Using Text Messaging to Decrease Opioid Use After Hip and Knee Replacement

The development of persistent opioid use disorder after surgery is a preventable complication. The need for opioid medications after total joint replacement surgery is necessary for a favorable recovery and optimal functional outcomes. Traditionally patients get a single postoperative phone call after discharge from the hospital. This phone call does not provide adequate support to patients about postoperative pain medication tapering and cessation. The purpose of this study was to evaluate if sending interval text messages to joint replacement patients after discharge would help them discontinue opioid medications sooner. One hundred and thirty-seven patients (69 in the control group and 68 in the experimental group) participated in a quasi-experimental after only study to compare the effectiveness of text messaging on opioid use in patients undergoing total knee and total hip arthroplasty. There were no significant differences in the demographic characteristics of the two groups. The z test for the Difference of Two Proportions was used to evaluate the outcomes of the study. The results found that patients that received the text messages in the experimental group stopped using opioid medications sooner than those patients in the control group at the 30-day and 60-day postoperative interval. The was no significant difference found at 90 days after surgery between the two groups. Utilization of text messaging platforms can improve the tapering and cessation of opioid medications in the early postoperative period in patients undergoing total hip and total knee arthroplasty. This project can be used as support for clinicians considering engaging patients through technology to improve postoperative outcomes

The use of opioids in the last week of life in an acute palliative care unit.

The aim of this survey was to assess the opioid use in the last week of life of cancer patients admitted at an acute palliative care unit. From a consecutive sample of patients surveyed for a period of one year, patients who died in the unit were selected. Type of opioid, route of administration, and doses were recorded one week before death (or at admission time if the interval admission-death was less than one week) (-7), and on the day of death (Tend). Seventy-seven patients died in the unit in the period taken into consideration (12.4%). Oral morphine equivalents were 170 mg/day and 262 mg/day at -7 and Tend, respectively. Patients were receiving transdermal drugs or intravenous morphine at Tend, with a trend in the use of intravenous morphine at Tend (p=0.07). Intravenous morphine was more frequently used in sedated patients at Tend (p=0.015).No differences in age, gender, opioid doses, and OEI were found among opioids used. In patients who were sedated doses of opioids were significantly increased (p=0.012). In the last week of life intravenous morphine is the preferred modality to deliver opioids in an acute palliative care unit. Doses increases prevalently observed in sedated patients were performed before starting sedation with the purpose to treat concomitant distressing symptoms, such as dyspnoea

Treating the Opioid Crisis: Assessing Programs to Address Overdose Deaths in West Virginia

Problem Statement: Too many people in West Virginia are dying from opioid overdose. West Virginia’s current policies and regulations are insufficient in addressing the opioid epidemic. West Virginia had the highest rate of overdose deaths in the country in 2016, that being 881 or 52 deaths per 100,000 people (“Drug Overdose Death Data”, 2017), and it is costing the state an estimated $8.8 billion per year (Eyre, 2018a). To address this issue, four different policy alternatives have been formulated in an attempt to decrease the number of opioid overdose deaths in West Virginia. These alternatives are allowing current trends to continue, increasing prescription opioid regulation, transforming the seven existing needle exchange programs (NEPs) into safe injection facilities (SIFs), and expanding Certified Community Behavioral Health Clinics (CCBHCs). Possible outcomes, tradeoffs, and limitations were projected for each policy alternative, and four different criteria were used to evaluate the policies and their outcomes. The projected outcomes that were considered for each policy alternative were saved productivity due to decreased overdose fatalities, saved productivity due to decreased opioid addictions, saved resources in the form of healthcare, substance abuse treatment, and criminal justice costs, and the cost of implementation. By subtracting the costs from the benefits, the net benefit of each policy alternative was evaluated. Four different criteria were then selected to evaluate each policy alternative holistically. These criteria were efficacy, efficiency, equity, and political acceptability. After considering the projected outcomes, tradeoffs, limitations, and applying the criteria for evaluation, the best policy to decrease opioid overdose deaths in West Virginia is a combination of expanding CCBHCs and increasing prescription opioid regulation. These alternatives aim to solve the opioid overdose epidemic in both the short and long term. CCBHCs were the most cost-effective policy, saving the state$437 million annually. With 24-hour crisis care, staff trained in life-saving naloxone administration, and same-day access, CCBHCs provide an immediate short term solution to opioid overdose deaths. Their other services such as outpatient mental health and substance use services, risk-management assessment, and targeted case management will decrease opioid addiction and overdose deaths in the long term as well. Increasing prescription opioid regulation will also be able to address overdose deaths in the long run, and aims to attack the root of opioid epidemic—prescription opioid abuse. Since 80% of heroin users transitioned from misuse of prescription opioids, limiting opioid prescriptions for acute pain to a seven-day supply will decrease the likelihood of continuous dependency. Enhancing West Virginia’s prescription drug monitoring program to include data sharing amongst prescribers, primary care physicians, law enforcement, and public health agencies provides a greater opportunity to identify individuals at-risk of developing an opioid use disorder, as well as unethical prescribers. With a cost of implementation of only $1 million, and a net benefit of$242 million, this policy is a worthwhile investment for the state of West Virginia. While either policy would succeed separately in decreasing the death rate due to opioid overdose, both policies in tandem is the most efficacious and efficient recommendation for addressing the opioid epidemic and decreasing overdose deaths in West Virginia.https://digitalcommons.morris.umn.edu/urs_2018/1004/thumbnail.jp

Pain Management: A Flowsheet for Providers

Many different factors led to the trend of providers prescribing opioids for chronic pain. However, the misuse of and many deaths related to opioid prescriptions have caused the trend to reverse its direction. National organizations call for providers to stay clear of opioid medication and increase the use of nonpharmacological pain management, but also to treat pain adequately. There are still many barriers to decreasing the use of opioids and increasing the use of nonpharmacological methods. This scholarly project hoped to use an educational flowsheet to assist providers in meeting the demands from national organizations to decrease the use of pain medications and patients to treat pain adequately

Predictors of painkiller dependence among people with pain in the general population

Aims: Self-medication with painkillers is widespread and increasing, and evidence about influences on painkiller dependence is needed to inform efforts to prevent and treat problem painkiller use. Design: Online questionnaire survey. Participants: People in the general population who had pain and used painkillers in the last month (n=112). Measurements: Pain frequency and intensity, use of over-the-counter and prescription painkillers, risk of substance abuse (SOAPP scale), depression, anxiety, stress, alexithymia, pain catastrophizing, pain anxiety, pain self-efficacy, pain acceptance, mindfulness, self-compassion, and painkiller dependence (Leeds Dependence Questionnaire). Findings: In multiple regression, the independent predictors of painkiller dependence were prescription painkiller use (ß 0.21), SOAPP score (ß 0.31), and pain acceptance (ß -0.29). Prescription painkiller use mediated the influence of pain intensity. Alexithymia, anxiety and pain acceptance all moderated the influence of pain. Conclusions: The people most at risk of developing painkiller dependence are those who use prescription painkillers more frequently, who have a prior history of substance-related problems more generally, and who are less accepting of pain. Based on these findings, a preliminary model is presented with three types of influence on the development of painkiller dependence: a) pain leading to painkiller use, b) risk factors for substance-related problems irrespective of pain, and c) psychological factors related to pain. The model could guide further research among the general population and high risk groups, and acceptance-based interventions could be adapted and evaluated as methods to prevent and treat painkiller dependence.The Leonardo Da Vinci Lifelong Learning Programme funded Joana Duarte’s graduate research placement at the University of Derb

Patient-controlled intravenous morphine analgesia combined with transcranial direct current stimulation for post-thoracotomy pain: A cost-effectiveness study and a feasibility for its future implementation

This prospective randomized study aims to evaluate the feasibility and cost-effectiveness of combining transcranial direct current stimulation (tDCS) with patient controlled intravenous morphine analgesia (PCA-IV) as part of multimodal analgesia after thoracotomy. Patients assigned to the active treatment group (a-tDCS

The Efficacy of Peripheral Opioid Antagonists in Opioid-Induced Constipation and Postoperative Ileus: A Systematic Review of the Literature.

Opioid-induced constipation has a negative impact on quality of life for patients with chronic pain and can affect more than a third of patients. A related but separate entity is postoperative ileus, which is an abnormal pattern of gastrointestinal motility after surgery. Nonselective μ-opioid receptor antagonists reverse constipation and opioid-induced ileus but cross the blood-brain barrier and may reverse analgesia. Peripherally acting μ-opioid receptor antagonists target the μ-opioid receptor without reversing analgesia. Three such agents are US Food and Drug Administration approved. We reviewed the literature for randomized controlled trials that studied the efficacy of alvimopan, methylnaltrexone, and naloxegol in treating either opioid-induced constipation or postoperative ileus. Peripherally acting μ-opioid receptor antagonists may be effective in treating both opioid-induced bowel dysfunction and postoperative ileus, but definitive conclusions are not possible because of study inconsistency and the relatively low quality of evidence. Comparisons of agents are difficult because of heterogeneous end points and no head-to-head studies

Trauma and acute care surgeons report prescribing less opioids over time.

IntroductionConfronted with the opioid epidemic, surgeons must play a larger role to reduce risk of opioid abuse while managing acute pain. Having a better understanding of the beliefs and practices of trauma and acute care surgeons regarding discharge pain management may offer potential targets for interventions beyond fixed legal mandates.MethodsAn Institutional Review Board-approved electronic survey was sent to trauma and acute care surgeons who are members of the American Association for the Surgery of Trauma, and trauma and acute care surgeons and nurse practitioners at a Level 1 trauma center in February 2018. The survey included four case-based scenarios and questions about discharge prescription practices and beliefs.ResultsOf 66 respondents, most (88.1%) were at academic institutions. Mean number of opioid tablets prescribed was 20-30 (range 5-90), with the fewest tablets prescribed for elective laparoscopic cholecystectomy and the most for rib fractures. Few prescribed both opioid and non-opioid medications (22.4% to 31.4 %). Most would not change the number/strength of medications (69.2%), dose (53.9%), or number of tablets of opioids (83.1%) prescribed if patients used opioids regularly prior to their operation. The most common factors that made providers more likely to prescribe opioids were high inpatient opioid use (32.4%), history of opioid use/abuse (24.5%), and if the patient lives far from the hospital (12.9%). Most providers in practice >5 years reported a decrease in opioids (71.9%) prescribed at discharge.ConclusionTrauma and acute care surgeons and nurse practitioners reported decreasing the number/amount of opioids prescribed over time. Patients with high opioid use in the hospital, history of opioid use/abuse, or who live far from the provider may be prescribed more opioids at discharge.Level of evidenceLevel IV

Experiences of people taking opioid medication for chronic non-malignant pain : a qualitative evidence synthesis using meta-ethnography

Objective To review qualitative studies on the experience of taking opioid medication for chronic non-malignant pain (CNMP) or coming off them. Design This is a qualitative evidence synthesis using a seven-step approach from the methods of meta-ethnography. Data sources and eligibility criteria We searched selected databases—Medline, Embase, AMED, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and Scopus (Science Citation Index and Social Science Citation Index)—for qualitative studies which provide patients’ views of taking opioid medication for CNMP or of coming off them (June 2017, updated September 2018). Data extraction and synthesis Papers were quality appraised using the Critical Appraisal Skills Programme tool, and the GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation working group - Confidence in Evidence from Reviews of Qualitative research) guidelines were applied. We identified concepts and iteratively abstracted these concepts into a line of argument. Results We screened 2994 unique citations and checked 153 full texts, and 31 met our review criteria. We identified five themes: (1) reluctant users with little choice; (2) understanding opioids: the good and the bad; (3) a therapeutic alliance: not always on the same page; (4) stigma: feeling scared and secretive but needing support; and (5) the challenge of tapering or withdrawal. A new overarching theme of ‘constantly balancing’ emerged from the data. Conclusions People taking opioids were constantly balancing tensions, not always wanting to take opioids, and weighing the pros and cons of opioids but feeling they had no choice because of the pain. They frequently felt stigmatised, were not always ‘on the same page’ as their healthcare professional and felt changes in opioid use were often challenging

Gabapentinoid use disorder. Update for clinicians

Gabapentinoids (gabapentin and pregabalin) are versatile drugs, indicated mainly for epilepsy and neuropathic pain, and have long been viewed as agents with little potential for abuse. Burgeoning prescribing patterns and studies indicate that these drugs are increasingly being abused, particularly by polydrug abusers who also abuse opioids. Gabapentinoid abuse is found in less 2% of the general population but may be as high as 15% to 22% among opioid abusers. Other risk factors for gabapentinoid abuse are less clear-cut but include mental health disorders. Gabapentinoids are relatively easy for drug abusers to obtain and many clinicians are not fully aware of their abuse potential. It is thought that gabapentinoids may offer psychoactive effects or enhance the effects of other drugs of abuse. Those who discontinue gabapentinoids abruptly may suffer withdrawal symptoms, but gabapentinoid overdose fatality is rare. Since gabapentinoids are often prescribed off-label to treat psychiatric disorders, these drugs may be dispensed to a particularly vulnerable population. Clinicians must be aware of the potential for Gabapentinoid Use Disorder: Update for Clinicians