesarean section under spinal anesthesia were assigned to two groups according to the way of administration of morphine: intrathecal sufentanil (5 ?g) plus intrathecal morphine (150 ?g) (ITM group), and intrathecal sufentanil (5 ?g) plus single administration of 10 mg subcutaneous morphine (SCM group). In both groups, the local anesthetic used was hyperbaric bupivacaine 0.5 percent (10 mg). Both groups received 1 g acetaminophen every 6 hours. In the postoperative period, pain was recorded on a 0-100 visual analog scale (VAS) and intravenous tramadol (100 mg) was administered if VAS score was >40 mm. Collateral effects, such us nausea, itching, respiratory depression, and sedation were assessed. VAS scores at rest and on coughing were significantly higher in the SCM group than in the ITM group between 3 and 24 hours. The mean titrated dose of tramadol consumed was also significantly greater in the SCM group than in the ITM group (p < 0.05). The time to first administration of tramadol was lower in the SCM group versus the ITM group (p < 0.05). The incidence of nausea was significantly lower in the SCM group than in the ITM group (p < 0.05). There was no significant group difference in the incidence of pruritus (p > 0.05). In conclusion, coadministration of sufentanil and morphine into the subarachnoid space was effective and provided longer pain relief than intrathecal sufentanil plus a single injection of subcutaneous morphine, despite a higher incidence of side effects such as nausea and vomiting. Key words: spinal anesthesia, local anesthetic, postoperative pain, spinal opioids, cesarean section
July/August 2009; pages 203-212 Abstract The rate of drug delivery to the central nervous system is believed to be an important predictor of the reinforcing strength of a drug. However, only a few studies have directly examined the relationship between drug-taking behavior and rate of drug administration. The purpose of the present experiment was to determine whether manipulating the infusion rate of a fixed dose of opioid alters its reinforcing effectiveness in humans. Twelve heroin-dependent participants (11 male, one female) completed the 2.5-week inpatient study. During test days, participants received $20 and a dose of drug (0 or 40 mg oxycodone administered intravenously over 2, 15, 30, 60, or 90 minutes) in random order during a morning sample session. Participants then worked for the sampled dose and/or money amount during an afternoon choice session by making finger presses on a computer mouse. Under these conditions, 40 mg oxycodone served as a reinforce only when it was delivered over 2 and 15 minutes. Subjective ratings of drug liking, good effect, and high were similar to the self-administration results. Peak plasma levels of oxycodone generally occurred at the end of each infusion, eg, 2 minutes for the 2-minute infusion duration. Extended-release opioid medications are commonly prescribed for treating pain. The present results provide empirical support for the development of extended-release opioid medications that are difficult to convert into more rapid-acting forms. Specifically, these “abuse-deterrent formulations” could prevent patients from tampering with their medications to enhance their euphoric and reinforcing effects. Key words: abuse deterrent, abuse liability, humans, opiates, oxycodone, rate of infusion, reinforcing effects, self-administration
July/August 2009; pages 213-218 Abstract Objective: Opioids may function to regulate food intake and body weight, an activity that could be predominantly centrally mediated. In this study, the authors evaluated the effects of a peripherally acting opioid receptor antagonist, methylnaltrexone, on weight changes in adult obese ob/ob mice. Results: After a 12-day treatment with naloxone 0.3 mg/kg, weight was reduced from 63.7 ± 1.1 g in the control group to 59.2 ± 0.9 g in the naloxone group (p < 0.05). After a 12-day treatment with methylnaltrexone 3.0 mg/kg, weight increase completely ceased. The body weight was 63.9 ± 1.0 g in the control group when compared with 55.9 ± 1.2 g in the drug group (p < 0.01). The effect of methylnaltrexone (1.0 mg to 3.0 mg/kg) on weight changes was dose-dependent (p < 0.01). Methylnaltrexone significantly reduced daily food intake (p < 0.05), but did not affect body temperature and energy expenditure. Using HPLC analysis, no detectable naltrexone levels were found in association with methylnaltrexone administration. Whether the observed methylnaltrexone effects are primarily related to the antagonism of endorphinergic system remains to be investigated. Conclusions: Our results suggest that the peripheral opioid mechanism contributes to modulating food ingestion and methylnaltrexone may have clinical importance in obesity management. Key words: opioid, naloxone, methylnaltrexone, body weight, food intake, body temperature, energy expenditure, ob/ob mice
July/August 2009; pages 219-227 Abstract More than 2.4 million people are currently incarcerated in the United States, many as a result of drug-related offenses. In addition, more than 200,000 active heroin addicts pass through the correctional system annually. New evidence suggests that both providing prisoners with referrals for community-based methadone programs and providing methadone prior to release reduces recidivism and adverse health and social consequences associated with drug use. This article reports the programmatic challenges associated with initiating methadone treatment in the Rhode Island correctional system. Significant obstacles to implementing methadone treatment include: stigma associated with pharmacological treatment, misconceptions regarding the nature of opioid addiction, logistics of control and storage of methadone, increased work load for nursing staff, and general safety and control concerns. The authors discuss strategies to address these barriers and conclude that providing methadone prior to inmate release is a feasible intervention with the potential to mitigate drugrelated health and social harms. Key words: methadone, incarceration, prisoner health, opiate replacement therapy
July/August 2009; pages 228-236 Abstract Objective: To evaluate female drug overdose deaths from the Office of the Chief Medical Examiner, Western Virginia (1997-2003) for demographics, medical history, toxicology results, and prescribed medications. Design: Autopsy reports, death investigations, and hospital/physician notes were reviewed for 330 fatal drug poisonings among women. Data were evaluated with both qualitative and quantitative methods. Results: Most decedents were Caucasian (95 percent), their average age was 42.8 years, and the predominant manner and cause of death was accidental and polydrug toxicity, respectively. Drugs were identified on toxicology or assigned as a cause of death in all 330 cases. The three most common drug classes detected on toxicology were opioids (n = 239; 72.4 percent), antidepressants (n = 201; 60.9 percent), and sedative/anxiolytic/muscle relaxant (SAMR) (n = 161; 48.8 percent) with all three drug classes detected in 89 (27 percent) cases. Illicit drugs identified included cocaine (n = 33; 10 percent) and heroin (n = 3; 0.9 percent). Prescriptions for opioids, SAMR, and antidepressants were found in decedent name in 48 percent, 67.1 percent, and 58 percent of cases, respectively, and 46.1 percent of cases were prescribed at least one medication from each of those three drug classes. Conclusion: Although many decedents held prescriptions, and often for multiple drugs, toxicological findings indicate the frequent presence of other therapeutic drugs in the absence of a prescription. Moreover, many of these cases held simultaneous prescriptions for which there are known drug interactions. It is likely that misuse, fatal medication errors, abuse, and addiction were factors in the increased numbers of these deaths. Interventions to prevent prescription overdose deaths must involve education of both physicians and patients. Key words: prescription drugs, overdose, opioids, antidepressants, sedatives Journal of Opioid Management September/October 2009, Volume 5, Number 5
September/October 2009; pages 245-246
September/October 2009; pages 247-255 Abstract Objective: In this study, the authors investigated the effect of the addition of remifentanil to tramadol or morphine for patient-controlled analgesia (PCA). Design: Prospective, randomized, double-blind, controlled study. Setting: University Hospital. Patients, participants: The authors randomly allocated 133 patients undergoing major abdominal surgery to receive IV PCA with tramadol alone, tramadol plus remifentanil, morphine alone or morphine plus remifentanil. Interventions: Bolus doses of tramadol (0.2 mg/kg), tramadol (0.2 mg/kg) plus remifentanil (0.2 µg/kg), morphine (0.02 mg/kg), or morphine (0.02 mg/kg) plus remifentanil (0.2 µg/kg) were available every 10 minutes without time limit or background infusion. Main outcome measure(s): Discomfort, sedation, pain scores, side effects, and total and bolus tramadol and morphine consumption were recorded for up to 24 hours after the start of PCA. Results: Pain scores at rest and movement were greater with tramadol alone than in the other groups at 1, 2, and 6 hours (p < 0.0125). The addition of remifentanil reduced cumulative tramadol consumption at 6, 12, and 24 hours, but not morphine consumption. More patients required supplementary rescue analgesia with meperidine, and with greater dosage, with tramadol alone (p < 0.001), and the incidence of nausea was greater with tramadol alone. The addition of remifentanil not only significantly improved discomfort scores in remifentanil groups, but also increased the degree of sedation in morphine-remifentanil group. Conclusions: After major abdominal surgery, adding remifentanil to PCA tramadol resulted in better pain scores, lower analgesic consumption, and fewer side effects when compared with tramadol alone. However, analgesic outcome with remifentanil was not prominent in MR group as much as in TR group. Key words: postoperative pain, analgesia, opioidremifentanil, opioid-morphine, special drugs, tramadol, pharmacology-drug interactions
September/October 2009; pages 257-286 Abstract Objectives: This study was conducted to better understand the characteristics of chronic pain patients seeking treatment with medicinal cannabis (MC). Design: Retrospective chart reviews of 139 patients (87 males, median age 47 years; 52 females, median age 48 years); all were legally qualified for MC use in Washington State. Setting: Regional pain clinic staffed by university faculty. Participants: Inclusion criteria: age 18 years and older; having legally accessed MC treatment, with valid documentation in their medical records. All data were de-identified. Main Outcome Measures: Records were scored for multiple indicators, including time since initial MC authorization, qualifying condition(s), McGill Pain score, functional status, use of other analgesic modalities, including opioids, and patterns of use over time. Results: Of 139 patients, 15 (11 percent) had prior authorizations for MC before seeking care in this clinic. The sample contained 236.4 patient years of authorized MC use. Time of authorized use ranged from 11 days to 8.31 years (median of 1.12 years). Most patients were male (63 percent) yet female patients averaged 0.18 years longer authorized use. There were no other gender-specific trends or factors. Most patients (n = 123, 88 percent) had more than one pain syndrome present. Myofascial pain syndrome was the most common diagnosis (n = 114, 82 percent), followed by neuropathic pain (n = 89, 64 percent), discogenic back pain (n = 72, 51.7 percent), and osteoarthritis (n = 37, 26.6 percent). Other diagnoses included diabetic neuropathy, central pain syndrome, phantom pain, spinal cord injury, fibromyalgia, rheumatoid arthritis, HIV neuropathy, visceral pain, and malignant pain. In 51 (37 percent) patients, there were documented instances of major hurdles related to accessing MC, including prior physicians unwilling to authorize use, legal problems related to MC use, and difficulties in finding an affordable and consistent supply of MC. Conclusions: Data indicate that males and females access MC at approximately the same rate, with similar median authorization times. Although the majority of patient records documented significant symptom alleviation with MC, major treatment access and delivery barriers remain. Key words: cannabis, marijuana, cannabinoids, chronic pain, opioids, opiates
September/October 2009; pages 287-300 Abstract Chronic opioid therapy continues to be an important “mainstream” option for the relief of pain, despite continued debate over the efficacy and safety of utilizing opioids with chronic noncancer populations. With this increase in utilization for medical purposes, the authors have also experienced a troubling rise in the abuse and diversion of prescription opioids. Providers should note this relationship and always perform due diligence when assessing whether a patient with chronic noncancer pain is an appropriate candidate for opioid therapy based on potential risk factors. Because of the relative shortage of board-certified pain practitioners in the United States, much of the practice of pain management falls on primary care providers, who might feel uncomfortable or overwhelmed when facing these issues. To this end, a set of guidelines are discussed to promote an approach to chronic noncancer pain utilizing “universal precautions” principles. In addition, several risk tools are evaluated, including the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R), the Opioid Risk Tool (ORT), and the Pain Assessment and Documentation Tool (PADT). Finally, discussion is presented regarding what practices seen in opioid prescribing can be considered “in-or-out” of the mainstream box. Key words: opioids, drug abuse, prescribing, risk, screening
September/October 2009; pages 301-305 Abstract Objective: Extended-release epidural morphine (EREM) is a single-dose, extended-release epidural morphine formulation intended to provide postoperative pain relief over a 48-hour period. There have been a few randomized controlled trials investigating the use and safety of EREM versus intravenous patient-controlled analgesia with opioids (IV-PCA); however, the adverse event of respiratory depression of this treatment is unclear. The authors have undertaken a meta-analysis to examine this issue. Methods: A systematic literature search of the National Library of Medicine’s PubMed database was conducted for terms related to EREM. Only randomized controlled trials, in the English language, assessing the rates of respiratory depression of EREM to IV-PCA were included for analysis. Data on pertinent study characteristics and relevant outcomes were extracted from accepted articles. Meta-analysis was performed using the Review Manager 4.2.7 (The Cochrane Collaboration, 2004). A random effects model was used. Results: The authors’ literature search yielded three articles which met all inclusion criteria. All studied doses of EREM were evaluated. Pooled estimates (odds ratio) were made for rates of adverse events of respiratory depression. Use of EREM was associated with significantly higher odds of respiratory depression compared to IV-PCA (odds ratio = 5.74; 95% confidence interval: 1.08, 30.54, p = 0.04). Even when examining only Food and Drug Administration approved dosages for EREM, the use of EREM was associated with significantly higher odds of respiratory depression when compared with IV-PCA (odds ratio = 5.80; 95% confidence interval: 1.05, 31.93, p = 0.04). Conclusions: Although perioperative single-dose epidural EREM (versus IV-PCA) was effective for postoperative pain relief for up to 48 hours, it is associated with significantly higher odds of respiratory depression. Further examination of the issue of respiratory depression of epidural EREM may be warranted. Key words: meta-analysis, respiratory depression, extended-release epidural morphine
September/October 2009; pages 307-312 Abstract Although patient-controlled analgesia (PCA) is considered the standard in postoperative pain control, research examining PCA use among cognitively impaired older adults is lacking. The authors reviewed a case series of 10 adults aged 65 years and older admitted to the geriatrics or orthopedic services of an urban tertiary care center in New York City with acute pain and cognitive impairment or dementia who were administered PCA. Four patients from this cohort are presented in detail, demonstrating the challenges of PCA use in this population. A series of clinical pearls follows each case, outlining strategies for improving pain management. The authors’ findings suggest that cognitive evaluations limited to alertness and orientation and failure to perform functional assessments may hinder the identification of patients who are poor candidates for PCA. Once PCA has been initiated, clinicians must regularly review device use and document cognitive function and pain score patterns to identify PCA underuse or misuse. Finally, rapid fluctuations in cognitive or functional status may require adoption of a more flexible pain management strategy. Despite these challenges, a subset of cognitively impaired older adults can successfully understand and operate PCA devices. Additional research is needed to (1) develop screening tools for identifying and monitoring older adults who may benefit from PCA and (2) create innovative approaches for improving pain management in the cognitively impaired. Key words: patient-controlled analgesia, cognitively impaired, dementia, pain Journal of Opioid Management November/December 2009, Volume 5, Number 6
November/December 2009; pages 321-329 Abstract Objectives: The purpose of the study was to investigate whether or not compliance monitoring by microchip could offer a feasible method for reducing abuse and/or diversion of medication from unsupervised substitution treatment for opioid addiction. Design: Naturalistic, 4-week pilot study in out patients. Patients and interventions: All our patients (N = 12) on buprenorphine—naloxone combination (Suboxone®) received their medication for 6 days in a compliance-monitoring device (PharmaDDSi®, StoraEnso), which registers date and time of tablet removal. Patients were instructed to take all tablets as one dose. Time cues were displayed and discussed with the patients during their weekly visits for supervised drug administration and counseling. Main outcome measures: Regularity of registered time cues, treatment costs in comparison with routine treatment, patients’ answers from a questionnaire on acceptability, and effect on drug diversion. Results: Six patients showed good compliance, in two patients irregularities were minor, but in two others lack of adherence to treatment instructions was detected. Patients with several comorbid psychiatric diagnoses showed on an average the longest intervals between removal of first and last tablet of the daily dose. One-fourth of the patients reported that compliance monitoring had helped to avoid diversion. Total cost savings during the 4-week period was a reduction of 39 percent, which was mainly due to fewer visits to the clinic. Conclusions: Compliance monitoring by PharmaDDSI® with weekly feedback was well accepted and subjectively increased compliance with substitution treatment. Future studies will show whether a technical solution for compliance monitoring in real time can help to reduce drug abuse and noncompliance in substitution treatment and other opioid treatments. Key words: compliance monitoring, microchip, buprenorphine, naloxone, substitution treatment
November/December 2009; pages 331-339 Abstract Background and methods: Intrathecal opioids (ITOs) have been used for decades to control postoperative pain. Intrathecal opioid dosing is limited, however, by opioid-related side effects, most importantly respiratory depression. To overcome these limitations, we combined intrathecal morphine with a continuous intravenous (IV) postoperative naloxone infusion to control opioid-related side effects. The purpose of this study is to document the efficacy and safety of high-dose intrathecal morphine combined with postoperative naloxone infusion to provide postoperative analgesia after major surgery. After IRB approval, a retrospective chart analysis was performed on 35 patients who had a radical prostatectomy from 2004 to 2006. All patients received a single injection of ITOs before anesthesia, a typical general anesthestic, followed by naloxone infusion at 5 µg/kg/h started 1 hour post-ITOs and continued for 22 hours postoperatively. The following information was collected: patient age, height, weight, anesthesia technique/time, and dose of ITOs given. Postoperative pain relief was assessed for 48 hours using the Visual Analog Score (VAS) for pain (0, no pain; 10, worst pain), perioperative opioid use, NSAID consumption, and ability of patient to ambulate. The safety of this novel treatment was assessed with opioid-related side effects and vital signs. All data are reported as mean (SD). Results: Mean ITOs given were morphine 1.3 (0.3) mg combined with fentanyl 56 (9) µg. The intrathecal morphine dose ranged from 0.8 to 1.7 mg. The mean worst pain VAS in the first 12 hours postoperatively was only 1.0 (1.7). The first NSAID dose was given 6.6 (3.1) hours post-ITOs. The first opioid on the floor was given an average of 22.6 (14.5) hours post-ITOs. A mean of only 5.7 (12.3) morphine equivalents were required on postoperative day 1 (POD 1). On POD 2, the mean worst pain VAS was only 2.6 (2.2) with only 5.7 (6.2) morphine equivalents needed to provide pain relief. On POD 1, 25 patients required no additional opioids for their entire hospital stay. Overall, 11 of 35 patients did not require any additional postoperative opioids. Thirtyfour patients (97 percent) were able to ambulate in the first 12 hours postoperatively. No opioid-induced respiratory depression was observed. Opioid-related side effects (pruritus, nausea) were infrequent and minor. Conclusions: High-dose ITOs combined with postoperative IV naloxone infusion provided excellent analgesia for radical prostate surgery. IV naloxone infusion appeared to control opioid side effects without diminishing the analgesia. No serious adverse effects were noted. Key words: intrathecal morphine, neuraxial opioids, postoperative analgesia, opioid side effects, radical prostatectomy, naloxone infusion
November/December 2009; pages 341-357 Abstract Historically and anecdotally cannabinoids have been used as analgesic agents. In recent years, there has been an escalating interest in developing cannabis-derived medications to treat severe pain. This review provides an overview of the history of cannabis use in medicine, cannabinoid signaling pathways, and current data from preclinical as well as clinical studies on using cannabinoids as potential analgesic agents. Clinical and experimental studies show that cannabis-derived compounds act as antiemetic, appetite modulating, and analgesic agents. However, the efficacy of individual products is variable and dependent upon the route of administration. As opioids are the only therapy for severe pain, analgesic ability of cannabinoids may provide a much-needed alternative to opioids. Moreover, cannabinoids act synergistically with opioids and act as opioid sparing agents, allowing lower doses and fewer side effects from chronic opioid therapy. Thus, rational use of cannabis-based medications deserves serious consideration to alleviate the suffering of patients due to severe pain. Key words: pain, cannabinoid, opioid, marijuana, cannabis
November/December 2009; pages 359-364 Abstract Objective: This study examined the ability of an algorithm applied to urine drug levels of oxycodone in healthy adult volunteers to differentiate among low, medium, and high doses of OxyContin®. Participants and interventions: Thirty-six healthy volunteers were randomized to receive 80, 160, or 240 mg of daily OxyContin® to steady state while under a naltrexone blockade. During days 3 and 4 of the study, urine samples of all participants were collected, and oxycodone levels detected in the urine were obtained using a liquid chromatography- mass spectrometry (LC-MS-MS) assay. Outcome measures: The concordance was calculated for raw and adjusted LC-MS-MS urine oxycodone values within each study participant between their third and fourth day values. Also, an analysis of medians was calculated for each of the dosage groupings using Bonett-Price confidence intervals for both raw and adjusted LC-MS-MS values. Results: The concordance correlation coefficient for the raw LC-MS-MS values between days 3 and 4 was 0.689 (95% confidence intervals = 0.515, 0.864), whereas the concordance correlation coefficient for the LC-MS-MS values using the algorithm (ie, normalized values) was 0.882 (95% confidence intervals = 0.808, 0.956). Because of greater variability in the raw values, some overlap was observed in the confidence intervals of the various OxyContin® doses, whereas no overlap was observed in the normalized confidence intervals regardless of the application of a Bonferroni adjustment. Conclusions: In contrast to raw LC-MS-MS values, an algorithm that normalizes oxycodone urine drug levels for pH, specific gravity, and lean body mass discriminates well among all three of the daily doses of OxyContin® tested (80, 160, and 240 mg), even with correcting for multiple analyses. Key words: urine drug testing, medication adherence, OxyContin®, oxycodone, algorithm
November/December 2009; pages 365-372 Abstract Objective: Opium is an overwhelming public health problem in some countries. Different studies have suggested this drug as a risk factor for cardiovascular disease. Although the effect of opium on immune system, lung disease, nephropathy, stroke, and cardiac arrhythmia has been found in different studies, its effect on postoperation complications is not clear yet. The authors conducted this study to assess the effect of opium on post operation in hospital complications among patients who underwent coronary artery bypass graft. Design: The authors retrospectively analyzed the data in this study. Setting: This study has been done at Tehran Heart Center. Patients: A total of 4,398 patients who had undergone isolated CABG were studied. Main outcome measure: Patients who fulfilled the DSM-IV-TR criteria for opium dependence (by smoking) were enrolled as Opium Dependent Patients. Also outcome variables were: Perioperative MI, septicemia, UTI, TIA, continuous coma, prolonged ventilation, pulmonary embolism, renal failure, acute limb ischemia, heart block, AF, mortality. Results: The prevalence of opium dependence was 15.6 percent among patients. The authors used a propensity matched model to analyze the relationship between opium and post operation complications. The authors adjusted opium and non-opium dependent patients in all of the baseline preoperative risk factors, so all of the matched patients were same and there was no bias in assessment. Conclusion: Opium dependent patients had significantly longer resource utilization. However, no significant relationship was found between opium dependence and other cardiac and non cardiac in hospital complications. Keywords: opium, coronary artery bypass grafting, addiction, postoperative complications
November/December 2009; pages 373-378 Abstract Objective: Leptin increases energy expenditure by enhancing systemic and brown adipose metabolism. In a neonatal rat model, retroperitoneal fat pad weight decreased significantly in leptin-treated animals, which reduced body weight. As opioids increase feeding, opioid antagonists may decrease food intake and body weight. However, interactions between leptin and the activity of peripheral opioids on body weight and fat accumulation have not been investigated. In this study, the authors evaluated the effects of naloxone (a nonselective opioid antagonist) and methylnaltrexone (a peripherally acting opioid antagonist) on the action of leptin in neonatal rats. Results: Compared with control, the weight gain of pups given a single daily intraperitoneal injection of leptin 0.5 mg/kg, leptin 0.5 mg/kg plus naloxone 0.3 mg/kg, or leptin 0.5 mg/kg plus methylnaltrexone 3.0 mg/kg for 8 consecutive days was significantly reduced (all p < 0.01). Naloxone or methylnaltrexone significantly potentiated leptin’s effect on body weight (p < 0.05 or p < 0.01, respectively). After coadministration of leptin plus naloxone or leptin plus methylnaltrexone, weight reduction in the right retroperitoneal fat pads was also significant compared with the reduction after leptin alone (p < 0.05 or p < 0.01, respectively). Conclusions: The data suggest the existence of a peripheral opioid-related mechanism in leptinactive modulation of body weight. Key words: leptin, opioids, naloxone, methylnaltrexone, body weight, adipose tissue, neonatal rat
November/December 2009; pages 379-382 Abstract It is not easy to diagnose lumbar disc herniation during pregnancy due to the limitation of the examinations and it is also difficult to control the severe pain during this time. A pregnant woman with lumbar disc herniation was transferred to our hospital at the 23rd week of gestation. The pain was successfully controlled with opioids and epidural anesthesia. At the 35th week of gestation, she delivered a girl weighing 2316 g smoothly with an Apgar score of 8/9 without neonatal abstinence syndrome from morphine. In this case, opioid administration was found to be useful for perinatal care with lumbar disc herniation. Key words: opioid rotation, pregnancy, lumbar disc herniation, neonatal abstinence syndrome
November/December 2009; pages 383-385 Abstract Opioids are becoming more common in the treatment of chronic nonmalignant pain. With increased availability of opioids for chronic pain we may expect an increased misuse of these as analgesics as well. The authors describe the case report of a young woman with chronic back pain and intranasal abuse of prescribed hydrocodone/acetaminophen who was diagnosed after presenting for hypernasal speech and foreign body in the nose. This case report highlights the need for vigilance on the part of the physician for any aberrant drug-related behaviors. Any unusual symptoms or signs such as hypernasal speech, chronic nasal infection, or unexplained foreign body sensation in the nose should be thoroughly investigated. Key words: intranasal opioid use, drug abuse, hydrocodone |
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