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By Steven Reinberg HealthDay Reporter
WEDNESDAY, Dec. 13, 2017 (HealthDay News) -- Opioid painkillers after surgery can be the first step toward addiction for some patients. But a common drug might cut the amount of narcotics that patients need, a new study finds.
When patients received a non-opioid medication called gabapentin before and after surgery, the need for continued opioid painkillers was reduced by 24 percent, said researchers at Stanford University School of Medicine.
The finding comes amid an opioid epidemic in the United States. Since 1999, overdose deaths have quadrupled, in large part due to abuse of prescription painkillers such as OxyContin (oxycodone) or heroin.
"Our country is facing an opioid crisis, and a lot of people are exposed to opioids after surgery," said researcher Dr. Sean Mackey, chief of the division of pain medicine.
More than 51 million Americans undergo surgery each year, according to background notes in the study. Most are given opioid painkillers afterward, and up to 13 percent become habitual users.
"There are some people who are vulnerable to the addictive proprieties of these drugs," Mackey said. "We would prefer to find ways of not having people get into problems with opioids."
Gabapentin (brand names: Neurontin, Gralise) is used to help prevent seizures and ease nerve pain from shingles. It's available as a generic, so it is inexpensive and covered by most drug plans.
Now, it appears to reduce the time patients feel they need opioid relief by a "modest" amount, the researchers said.
"This means that people are less likely to become addicted to opioids and less likely to have the side effects of an opioid," Mackey said.
Those side effects can include sedation, nausea and constipation.
Surprisingly, the drug had no effect on how long it took for post-operative pain to subside, Mackey said. But it did effect how long patients needed opioids.
For the study, Mackey and his colleagues randomly assigned 410 surgical patients to receive gabapentin or a placebo before surgery and for three days afterward. Patients were followed for up to two years.
Procedures included chest surgery, knee replacements, and hand and breast surgery, to name a few. The study found that gabapentin seemed to help regardless of the type of operation.
It's not clear how gabapentin might reduce the need for opioids, Mackey said. Perhaps it's changing brain chemistry after surgery, he said.
"It's probably having pain-relieving properties along with the opioid, and you don't need so many opioids because the effects of the gabapentin are long-lasting," he said.
Gabapentin is considered nonaddictive.
Mackey said more work needs to be done to determine which patients would benefit most from gabapentin, at what dose and for how long.
It's also possible that gabapentin might benefit patients with pain from trauma. Given in the emergency room, it might help reduce the need for opioids, and thus help to prevent addiction in that setting, he said.
The findings were published online Dec. 13 in the journal JAMA Surgery.
Dr. Michael Ashburn is director of pain medicine at the Penn Pain Medicine Center in Philadelphia. He said this study may have important implications.
"This and other studies have reported that the duration of opioid administration may impact whether or not patients transition to chronic opioids after surgery," said Ashburn, co-author of an accompanying journal editorial.
Although gabapentin doesn't seem to reduce the length of time it takes for pain to cease after surgery, it "may allow for opioids to be discontinued more quickly following surgery," Ashburn said.
Giving gabapentin after surgery is already part of clinical practice at Lenox Hill Hospital in New York City, said Dr. Kiran Patel.
"I am constantly looking for ways to reduce opioid requirements and to get patients off opioids so they don't transition to chronic opioid use," said Patel, an anesthesiologist and pain management specialist at the hospital.
There are ways to manage pain aside from opioids and anti-inflammatories after surgery, she noted. "Incorporating them with the right patients, we might be able to reduce their overall use of opioids," she said.
More information
For more about opioid use, visit the U.S. National Institute on Drug Abuse.
SOURCES: Sean Mackey, M.D., Ph.D., chief, pain medicine, and director, Stanford Systems Neuroscience and Pain Lab, Stanford University School of Medicine, Palo Alto, Calif.; Michael Ashburn, M.D., M.P.H., professor, anesthesiology and critical care, and director, pain medicine, Penn Pain Medicine Center, Philadelphia; Kiran Patel, M.D., anesthesiologist and pain management specialist, Lenox Hill Hospital, New York City; Dec. 13, 2017, JAMA Surgery, online
Last Updated: Dec 13, 2017
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A team of partners from MCW, Dryhootch and Mental Health America of Wisconsin contributed to the development of this project.
By Medical College of Wisconsin - Dec 6th, 2017 01:12 pm
Pills by Tom Varco (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.
Using a community-engaged research (CEnR) approach, Milwaukee Prevention of Opioid Misuse through Peer Training (PROMPT) integrates chronic pain treatment and trauma-informed care with input from local military veterans to develop innovative ways of addressing OUD. CEnR emphasizes community stakeholder involvement in all phases of the research including project/concept development, data collection and interpretation and dissemination of the results.
A team of partners from MCW, Dryhootch and Mental Health America of Wisconsin (MHA) contributed to the development of this project. Dryhootch is a nonprofit organization founded in 2008 by a Vietnam veteran with a mission of helping veterans and their families. MHA is an affiliate of the national non-profit dedicated to helping all Americans achieve wellness by living mentally healthier lives, and has extensive experience implementing programs for populations affected by opioid addiction.
“Veterans are trained to have the back of another brother or sister in combat. So peer mentoring is the most effective in reaching the veterans that we work with. Our goal is to provide wrap-around services and support to fellow veterans while building a sense of camaraderie,” said Bob Curry, Founder and President of Dryhootch. “It’s great that this research project involves us as equal voices at the table to hear our perspectives and understand our needs.”
Academic partners L. Kevin Hamberger, PhD, MCW professor of family and community medicine; Kajua Lor, PharmD, MCW chair of the department of clinical sciences and associate professor in the School of Pharmacy; and Robert Hurley, MD, PhD, professor and executive director of Pain Shared Services at Wake Forest Baptist Medical Center round out the team of RWJF Clinical Scholars. The project team also includes Zeno Franco, PhD, MCW associate professor of community engagement; Sarah O’Connor, MCW community engagement program manager, and Tiffiney Gray, MCW program coordinator; Bob Curry and Otis Winstead of Dryhootch; and Martin Gollin-Graves and Anne Ruiz of MHA.
This project is supported by the Robert Wood Johnson Foundation Clinical Scholars leadership development program, which funds teams of clinicians from different disciplines who collaborate to address a problem in their community.
People: Anne Ruiz, Bob Curry, Kajua Lor, L. Kevin Hamberger, Martin Gollin-Graves, Otis Winstead, Sarah O’Connor, Syed Ahmed, Tiffiney Gray, Zeno Franco
Organizations: Medical College of Wisconsin
Egalet Corporation recently announced that Egalet-002, an extended-release, abuse-deterrent form of oxycodone, demonstrated safety and efficacy endpoints for the treatment of moderate-to-severe chronic low back pain in a phase 3 trial.
The multicenter, double-blind, enriched enrollment, randomized withdrawal study evaluated how safe and effective Egalet-002 was in opioid-experienced and opioid-naïve patients with moderate-to-severe chronic low back pain compared with placebo.
The results showed that average pain intensity from randomization to week 16 was statistically and significantly different among patients with receiving Egalet-002 vs. placebo.
In a previous safety study of Egalet-002, the drug was found to be generally well-tolerated for up to 56 weeks in opioid-experienced patients with moderate-to-severe chronic noncancer pain.
The current study did not identify any new safety concerns.
“These results demonstrate Egalet-002, an abuse-deterrent, extended-release oxycodone, provided effective pain relief for patients with moderate-to-severe chronic back pain,” Bob Radie, president and CEO of Egalet, said in a press release. “Given the prevalence of chronic back pain combined with the prescription abuse epidemic, we believe development of more abuse-deterrent products like Egalet-002 is important for our communities.”
Disclosure: Healio Internal Medicine was unable to confirm relevant financial disclosures at the time of publication.
HealthDay News — For reversal of opioid overdose, higher-concentration intranasal naloxone has similar efficacy to that of intramuscular naloxone administered at the same dose, according to a review published online November 27 in the Annals of Internal Medicine.
Roger Chou, MD, from the Oregon Health & Science University in Portland, and colleagues conducted a systematic review to synthesize evidence on the effects of naloxone route of administration and dosing for suspected overdose in out-of-hospital settings, and the need for transport to a health care facility after reversal of overdose with naloxone. Data were included from 13 eligible studies.
The researchers found that 1 trial demonstrated similar efficacy between higher-concentration intranasal naloxone and intramuscular naloxone administered at the same dose (2mg/mL). One trial found that lower-concentration intranasal naloxone was less effective than intramuscular naloxone, but the risk for agitation was reduced (low strength of evidence). There was insufficient evidence to assess other comparisons for administration route. Low rates of death and serious adverse events were reported in 6 uncontrolled studies in non-transported patients after successful naloxone treatment.
"Higher-concentration intranasal naloxone (2mg/mL) seems to have efficacy similar to that of intramuscular naloxone for reversal of opioid overdose, with no difference in adverse events," the authors write. "Non-transport after reversal of overdose with naloxone seems to be associated with a low rate of serious harms, but no study evaluated risks of transport versus non-transport."
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More than half of Wisconsin counties have sued opioid manufacturers, as 20 more counties announced Tuesday that they are filing lawsuits.
The counties are led by the Milwaukee-based law firm Crueger Dickinson and Simmons Hanly Conroy, which has offices throughout the country and has filed similar suits in five other states.
The counties allege that the drug manufacturers' business strategies helped create the opioid epidemic.
Milwaukee County officials highlighted $2.6 million in grants that will help them expand addiction treatment programs at a press conference Monday.
County Executive Chris Abele said that the funding is “a huge step forward” and will support local efforts to fight the opioid epidemic.
“As a country, we need to use every dime we’ve got,” he said. “We need to focus on an issue that is growing faster and killing more people than just about anything you can imagine.”
Milwaukee County Family Drug Treatment Court is receiving $2.1 million over the next five years from the Substance Abuse Mental Health Services Administration.
“We are transforming these families,” said Milwaukee County Court Judge Joe Donald.
Robyn Ellis, who participated in the county’s family drug treatment court, started using alcohol as a child and illegal drugs as a teenager.
In 2013, she lost custody of her daughter. Then family drug treatment court got involved.
“It’s hard for me to stand up here and share all of this because I’m in such a different place today,” she said.
The court helped her get and stay sober, and she regained custody of her daughter in 2014.
An additional $506,000 grant from the Wisconsin Department of Health Services will allow the county’s Behavioral Health Administration to expand its alcohol and other drug addiction treatment and recovery services to 75 more people.
Those services include medication-assisted treatment, residential treatment, recovery housing and counseling.
The legislature is considering legislation based on proposals from the Workers Compensation Advisory Council. The proposals were developed Labor and Management representatives on the Council. But not all of the proposals share the support of the Council’s health care representatives, including a recommended fee schedule. Health care organizations will need to be even more active this session than last to again defeat the fee schedule proposal.
It is important to note that works compensation premiums have dropped – without a government mandated fee schedule. This year alone, employers received an 8.46 percent reduction in their worker’s compensation insurance premiums, saving employers an estimated $170 million. At the same time, Wisconsin’s health care system continues to lead the nation in outcomes with injured employees returning to work a full three weeks earlier than the national average. And health care costs per worker’s comp claim lower than the national average.
Your calls are needed to both the State Assembly and State Senate to explain why the proposed health care fee schedule could harm Wisconsin’s model worker’s compensation system. You can find your legislators contact information on the state legislature’s website.
Let your State Representative and State Senator know you are a physician in their district, serving patients who are also constituents and that you are opposed to an artificial fee schedule for a worker’s compensation system that provides the nation’s best care at a below-average worker’s compensation cost. Thank you for your time and action on this important issue.
November 27, Wisconsin Health News
The state’s Supreme Court agreed last week to review a lower court’s decision striking down a cap on how much patients can receive for some malpractice claims.
An appeals court ruled in July that a state law capping awards for noneconomic damages at $750,000 was unconstitutional. Noneconomic damages seek to compensate patients for pain and suffering. The Wisconsin Hospital Association and the Wisconsin Medical Society have raised concerns about the court’s decision and its potential ramifications for providers and accessibility to healthcare. In her opinion striking down the decision, Judge Joan Kessler said the law placed an “unfair and illogical burden only on catastrophically injured patients, thus denying them the equal protection of the laws.”
The case involves Ascaris Mayo, who lost her limbs after providers at a Milwaukee-area emergency room failed to notify her she had an infection. A jury awarded Mayo and her husband $16.5 million for noneconomic damages, which the state sought to reduce.
HealthDay Reporter
TUESDAY, Nov. 21, 2017 (HealthDay News) -- The U.S. opioid epidemic seems to be taking its biggest toll on the baby boomer and millennial generations, a new study suggests.
Researchers found that since 2010, boomers -- born between 1946 and 1964 -- have had heightened rates of death from prescription opioids and heroin. Meanwhile, millennials -- people in their 20s and 30s -- also have been hard hit by heroin overdoses.
"The opioid epidemic has affected everyone," said senior researcher Dr. Guohua Li. "But what we're seeing is that these two generations are at highest risk," said Li, a professor of epidemiology at Columbia University.
Li said he could only speculate on the reasons.
But the findings on boomers were not surprising, he noted. That generation is known to have a relatively high rate of drug abuse, versus other generations. Plus, Li said, they were middle-aged when prescriptions for opioids were taking off in the 1990s -- which means they were a "primary target" for the medications.
According to the U.S. National Institute on Drug Abuse, more than 2 million Americans were abusing opioids in 2015. That included heroin and prescription opioids, such as painkillers like Vicodin (hydrocodone), OxyContin (oxycodone) and codeine.
Recent research has found that Americans' prescription opioid abuse has leveled off. But overdose deaths are still climbing.
Earlier this year, a U.S government study highlighted the toll that heroin alone is taking. Between 2002 and 2016, deaths from the drug soared by 533 percent nationwide -- from just under 2,100 deaths to more than 13,200.
So while efforts to curtail opioid prescriptions have worked, opioid deaths overall have not yet declined, said Robert Heimer, a professor of epidemiology at Yale School of Public Health.
Unfortunately, some people addicted to prescription opioids switch to heroin or, more recently, illicitly made "synthetic" opioids such as fentanyl.
"Often, people on heroin started with prescription opioids," Heimer said. However, he added, these are typically illegally sold prescription drugs.
Heimer, who was not involved in the new study, said the findings are "useful."
"It really suggests it's the older and younger generations that are being most affected by this epidemic," he said.
The study analyzed national vital statistics for the years 1999 to 2014.
Li's team found that compared with people born in the late-1970s, boomers were up to 27 percent more likely to die of a prescription opioid overdose. And they were up to one-third more likely to die of a heroin overdose.
Meanwhile, the rate of heroin overdose death accelerated most among millennials -- people born in the 1980s to early '90s. For example, those born in 1989 and 1990 were 23 percent more likely to die of a heroin overdose compared with Americans born in the late 1970s.
According to Li, it's not clear why millennials face a higher risk than their "Generation X" predecessors. But he speculated that they have had relatively less economic security than Gen Xers.
On the prevention side, various medical groups have changed guidelines to rein in opioid prescriptions.
Also, U.S. states have launched drug monitoring programs, which electronically track prescriptions for controlled substances. Doctors can check them before prescribing opioids, to help catch "doctor shoppers" -- people who go from one provider to the next, seeking a new opioid prescription.
But those efforts only go so far, Heimer pointed out.
To cut down overdose rates, access to addiction treatment is vital, Heimer and Li agreed.
"Medication-assisted treatment" -- with the drugs methadone, buprenorphine or naltrexone -- is considered the most effective therapy for opioid dependence. The medications act on the same brain targets as opioids do, and help suppress withdrawal symptoms and cravings.
But there are big barriers to receiving that kind of treatment. Only a small number of U.S. doctors prescribe them, and lack of training is one reason, according to Heimer.
"Stigma" is a wider, underlying issue, he said. The drugs used to treat opioid addiction are sometimes seen as nothing more than a substitution, and there is still a belief that total abstinence should be the goal.
"The biggest problem is that medication-based therapy is stigmatized," Heimer said. "We don't do that with any other chronic disease, and addiction is a chronic disease."
The findings were published online Nov. 21 in the American Journal of Public Health.
The U.S. National Institute on Drug Abuse has more on treating opioid addiction.
SOURCES: Guohua Li, M.D., Dr.PH., professor, epidemiology, Columbia University Mailman School of Public Health, New York City; Robert Heimer, Ph.D., professor, epidemiology, Yale School of Public Health, New Haven, Conn.; Nov. 21, 2017, American Journal of Public Health, online
Last Updated: Nov 21, 2017
President Donald Trump delivers remarks on combatting drug demand and the opioid crisis on October 26, 2017 in the East Room of the White House in Washington, DC.
The White House says the true cost of the opioid drug epidemic in 2015 was $504 billion, or roughly half a trillion dollars.
In an analysis to be released Monday, the Council of Economic Advisers says the figure is more than six times larger than the most recent estimate. The council said a 2016 private study estimated that prescription opioid overdoes, abuse and dependence in the U.S. in 2013 cost $78.5 billion. Most of that was attributed to health care and criminal justice spending, along with lost productivity.
The council said its estimate is significantly larger because the epidemic has worsened, with overdose deaths doubling in the past decade, and that some previous studies didn't reflect the number of fatalities blamed on opioids, a powerful but addictive category of painkillers.
The council also said previous studies focused exclusively on prescription opioids, while its study also factors in illicit opioids, including heroin.
"Previous estimates of the economic cost of the opioid crisis greatly underestimate it by undervaluing the most important component of the loss — fatalities resulting from overdoses," said the report, which the White House released Sunday night.
Last month at the White House, President Donald Trump declared opioid abuse a national public health emergency. Trump announced an advertising campaign to combat what he said is the worst drug crisis in the nation's history, but he did not direct any new federal funding toward the effort.
Trump's declaration stopped short of the emergency declaration that had been sought by a federal commission the president created to study the problem. An interim report by the commission argued for an emergency declaration, saying it would free additional money and resources.
But in its final report earlier this month, the panel called only for more drug courts, more training for doctors and penalties for insurers that dodge covering addiction treatment. It did not call for new money to address the epidemic.
More than 64,000 Americans died from drug overdoses last year, most involving a prescription painkiller or an illicit opioid like heroin.
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