Substance Use

Nicotine Replacement in Hospitalized Coronary Patients

Some concern exists as to the cardiac safety of using nicotine replacement patches in cardiac disease. The majority of studies indicate it safe to use in stable disease but this observational study is reassuring in finding: “Among smokers hospitalized for treatment of coronary heart disease, use of nicotine replacement therapy was not associated with any differences in short‐term outcomes”.

Outcomes included inpatient mortality, hospital length of stay, and one-month readmission.

These patients had a high degree of cardiac acuity but the authors caution that, due to the known cardiovascular effects of nicotine, randomized along with longer term studies are needed to confirm these reassuring findings in tackling smoking cessation at an early stage of hospitalization.



Post-op Opioid Consumption

It would appear that opioid prescription post operatively is still excessive after abdominal surgery. “Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion”.  This study shows just how little opioid amounts are needed on average.



Opioid-Induced Adrenal Insufficiency

An important reminder of the endocrine effects of chronic opioid use, namely opioid induced adrenal insufficiency. Symptoms of adrenal insufficiency include fatigue, nausea, vomiting, weight loss, dizziness, and muscular aches, many of which overlap with or may compound symptoms related to chronic pain syndrome.  The etiology, diagnosis and management are discussed in this Mayo Clinic review. The possibility should be considered in all anesthesia and critically ill patients, and appropriate steroid supplementation instituted.


Pre-operative Opiod Use and Characteristics

23% of this group reported pre-operative opioid use. “Age, tobacco use, illicit drug use, higher pain severity, depression, higher Fibromyalgia Survey scores, lower life satisfaction, and more medical comorbidities were independently associated with preoperative opioid use”. Use was highest in those presenting for orthopedic and neurosurgical procedures. This data may be important in pre-operative management, weaning or risk mitigation and peri-operative and post-discharge opioid prescribing.



Cannabis and Chronic Non-Cancer Pain


A study on cannabis dispels the hype again, finding no evidence that it reduces pain, improves outcome or reduces opioid use. “People who used cannabis had greater pain and lower self-efficacy in managing pain” – this is increasingly the key to managing (not eliminating) pain, using education, quality of life and function improvement rather than focus on pain.



Surgery Link to Opioid Misuse Potential

Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. Later it falls to family practice. This study emphasizes the role of postoperative opioid prescription and its renewal by family doctors as an important target for identifying risks of dependence and misuse.