Substance Use

Slow Release Opiods and Acute Pain

ANZCA release a position paper:

Slow-release opioids are not recommended for use in the management of patients with acute pain.
The inappropriate use of slow-release opioids for the treatment of acute pain has been associated with a significant risk of respiratory depression, resulting in severe adverse events and deaths. Immediate release opiods are the choice in acute pain, barring individual cases of prolonged pain and then  only after careful consideration and monitoring.

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Gabapentinoid Misuse

Gabapentin (Neurontin) and Pregabalin (Lyrica) have side effects which are nontrivial and can include psychiatric or even respiratory issues ( link ), alone or in combination. Their increased prescription way outside their few indications reflect in part desperation in the face of the opioid epidemic. In the US, the FDA is assessing the misuse/abuse threat of these agents  link

Cannabis Legalization and the Opioid Crisis

A study  suggests that cannabis legalization may play a beneficial role in the opioid crisis. Pre-clinical research suggests cannabinoid and opioid receptor systems mediate common signaling pathways central to clinical issues of tolerance, dependence, and addiction. A previous study showed the opposite in illicit cannabis, in that users had an increased opioid abuse risk. Policy, taxes and corporate interests have raced ahead of science and the JAMA editorial discusse this  link

 

Opioid Use Disorder Guidelines

New Canadian guidelines largely focussed on opioid agonist therapy

Begin opioid agonist therapy with buprenorphine–naloxone.
If patient doesn’t  respond well to buprenorphine–naloxone, consider transition to  methadone.
When buprenorphine–naloxone is not the preferred treatment, use methadone as initial therapy.
When both buprenorphine–naloxone and methadone are contraindicated or not effective, slow-release oral morphine may be considered.
Withdrawal management alone should be avoided. If cessation of opioid use is achieved, oral naltrexone can be considered as an adjunct medication to support abstinence.
Psychosocial treatment interventions should be offered routinely but should not be viewed as mandatory.

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Multimodal Analgesia Benefits

In the eye of the opioid storm, some data on the use of multimodal analgesia techniques in hip and knee replacement : while not a controlled trial, the data encourage our use of techniques such as nerve blocks, acetaminophen, NSAIDS, COX2 Inhibitors, gabapentinoids, and ketamine. Benefits included lower opioid use, reduced respiratory and gastrointestinal side effects, as well as reduced length of stay   link ASA

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Opioid Balance – Pain vs Misuse

“Opioid analgesics are an important part of our therapeutic armamentarium, but they have serious consequences when used improperly. As the pendulum swings from liberal opioid prescribing to a more rational, measured, and safer approach, we can strive to ensure that it doesn’t swing too far, leaving patients suffering as the result of injudicious policies”.

A reflection on controlling the current opioid pendulum swing from the New England Journal. Buprenorphine has a role in anslgesia   link