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Managing opioid use disorder in primary care: PEER simplified guideline Vol 65: MAY | MAI 2019 | Canadian Family Physician | Le Médecin de famille canadien 321 CLINICAL PRACTICE GUIDELINES Editor’s key points ? This simplified guideline for managing opioid use disorder (OUD) was developed with a primary care focus using a systematic review of systematic reviews design. Recommendations are accompanied by practice pearls and additional resources to support primary care practitioners and shared (...) , informed decision making with patients. ? Managing patients with OUD in primary care and offering long-term opioid agonist therapy can improve patient outcomes. Adding psychosocial interventions and avoiding punitive measures might also be helpful. All discussions of treatment should involve the patient’s preferences and values. ? Future randomized controlled trials should clarify the effects of pharmacologic treatments on morbidity, mortality, and social functioning (eg, employment); the management
Are opioids effective in the treatment of chronic low back pain? Are Opioids Effective in the Treatment of Chronic Low Back Pain? – Clinical Correlations Search Are Opioids Effective in the Treatment of Chronic Low Back Pain? April 17, 2019 4 min read By Anna Hirsch Peer Reviewed The use of opioid medications for chronic low back pain, or for any chronic non-cancer pain complaint, is still a source of controversy in the medical community, with a large divide between the recommendations (...) of professional societies and actual physician prescribing data. In the , 1 the 2 and the 3 have all issued guidelines urging caution with the use of opioids for chronic back pain, specifically emphasizing the poor-to-moderate quality of the evidence demonstrating benefit from this therapeutic modality. All three organizations reinforce that opioids should only be used after failure of other non-opioid and non-pharmacologic treatment options and recommend that if physicians choose to prescribe opioids
Inappropriate opioid prescription after surgery. Worldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm (...) . In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. We summarise evidence on the extent of opioid overprescribing after surgery and its potential association with subsequent opioid misuse, diversion, and the development of opioid use disorder. We discuss evidence on patient, physician, and system-level predictors of excessive prescribing after surgery, and summarise recent work on clinical and policy
Perioperative opioid analgesia-when is enough too much? A review of opioid-induced tolerance and hyperalgesia. Opioids are a mainstay of acute pain management but can have many adverse effects, contributing to problematic long-term use. Opioid tolerance (increased dose needed for analgesia) and opioid-induced hyperalgesia (paradoxical increase in pain with opioid administration) can contribute to both poorly controlled pain and dose escalation. Hyperalgesia is particularly problematic (...) as further opioid prescribing is largely futile. The mechanisms of opioid tolerance and hyperalgesia are complex, involving μ opioid receptor signalling pathways that offer opportunities for novel analgesic alternatives. The intracellular scaffold protein β-arrestin-2 is implicated in tolerance, hyperalgesia, and other opioid side-effects. Development of agonists biased against recruitment of β-arrestin-2 could provide analgesic efficacy with fewer side-effects. Alternative approaches include inhibition
Intensive Models of Hepatitis C Care for People Who Inject Drugs Receiving Opioid Agonist Therapy: A Randomized Controlled Trial. Many people who inject drugs (PWID) are denied treatment for hepatitis C virus (HCV) infection, even if they are receiving opioid agonist therapy (OAT). Research suggests that HCV in PWID may be treated effectively, but optimal models of care for promoting adherence and sustained virologic response (SVR) have not been evaluated in the direct-acting antiviral (DAA
American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation - Gastroenterology Email/Username: Password: Remember me Search AGA Journals Search Terms Search within Search Access provided by Volume 156, Issue 1, Pages 218–226 American Gastroenterological Association Institute Guideline on the Medical Management of Opioid (...) of opioid-induced constipation. The guideline was developed by the AGA Institute’s Clinical Guidelines Committee and approved by the AGA Governing Board. It is accompanied by a technical review that is a compilation of clinical evidence from which these recommendations were formulated. x 1 Hanson, B., Siddique, S.M., Scarlett, Y. et al. American Gastroenterological Association Institute Technical Review on the Medical Management of Opioid-Induced Constipation. Gastroenterology . 2019 ; 156 : 229–253
Strategies for Addressing the Opioid Crisis in the United States and Canada: Cross-Border Knowledge Sharing www.ccsa.ca • www.ccdus.ca Canadian Centre on Substance Use and Addiction • Centre canadien sur les dépendances et l’usage de substances Page 1 Strategies for Addressing the Opioid Crisis in the United States and Canada: Cross-Border Knowledge Sharing Introduction Both Canada and the United States (U.S.) have been experiencing increasing rates of opioid related harms in recent years (...) with overdose or poisoning deaths reaching staggering numbers. In 2017 alone, 3,998 Canadians were lost to opioid-related deaths, (Government of Canada, 2018a) and an overwhelming 47,600 lives were lost in the U.S (National Institute of Drug Abuse, 2019). These increases have prompted both countries to try to understand better how this crisis emerged — an exploration that has revealed complex and multifaceted precursors including social factors, physical conditions and gaps in the healthcare system, to name
Initial Opioid Prescriptions among U.S. Commercially Insured Patients, 2012-2017. The United States is undergoing a crippling opioid epidemic, spurred in part by overuse of prescription opioids by adults 25 to 64 years of age. Of concern are long-duration and high-dose initial prescriptions, which place the patients and their friends and relatives at heightened risk for long-term opioid use, misuse, overdose, and death.We estimated the incidence of initial opioid prescriptions in each month (...) between July 2012 and December 2017 using administrative-claims data from across the United States (accessed through Blue Cross-Blue Shield [BCBS] Axis); monthly incidence was estimated as the percentage of enrollees who received an initial opioid prescription among those who had not used opioids (i.e., no opioid prescription or a diagnosis of opioid use disorder in the 6 months before a given month). We then estimated the percentage of enrollees initiating opioid therapy who received a long-duration
Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans: A Nested Case-Control Study. More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care (...) or if prescription use is not tracked between systems.To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose.Nested case-control study.VA and Medicare Part D.Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients
Efficacy and safety of a monthly buprenorphine depot injection for opioid use disorder: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. RBP-6000, referred to as BUP-XR (extended-release buprenorphine), is a subcutaneously injected, monthly buprenorphine treatment for opioid use disorder. BUP-XR provides sustained buprenorphine plasma concentrations to block drug-liking of abused opioids over the entire monthly dosing period, while controlling withdrawal and craving (...) symptoms. Administration of BUP-XR in a health-care setting also mitigates abuse, misuse, diversion, and unintentional exposure. We aimed to investigate the efficacy of different BUP-XR dosing regimens in participants with opioid use disorder.This randomised, double-blind, placebo-controlled, phase 3 trial was done at 36 treatment centres in the USA. Treatment-seeking adults aged 18-65 years who had moderate or severe opioid use disorder (as defined by the fifth edition of the Diagnostic
Quick guide: National clinical guideline on opioid treatment of chronic non-malignant pain National clinical guideline on opioid treatment of chronic non-malignant pain. Published by the Danish Health Authority, December 2018 NATIONAL CLINICAL GUIDELINE ON OPIOID TREATMENT OF CHRONIC NON-MALIGNANT PAIN Quick guide 1 Optimise non-pharmacological and pharmacological non-opioid treatment rather a trial of opioids in patients with chronic non-malignant pain conditions. Strong recommendation (...) For some patients with neuropathic pain, the possible pharmacological treatment options apart from opioids are tricyclic antidepressants and anticonvulsants. For patients with nociceptive pain, in specific instances NSAIDs can be used at the lowest possible dose for the shortest possible time and in accordance with the recommendations of the Danish Health Authority’s National Recommendations List for treatment of chronic nociceptive pain with NSAIDs. The evidence profile for paracetamol has not been
Opioid Prescription Patterns for Children Following Laparoscopic Appendectomy To describe variability in and consequences of opioid prescriptions following pediatric laparoscopic appendectomy.Postoperative opioid prescribing patterns may contribute to persistent opioid use in both adults and children.We included children <18 years enrolled as dependents in the Military Health System Data Repository who underwent uncomplicated laparoscopic appendectomy (2006-2014). For the primary outcome (...) of days of opioids prescribed, we evaluated associations with discharging service, standardized to the distribution of baseline covariates. Secondary outcomes included refill, Emergency Department (ED) visit for constipation, and ED visit for pain.Among 6732 children, 68% were prescribed opioids (range = 1-65 d, median = 4 d, IQR = 3-5 d). Patients discharged by general surgery services were prescribed 1.23 (95% CI = 1.06-1.42) excess days of opioids, compared with those discharged by pediatric
Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain (...) completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels
Association of Prescribed Opioids With Increased Risk of Community-Acquired Pneumonia Among Patients With and Without HIV Some opioids are known immunosuppressants; however, the association of prescribed opioids with clinically relevant immune-related outcomes is understudied, especially among people living with HIV.To assess the association of prescribed opioids with community-acquired pneumonia (CAP) by opioid properties and HIV status.This nested case-control study used data from patients (...) .Prescribed opioid exposure during the 12 months before the index date was characterized by a composite variable based on timing (none, past, or current); low (<20 mg), medium (20-50 mg), or high (>50 mg) median morphine equivalent daily dose; and opioid immunosuppressive properties (yes vs unknown or no).CAP requiring hospitalization based on VA and Centers for Medicare & Medicaid data.Among the 25 392 VACS participants (98.9% male; mean [SD] age, 55  years), current medium doses of opioids
Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse Through prescription writing, dental clinicians are a potential source of initial opioid exposure and subsequent abuse for adolescents and young adults.To examine the association between index dental opioid prescriptions from dental clinicians for opioid-naive adolescents and young adults in 2015 and new persistent use and subsequent diagnoses of abuse (...) in this population.This retrospective cohort study examined outpatient opioid prescriptions for patients aged 16 to 25 years in the Optum Research Database in 2015. Prescriptions were linked by National Provider Identifier number to a clinician category.Individuals were included in the index dental opioid (opioid-exposed) cohort if they filled an opioid prescription from a dental clinician in 2015, had continuous health plan coverage and no record of opioid prescriptions for 12 months before receiving
Opioid drugs are no better than standard painkillers for long-term back and joint pain Opioid drugs are no better than standard painkillers for long-term back and joint pain Discover Portal Discover Portal Opioid drugs are no better than standard painkillers for long-term back and joint pain Published on 3 July 2018 doi: People with long-term back pain, or osteoarthritis of their hips or knees, do not get better pain relief from opioid drugs and are more likely to get side effects than those (...) who take paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), like naproxen or ibuprofen. A US study assigned 240 patients to either opioid or non-opioid pain relief drugs and measured their pain over 12 months. Those who were assigned opioid drugs had less relief of their pain and also were more likely to have side-effects related to their medication. The findings may surprise some doctors and patients with long-term pain, because of the widely held belief that opioids have a stronger
Opioid use disorder Opioid use disorder - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search Opioid use disorder Last reviewed: February 2019 Last updated: January 2019 Summary Heroin and prescription opioid misuse is a major health concern. From a diagnostic perspective, it is imperative that the physician understands the criteria for opioid use disorder. Comorbid medical and psychiatric illnesses, as well as other (...) substance use disorders, should be assessed. Physicians should be aware of methods for screening and detection of opioid use in clinical settings. Evidence-based treatments include detoxification, maintenance therapy, and psychosocial and supportive therapies. Treatment requires a multidisciplinary approach, is long term, and involves modifying deeply ingrained behaviours through the use of medications and psychosocial treatments. Definition An opioid is a synthetic or natural agent that stimulates
Opioid overdose Opioid overdose - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search Opioid overdose Last reviewed: February 2019 Last updated: January 2019 Summary The patient's history from bystanders/friends/family can assist diagnosis. Signs include central nervous system and respiratory depression, miosis, and apnoea. Initial treatment consists of ensuring adequate ventilation followed by administration of the opioid (...) antagonist naloxone. Monitor patients for re-sedation and repeat antidote dose if necessary. Definition An opioid is any synthetic or natural agent that stimulates opioid receptors and produces opium-like effects. Opiates are opioids naturally derived from the opium poppy, Papaver somniferum , and include morphine and codeine. Opioids are used in the treatment of pain but are often sold illicitly and abused for their euphoric effects. An overdose occurs when larger quantities than physically tolerated
Side Effect Rates of Opioids in Equianalgesic Doses Via Intravenous Patient-Controlled Analgesia: A Systematic Review and Network Meta-analysis Side effects of opioids used for the treatment of acute pain frequently limit their analgesic quality. Many studies have compared opioid side effects in patient-controlled analgesia (PCA), but it remains unclear whether there are specific side effect profiles that can be exploited when choosing an opioid for a patient. In this review, we wanted (...) to determine the risk ratios (RRs) for the most common side effects when using different opioids for intravenous PCA in equianalgesic doses and rank the substances accordingly.A search of MEDLINE, EMBASE, the Cochrane Library (CENTRAL), and Web of Science identified 63 randomized controlled trials comparing opioids under equianalgesic conditions. Inclusion criteria were comparable pain stimulus between groups, equal coanalgesic treatment, and comparable resulting pain scores. Quality of studies