Journal of pain & palliative care pharmacotherapy
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J Pain Palliat Care Pharmacother · Sep 2019
Opioid-related respiratory and gastrointestinal adverse events in patients with acute postoperative pain: prevalence, predictors, and burden.
Opioid-induced respiratory depression (OIRD) and postoperative nausea and vomiting (PONV) are challenging, resource-intensive, and costly opioid-related adverse events (ORAEs). Utilizing the Premier Healthcare Database, we identified patients > 18 years old, who underwent at least one surgical procedure of interest (i.e., cardiothoracic/vascular, general/colorectal, obstetric/gynecologic, orthopedic, or urologic), and received at least one dose of intravenous morphine, hydromorphone, or fentanyl for acute postoperative pain. The incidence of OIRD and PONV using ICD-9 codes, factors influencing these AEs, length of stay (LOS) and related costs were analyzed. ⋯ Increased odds of PONV were associated with younger age, female sex, and major disease severity. When respiratory depression or nausea/vomiting was present versus absent, LOS was significantly longer, and hospital costs were higher. In this analysis, OIRD and PONV were more prevalent than previously reported, were associated with identifiable risk factors, and had substantial effects on resource utilization and costs.
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J Pain Palliat Care Pharmacother · Sep 2019
Case ReportsKetamine: When Delirium and Desperation Call for a Hero.
The use of ketamine in palliative care is becoming more common for challenging symptom management, namely cancer related pain and psychiatric conditions. However, there is much that remains unstudied and uncertain about ketamine's clinical utility. ⋯ Despite concerns regarding baseline delirium we successfully used ketamine to better manage neuropathic pain, decrease overall opioid need, without exacerbating the preexisting delirium. Our case highlights the benefits of ketamine for neuropathic pain control in the face of delirium.
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J Pain Palliat Care Pharmacother · Sep 2019
Case ReportsOpioid Rotation to Methadone for Refractory Cancer Pain: A Case Series.
Methadone has been increasingly used in the treatment of refractory cancer pain with different conversion methods and ratios described. A retrospective chart review of patients on methadone for cancer pain was conducted to assess its use as the primary opioid, focusing on pain characteristics, opioid rotation indication, previous analgesics, adverse effects and final methadone dose in comparison with the pre-rotation Morphine Equivalent Daily Dose (MEDD). Eight patients were rotated to methadone due to refractory moderate-severe cancer pain and achieved good pain relief. ⋯ Methadone is effective for the treatment of refractory cancer pain. The eventual required methadone doses for these patients were significantly different from predicted doses suggested by equianalgesic conversion tables and guidelines. This highlights the importance of individualized titration and careful clinical assessment during the rotation and in the days after, to prevent serious adverse effects.
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Opioids are often the foundation of pain management in seriously ill patients. Unfortunately, even experienced providers carry with them information that they consider "fact", when this information is not based on scientific evidence, but on "myth". Several topics were elicited based on common beliefs and misconceptions in clinical practice. ⋯ They are intended to make readers give thought to opioid therapy which is strictly evidence-based, and not historical or anecdote-based. Practical recommendations are provided to give readers a starting point to base clinical decisions going forward. Readers may discover that "facts" they once learned about opioid use in seriously ill patients are actually "myths" that are a figment of the past.
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J Pain Palliat Care Pharmacother · Mar 2019
Case ReportsUse of Dexmedetomidine for Postoperative Pain Management Following Spine Fusion Surgery in a Highly Opioid-Tolerant Patient.
A 51-year-old man with metastatic renal cell carcinoma whose fentanyl requirement was 3000-4000 µg/h in inpatient hospice presented for a thoracic (T) vertebral 4-10 posterior spinal fusion for a lytic T7 compression fracture. He underwent total intravenous (IV) anesthesia with propofol, remifentanil, and ketamine; liposome bupivacaine was locally infiltrated at the end of the case. ⋯ He participated in neurological examinations and fulfilled both surgical and pain management goals without side effects. Dexmedetomidine was successfully weaned off on POD 3.