Opioid-Induced Constipation

Chronic Pain Patients: Opioid Induced Constipation a Serious Concern After Surgery

PainRelief.com Interview with:

Jonathan Jahr, MD, DABA, FASA

Dr. Jonathan Jahr is an anesthesiologist in Los Angeles, California and is affiliated with multiple hospitals in the area, including UCLA Medical Center and UCLA Medical Center-Santa Monica. He received his medical degree from New York Medical College and has been in practice for more than 20 years.

Dr-Jonathan-Jahr

PainRelief.com:  What is the background for this study?  Why is it important?

Response: I have worked in the hospital setting for the past 25 years and have conducted multiple studies on different opioid and non-opioid strategies for managing both chronic and acute pain. I also co-edited a textbook entitled Essence of Analgesia and Analgesics. My background and the research I’ve done sets the stage for newer pain management protocols that can provide patients with significant pain relief, and improved satisfaction and outcomes due to fewer or avoided opioid related side effects (ORADS) such as opioid-induced constipation (OIC).

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EXPAREL TAP Block Provides Pain Relief For Cesarean Delivery With Less Opioids

PainRelief.com Interview with:

B. Wycke Baker, MD
Chief of Service, Anesthesiology at Texas Children’s Pavilion for Women
Clinical Professor of Anesthesiology, Obstetrics and Gynecology
Baylor College of Medicine 

pacira pharmaceuticals

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: For this study, we reviewed the charts of 201 women who underwent cesarean deliveries and received a multimodal pain management protocol with or without a TAP block utilizing EXPAREL, a long-acting, non-opioid option to manage pain following surgery. A TAP block, or a transversus abdominis plane block, is a field block that numbs the nerves that supply the abdominal wall. The study included patients who underwent elective, unscheduled waiting list, or emergency cesarean delivery with combined spinal-epidural anesthesia and post-cesarean pain management at Texas Children’s Hospital Pavilion for Women between 2012 and 2015.

The findings revealed many positive outcomes for patients who received a TAP block utilizing EXPAREL compared to those who received multimodal pain control without a TAP block utilizing EXPAREL. For instance, patients who received EXPAREL TAP block showed a significant decrease in postsurgical pain as well as a significant decrease in opioid consumption. On average, patients who received EXPAREL TAP block had shorter time to discharge from PACU, shorter time to readiness for discharge to home, and shorter length of stay in hospital than those who did not receive EXPAREL TAP block.

Further, a significantly higher number of patients treated with EXPAREL TAP block (12%) compared to those without EXPAREL TAP block (3%) consumed no opioids after surgery. Fewer patients treated with EXPAREL TAP block (34%) compared to those without EXPAREL TAP block (50%) reported any adverse events following the delivery.

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Online Patient Materials Unlikely to Discuss Risk of Opioids Prescribed for Pain Relief

PainRelief.com Interview with:

Edward R. Mariano, MD, MAS (Clinical Research)
Chief, Anesthesiology and Perioperative Care Service and
Associate Chief of Staff for Inpatient Surgical Services
VA Palo Alto Health Care System
Professor of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Palo Alto, CA  94304

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: Today, there is so much attention on the opioid epidemic, and patients and clinicians are constantly reminded about the dangers of opioids. Guidelines have recommended the provision of patient and caregiver education on pain management, especially on how to taper (safely decrease and eventually stop taking) opioids after surgery. With over 70 fellowship programs in regional anesthesiology and acute pain medicine, we assumed that there would be plenty of information for patients on safe opioid management online since most people use the internet to find health-related information. We conducted a rigorous search for online patient education materials related to safe opioid management, evaluated to reading level and content, and compared materials produced by fellowship programs to other online educational materials. Unfortunately, the average reading level for all materials we found was above the level recommended for patients (sixth grade or lower). Most fellowship programs in regional anesthesiology and acute pain medicine did not even offer online patient education materials and were less likely to describe overdose risk and opioid disposal. Less than half of all materials mentioned tapering or cessation of opioids after surgery (see visual abstract attached).

PainRelief.com: What should readers take away from your report?

Response: Since our patients reliably go to the internet for information, we as a healthcare community need to get out there and put valuable information online that people can use. Overdoses due to opioids are a public health crisis, and direct-to-patient education on safe opioid storage, tapering, and disposal through the internet can make a difference. Fellowship programs should take the lead. As the institutions training the next generation of physician leaders in regional anesthesiology and acute pain medicine, one priority should be teaching fellows modern communication tools to help educate their patients and society in general.


PainRelief.com: What recommendations do you have for future research as a result of this work?

Response: For this study, we focused on written materials only in order to assess readability, but we do not yet know what is the ideal format (e.g., video) for providing patient education. This preference may be influenced by a number of factors and should be studied. We also do not know the best location for patient educational materials online or how to most efficiently disseminate this information to people likely to benefit from it. Another important research question is when and how patients access information related to their own care as this may influence when to promote online educational materials to patients preparing for surgery.

PainRelief.com: Is there anything else you would like to add?

Response: None of the authors has financial conflicts of interest to disclose. I currently serve on the Board of Directors for the American Society of Regional Anesthesia and Pain Medicine (ASRA), Chair of the Committee on Regional Anesthesia and Acute Pain Medicine for the American Society of Anesthesiologists (ASA), Speaker of the House of Delegates for the California Society of Anesthesiologists, and National Academy of Medicine Action Collaborative Countering the U.S. Opioid Epidemic. 

Citation:

Gunjan Kumar, Kellie M Jaremko, Alex Kou, Steven K Howard, T Kyle Harrison, Edward R Mariano; Quality of Patient Education Materials on Safe Opioid Management in the Acute Perioperative Period: What Do Patients Find Online?, Pain Medicine, , pny296, https://doi.org/10.1093/pm/pny296

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Pain and Substance Use Can Interact in a Vicious Cycle

PainRelief.com Interview with:

Emily L. Zale PhD Department of Psychology Syracuse University Syracuse, New York

Dr. Zale

Emily L. Zale PhD
Department of Psychology
Syracuse University
Syracuse, New York

PainRelief.com: What is the background for this study? What are the main findings?

Response: When people think of pain and substance use, it’s common for opioids to come to mind. While the opioid crisis has rightfully garnered considerable attention, our research suggests that non-opioid substances, like nicotine/tobacco, alcohol, and cannabis, are also important to consider in relation to pain. In fact, nicotine/tobacco, alcohol, and cannabis are the most commonly used substances in the US, and research into associations between pain and these non-opioid substances is continuing to increase in popularity.

Research studies usually examine either how substance use affects pain or how pain affects substance use. We looked at results from over 100 studies and put these two different types of research together to understand how pain and substance use affect each other.

On one hand, substance use can be a risk factor for chronic pain and may worsen pain over time. On the other hand, experiencing pain can motivate people to use substances and might make it harder to quit. By putting these two types of studies together, we found that pain and substance use  interact in a vicious cycle that can ultimately worsen and maintain both chronic pain and addiction.

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Study Suggest Opioids Should Not Be First Line Therapy for Chronic Non-Cancer Pain

PainRelief.com Interview with:

Dr. Jason Busse PhD Associate Professor McMaster University

Dr. Busse


Dr. Jason Busse PhD
Associate Professor
McMaster University

PainRelief.com: What is the background for this study?  

Response: The United States prescribes more opioids per capita than any other country in the world, and opioids are associated with addiction, overdose, and death. Many individuals living with chronic noncancer pain are managed with opioid therapy; however, we have limited knowledge regarding benefits and harms. We conducted a systematic review and meta-analysis to synthesize the evidence from all RCTs that explored an opioid vs. a non-opioid comparator for patients with chronic noncancer pain, and followed participants for at least 1 month. Continue reading

New Opioid Ligands May Provide Pain Relief Without Addiction Risk

PainRelief.com Interview with:

Prof. Dr. Christoph Stein Direktor Institut für Experimentelle Anaesthesiologie Charité Campus Benjamin Franklin Freie Universität Berlin 

Prof. Stein

Prof. Dr. Christoph Stein
Direktor
Institut für Experimentelle Anaesthesiologie
Charité Campus Benjamin Franklin
Freie Universität Berlin 

PainRelief.com: What is the background for this study? What are the main findings? 

Response: Our group has studied the biology and pharmacology of opioid receptors on peripheral sensory neurons (i.e. outside the central or intestinal nervous system) for over 25 years. We have always aimed at finding mechanisms and opioid receptor ligands that can be developed into drugs inhibiting pain without eliciting typical adverse effects of conventional opioids such as apnoea, addiction, sedation or constipation.

From our previous work we knew that the selective activation of opioid receptors on peripheral sensory neurons can produce powerful pain relief in animals and human patients. Those analgesic effects are particularly strong in pain caused by tissue injury and inflammation (e.g. postoperative pain, arthritis). Together with mathematicians (Dr. Marcus Weber) at the Zuse Institute Berlin, we started out with computer simulations examining the interaction between opioid ligands and receptors in normal (noninflamed) and inflamed environments. These studies indicated a stronger binding of conventional opioid ligands (morphine, fentanyl) to opioid receptors at increased proton concentrations (i.e. low pH, as present in acidotic/inflamed tissue). We also knew that the protonation of a tertiary amine in the ligand is required for opioid receptor activation. Using those in silico simulations, we now designed a new ligand (NFEPP) that is only protonated (and capable of activating opioid receptors) at low pH, but not at normal pH (as in brain and intestinal wall). After synthesis of NFEPP (and similar derivatives) by a contractor we tested them in vitro and in vivo. NFEPP produced opioid receptor activation and analgesia selectively at low pH/tissue inflammation (as present in nerve injury/neuropathy and abdominal inflammation) without eliciting respiratory depression, addiction potential, sedation or constipation. 

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New Technique Can Help Pinpoint Where Heroin Batches Come From

New method describes measuring  strontium isotopes can be used as a chemical marker for geography and geology to differentiate heroin samples from different geographic regions.

Joshua DeBord, Ali Pourmand, Sarah C. Jantzi, Sini Panicker, Jose Almirall. Profiling of heroin and assignment of provenance by 87 Sr/ 86 Sr isotope ratio analysis. Inorganica Chimica Acta, 2017; DOI: 10.1016/j.ica.2017.07.049