Opioids
Decision-Making Capacity, Opioid Use Disorder, and the 3-Stage Model of Addiction
The assessment of decision-making capacity in hospitalized individuals with acute decompensation of chronic illness is challenging. Such decompensations are often accompanied by pathophysiologic processes that impair cognition and judgment, sometimes subtly. The standard of care has thus evolved such that assessment of decisional capacity is best performed once acute decompensation is stabilized with evidence-based treatment, a process that can take several hours to days.1,2Shell Shock and PTSD: A Tale of Two Diagnoses
Ever since human beings first went to war, the people who fight in those wars have sustained not only physical wounds but also psychological wounds, which may spare the body but scar the mind. And for almost as long as human beings have been waging war, societies have struggled with two fundamental questions about these psychological wounds. First, how do we identify and define these unseen wounds, wounds that lead to the type of consequences that defy simple physiologic explanation? Second, given that some people clearly return from war with psychological issues that impair their ability to function, how do we justly compensate those who experience these psychological wounds (an issue that becomes particularly salient as the number of people affected increases)?The System Is Broken: A Qualitative Assessment of Opioid Prescribing Practices After Spine Surgery
To elucidate factors that influence opioid prescribing behaviors of key stakeholders after major spine surgery, with a focus on barriers to optimized prescribing.An Institutional Approach to Managing the Opioid Crisis
The opioid crisis is a major concern of most health care institutions, including our large academic center. In this article, an organized approach to managing the epidemic institutionally is discussed. An Opioid Stewardship Program was instituted at our tertiary-care center with multiple sites and states of practice, which included diverse membership and expertise. Charges of the program included reviewing current practice, workflows, and external and internal guidelines and evaluating and standardizing prescribing practices.Can Pain Management be Safely Optimized in Older Adults?
Managing chronic pain is a challenging task. Older adults (OAs) (>65 years) are the fastest growing segment of our population, and are substantially affected by chronic pain of various etiologies. Chronic pain, which affects a significant proportion of community-dwelling OAs and may be nearly universal in long-term care residents, is associated with numerous other conditions, including frailty, debility, and depression.1 Optimizing its management is critical for achieving optimal health outcomes in OAs.Balancing the Risks and Benefits of Opioid Therapy: The Pill and the Pendulum
Over the past 20 years, the medicinal use of opioids has swung back and forth like a pendulum. However, unlike Edgar Allan Poe's classic short story, the likelihood of a last-second rescue seems remote. In the 1990s, a confluence of economic, medical, and governmental factors coalesced into a mutual driver of widespread prescription opioid use for chronic pain.1 The havoc wrought by this shift in prescribing practices ushered in the most devastating addiction crisis in US history. The ramifications of indiscriminate opioid prescribing are ubiquitous across the United States, and the statistics are grim.Prescription Opioid Epidemic and Trends in the Clinical Development of New Pain Medications
To evaluate trends in the clinical development of new pain and reformulated pain medications given the ongoing opioid crisis and the public health burden of inadequately controlled pain.Medication-Assisted Treatment for Opioid-Use Disorder
The United States is in the midst of a national opioid epidemic. Physicians are encouraged both to prevent and treat opioid-use disorders (OUDs). Although there are 3 Food and Drug Administration-approved medications to treat OUD (methadone, buprenorphine, and naltrexone) and there is ample evidence of their efficacy, they are not used as often as they should. We provide a brief review of the 3 primary medications used in the treatment of OUD. Using data from available medical literature, we synthesize existing knowledge and provide a framework for how to determine the optimal approach for outpatient management of OUD with medication-assisted treatments.Spinal Stimulation for the Treatment of Intractable Spine and Limb Pain: A Systematic Review of RCTs and Meta-Analysis
To synthesize the evidence regarding the effect of spinal stimulation (SS) vs medical therapy (MT) and the effect of newer SS technologies vs conventional SS on pain reduction in patients with intractable spine or limb pain.Chronic Constipation
Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. Although most constipation is self-managed by patients, 22% seek health care, mostly to primary care physicians (>50%) and gastroenterologists (14%), resulting in large expenditures for diagnostic testing and treatments. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted μ-opiate antagonists are effective and safe; the lattermost drugs are a major advance for managing opioid-induced constipation.In Reply—The Importance of Educational Interventions and Regional Analgesia in Tackling the Opioid Crisis in the United States
Overprescribing opioids has true risks for our patients. A study by Sanger et al1 found that more than half of patients in a methadone maintenance treatment program were introduced to opioids through a prescription. This carries particular relevance for surgeons, who prescribe a significant portion of all opioids, including many for patients without a history of exposure.2,3 Optimal prescribing practices therefore toe the delicate line between providing adequate pain control and minimizing the risk of medication misuse and abuse.The Importance of Educational Interventions and Regional Analgesia in Tackling the Opioid Crisis in the United States
Ziegelmann et al1 recently published an interesting report titled “Wide variation in opioid prescribing after urological surgery in tertiary care centers” that strives to shed light on the mounting opioid crisis in the United States. In accordance with previous studies, the analysis revealed a considerable variation in postoperative opioid prescribing patterns both for a given procedure and among procedures. This was ascribed to patient-related factors such as younger age, male sex, cancer diagnosis, and prolonged hospital stay and more importantly to lack of standardization and physician and patient expectations.Wide Variation in Opioid Prescribing After Urological Surgery in Tertiary Care Centers
To describe postoperative opioid prescribing practices in a large cohort of patients undergoing urological surgery.Management Options for Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is associated with diverse pathophysiologic mechanisms. These mechanisms include increased abnormal colonic motility or transit, intestinal or colorectal sensation, increased colonic bile acid concentration, and superficial colonic mucosal inflammation, as well as epithelial barrier dysfunction, neurohormonal up-regulation, and activation of secretory processes in the epithelial layer. Novel approaches to treatment include lifestyle modification, changes in diet, probiotics, and pharmacotherapy directed to the motility, sensation, and intraluminal milieu of patients with IBS.Advances in the Treatment of Sickle Cell Disease
Sickle cell disease (SCD) is a monogenic disorder that afflicts approximately 100,000 Americans and millions of people worldwide. It is characterized by hemolytic anemia, vaso-occlusive crises, relentless end-organ injury, and premature death. Currently, red blood cell transfusion and hydroxyurea are the major disease-modifying therapies available for SCD. Hematopoetic stem cell transplant is curative, but barriers to treatment are substantial and include a lack of suitable donors, immunologic transplant rejection, long-term adverse effects, prognostic uncertainty, and poor end-organ function, which is especially problematic for older patients.A Before and After Analysis of Health Care Utilization by Patients Enrolled in Opioid Controlled Substance Agreements for Chronic Noncancer Pain
To evaluate the impact of opioid controlled substance agreements (CSAs) enrollment on health care utilization.In Reply II—Root Causes of Opioid Crisis
Dr Pendyal highlights an important point that the opioid crisis is much bigger than just the “supply side” of the problem. It is truly a biological-psychological-social-spiritual problem that impacts both the “supply side” and the “demand side.”1 However, in his description of the social factors, of which there are many, he too fails to acknowledge many of the drivers of the opioid crisis. Many of the drivers go beyond “unemployment, poverty, and wealth inequality,” with an increasing number of those dying from opioids being employed, middle- and upper-class individuals.The Root Causes of the Current Opioid Crisis
I read with a great deal of interest the article by Rummans et al1 and the accompanying editorial by Srivastava and Gold2 in the March 2018 issue of the Mayo Clinic Proceedings.In Reply I—Root Causes of the Opioid Crisis
We thank Dr. Pendyal for the thoughtful and articulate response to our article.1 We agree that a thorough examination of opioid use disorders and overdoses includes evaluation of structural- and societal-level factors. Indeed, income inequality, social disparities, and other structural inequities are important considerations in chronic illnesses, disease management, premature deaths, infant mortality, maternal illness, and all epidemics past and present, not just the current opioid epidemic. Similarly, depression, despair, hopelessness, and suicide are not exclusively linked to the current opioid crisis but are reflective of the state of health and wellness in our society.Telemedicine’s Role in Addressing the Opioid Epidemic
Adverse health effects of the opioid epidemic continue to climb. Opioid-related overdose deaths reached an all-time high of 42,249 in 2016,1 prompting President Trump to declare an opioid public health emergency in 2017. From July 2016 to September 2017, emergency department visits associated with opioid-related overdoses spiked about 30%.2 Those with opioid use disorders (OUDs) face dramatically increased risk of early death, typically from overdose. Provision of evidence-based medication-assisted treatment (MAT), which can involve methadone, buprenorphine, or naltrexone, to those with OUDs has been shown to reduce the risk of death by as much as 50%.CAREFUL: A Practical Guide for Improving the Clinical Surveillance of Long-Term Opioid Therapy
To the Editor: National prescribing guidelines for opioid use provide recommendations for clinical surveillance aimed at enhancing the safe use of these medications in patients with chronic pain.1 However, despite the widespread availability of these guidelines, most clinicians do not follow recommendations for clinical surveillance.2 The purpose of this letter was to describe an acronym that provides a summary of many key components of clinical surveillance that have been recommended for patients receiving long-term opioid therapy.In Reply—Additional Safety Considerations Before Prescribing Opioids to Manage Restless Legs Syndrome
We thank Dr Geller for his interest in our article on the appropriate use of opioids in refractory restless legs syndrome (RLS).Additional Safety Considerations Before Prescribing Opioids to Manage Restless Legs Syndrome
Silber et al1 are commended for espousing the merit of low and stable dose opioid treatment of refractory restless legs syndrome (RLS) given the risks of suicide and severely compromised quality of life if untreated. Opioid agreements reduce risks of RLS treatment with opioids as agreements mandate drug testing as well as frequent query of prescription drug monitoring programs.Opioid-Induced Adrenal Insufficiency
One in 10 Americans experience chronic pain. Although opioids do play a role in the management of pain, long-term opioid use may lead to adverse effects. Endocrine-related adverse effects have been described but remain poorly recognized. Opioid-induced adrenal insufficiency occurs because of suppression of hypothalamic-pituitary-adrenal communication and may be challenging to diagnose but has been reported in 9% to 29% of patients receiving long-term opiate therapy. Little data exist to guide case detection and patient management.Younger Adults Initiating Hemodialysis: Antidepressant Use for Depression Associated With Higher Health Care Utilization
To examine associations between antidepressant use and health care utilization in young adults beginning maintenance hemodialysis (HD) therapy.
