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Surgical protocol reduces opioid use for breast reconstruction patients

Breast cancer surgeries can be quite painful, so a team at Houston Methodist West Hospital has worked to develop pain management protocols that help some patients while reducing the use of narcotics.

Dr. Candy Arentz, a breast surgical oncologist, and Dr. Warren Ellsworth, a plastic surgeon, have been using an enhanced recovery after surgery (ERAS) protocol with non-narcotic medications and nerve blocks to lessen pain and the need for narcotics in reconstructive surgeries.


A DIEP flap reconstruction uses tissue and fat from the abdomen and other areas to reconstruct the breast after a lumpectomy or a mastectomy. Ellsworth said the reconstruction can be beneficial because it can look more natural than implants and can last the rest of a patient’s life. But it can be more painful because of the extra incisions. He recognizes that opioid overuse is an issue and said that is just one reason why he and Arentz are working to reduce opioid use.

“We have also, I would say, across the entire house of medicine known about this opioid overuse, opioid dependence and all these challenges that our narcotics impose on our patients, not only the basic side effects of narcotics like nausea, vomiting, constipation, but of course, the dependency,” Ellsworth said.

The ERAS protocol helps patients with pain starting the day before the surgery. “So it prepares their body for the surgery and the pain that could occur, and then we continue the pain control throughout the surgery and then of course postoperatively and have found a significant reduction in the use of narcotics because of this protocol,” Ellsworth said.

As Arentz and Ellsworth were coming up with the protocol, Ellsworth consulted with plastic surgeons at the University of Pennsylvania and Stanford University, modeling the Methodist West protocol after their programs. But according to Ellsworth, Methodist West is the first in the Houston area to make the non-narcotic protocols a priority with their patients in the area of DIEP flap reconstructions.

Ellsworth said starting ERAS required bringing in others in the hospital on board, including the head of anesthesiology so that anesthesiologists could administer nerve blocks, or long-lasting numbing injections into patients’ nerves, and the head of the ICU (intensive care unit) because the new protocols were a big change in pain management. Arentz said it required patient buy-in as well.

“It starts with our conversations in clinic and assuring the patients that they will have decreased pain afterwards than probably what they were expecting,” Arentz said, adding that the protocol is done without using IV medications, which is what most people expect when they are going to have surgery.

Arentz and Ellsworth had planned to start using ERAS in February or March, but COVID-19 shifted it back some. So they started in April. Ellsworth said that all

Acupuncture before surgery may reduce pain, opioid use

A new pilot study concludes that using acupuncture before surgery can reduce a person’s need for opioids following surgery. The Detroit-based researchers believe that acupuncture is a low-cost, safe method that reduces pain and anxiety in some people.

In the United States, the opioid crisis claimed the lives of 47,000 people in 2018, and almost a third of those deaths involved prescription opioids.

According to the Centers for Disease Control and Prevention (CDC), in 2018, two-thirds of drug overdose deaths involved an opioid. A 2018 report from Substances Abuse and Mental Health Services Administration (SAMHSA) states that 10.3 million people in the U.S. aged 12 or older misused opioids in the past year.

Opioids are a class of drugs that include the illegal drug heroin and the prescription drug fentanyl. Other prescription opioids include oxycodone, hydrocodone, morphine, and codeine.

According to a 2017 paper, over 80% of people receive a prescription for opioids after low-risk surgery. Almost 87% of these prescriptions include oxycodone or hydrocodone, which are the most common culprits in drug overdose deaths.

Doctors often use these opioids in inpatient settings and prescribe them to people when they leave the hospital.

In 2020, researchers found that opioid-related overdoses are 28% higher than reported because of incomplete death records.

Veterans are twice as likely to die from an accidental overdose compared with the general U.S. population. One study showed that the number of veterans’ who died due to an opioid overdose increased by 65% from 2010 to 2016.

In light of this opioid epidemic, there is an urgent need to decrease opioid use before or during surgeries.

In a recent pilot study, a team of researchers evaluated the efficacy of two different acupuncture techniques before a group of veterans underwent surgeries: battlefield acupuncture and traditional acupuncture.

They presented their findings at the Anesthesiology 2020 annual meeting in Chicago, IL, on October 5.

The researchers conducted two experiments. In the first, they divided participants into two groups of 21 veterans due to undergo hip replacement surgery.

The first group received traditional acupuncture before their surgery, and the second group received sham acupuncture. Sham acupuncture, or placebo acupuncture, mimics acupuncture.

People in the control group needed an average of 56 of morphine milligram equivalent (MME) in the first 24 hours after surgery. MME is a method of calculating a patient’s cumulative intake of any opioid drugs over 24 hours.

In comparison, those who had traditional acupuncture received an average of only 20.4 MME. Almost two-hirds less than the control group.

The veterans who underwent traditional acupuncture also reported higher satisfaction with their pain management 24 hours post-surgery.

After rating their treatment satisfaction on a scale of 1–10, those who had acupuncture reported less pain. They also experienced 15% less anxiety than the control group, although this was not statistically significant.

In the second experiment, 28 veterans scheduled for general surgery procedures received battlefield acupuncture. In the control group, 36 participants received sham acupuncture.

Battlefield acupuncture involves putting needles on ear acupoints.

how the pandemic has worsened opioid addiction

Destiny Rozek, 22, of Holbrook, New York on Long Island has struggled with opioid addiction for the past four years, a struggle she said has worsened during America’s coronavirus pandemic.



a man wearing a hat: Photograph: Morgan Lee/AP


© Provided by The Guardian
Photograph: Morgan Lee/AP

Rozek explained that several detox facilities have closed and coronavirus safety protocols have limited the assistance several other facilities once provided. She went to a detox facility several weeks ago, but was discharged after a couple of nights because they needed space in the ward.

“There was no therapy or anything to help me. They didn’t even help me find an outside place to go to after and I was still sick when they let me out but they needed space because it was busy,” Rozek said.

Related: Bleak new record as 71,000 Americans died from drug overdoses last year

Many addiction treatment centers around the US have shut down or turned away patients because of the pandemic, as they struggle with financial losses and adhering to safety protocols. Rozek is currently in an outpatient program, but complained she was only given medicine to try to detox at home and in person support groups aren’t currently available.

“I’m genuinely trying but it feels like I’m stuck, and so do a lot of the other addicts I know,” Rozek added.

Mass layoffs, furloughs, isolation, and cuts to resources for recovering addicts have been cited as contributing factors to reported rises in opioid use and overdoses during the pandemic.

Based on data from the Overdose detection mapping application program, opioid overdoses increased in March 2020 by 18% compared to the same month in 2019, 29% in April 2020, and 42% in May 2020. According to the American Medical Association, over 40 states have reported increases in opioid related deaths during the pandemic, even as the US experienced a record of nearly 71,000 opioid related deaths in 2019.

“Drug users are doubly vulnerable right now. They are vulnerable in terms of increased risk of relapse, increased risk of misuse during the pandemic, but they’re also at increased risk for being infected by Covid and having adverse reactions to Covid,” said Dr Magdalene Cerda, of NYU Langone Health.

Cerda said states should be taking advantage of the loosening of regulations on opioid disorder medications methadone and buprenorphine to increase access to medication, increased funding for harm reduction services and loosening of restrictions by states for naloxone, an overdose reversal medication.



a sign above a store: Coronavirus warning signs hang on the doors of a detox facility in Gallup, New Mexico. Photograph: Morgan Lee/AP


© Provided by The Guardian
Coronavirus warning signs hang on the doors of a detox facility in Gallup, New Mexico. Photograph: Morgan Lee/AP

She also said social and economic benefits, such as sustained unemployment benefits, workplaces covering mental health and substance abuse care, are critical to preventing the worsening of the opioid crisis during the pandemic.

Dr Caleb Banta-Green, of the University of Washington, said some programs have struggled to adapt to loosening regulations on opioid use disorder medications in terms of ensuring easier access, which has been a constant struggle for opioid use disorder

Signs America’s Opioid Epidemic Might Finally Be Waning | Health News

By Robert Preidt, HealthDay Reporter

(HealthDay)

SATURDAY, Oct. 3, 2020 (HealthDay News) — Here’s some heartening news on the opioid painkillers front: Abuse of the prescription medicines in the United States fell by more than one-quarter between 2007 and 2018.

“Prior research has shown slight reductions in abuse rates, but our analysis shows we’re tracking statistically significant year-to-year declines in abuse, indicating that the decrease is not an anomaly and truly represents a trend in falling prescription drug abuse levels,” said study author Mario Moric, a biostatistician at Rush University Medical Center in Chicago.

He and his colleagues analyzed data from the National Survey on Drug Use and Health, an annual survey of about 70,000 Americans aged 12 and older who are asked about their use of tobacco, alcohol and drugs.

For the study, prescription opioid abuse was defined as use without the consent of a physician.

The percentage of survey respondents who said they’d abused prescription opioids in the previous year fell from 4.9% in 2007 to 3.7% in 2018, a 26% decrease.

There were significant declines in prescription opioid abuse from 2012 to 2018, with the exception of 2015, when higher numbers were reported due to a survey redesign introduced that year, the researchers said.

The findings were to be presented Saturday at the virtual annual meeting of the American Society of Anesthesiologists.

“We believe the message of the dangers of opioid use without supervision of a medical professional is finally getting through and changing people’s mindset and behavior,” Moric said in a meeting news release.

“Pain medications such as opioids are an important resource in the treatment and care of patients, but they are not a cure-all,” said study co-author Dr. Asokumar Buvanendran, chair of the American Society of Anesthesiologists Committee on Pain Medicine and executive vice chair of anesthesiology at Rush University Medical Center.

“Since opioids have risks and can be highly addictive, they should be used only under the supervision of a physician who can consider their safety and how the medication will affect a patient over time,” Buvanendran said in the release. “Prescribers and patients are now better armed with the information they need to make educated choices in pain management.”

Research presented at meetings is considered preliminary until published in a peer-reviewed journal.

Copyright © 2020 HealthDay. All rights reserved.

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Dax Shepard’s Opioid Relapse | MedPage Today

Actor/comedian Dax Shepard has always been open about his past struggles with addiction and how he has been sober for the past 16 years. However, it was still surprising when, on the September 25th episode of his podcast Armchair Expert, Shepard revealed that he relapsed and has again been taking opioids.

About 6 months ago, Shepard broke his right hand, which required the temporary placement of a pin. Then in August, the avid motorcycle rider went over the handlebars of a bike during a race, breaking four ribs and shattering his shoulder. He again underwent surgery. Although he was prescribed hydrocodone/acetaminophen (Vicodin) for the pain, monitored by his wife, actress Kristen Bell, Dax began to “supplement” these pills with others that he purchased on his own.

As he told his podcast co-host, Monica Padman: “For the last 8 weeks maybe, I don’t really know … I’m on them all day … And I’m allowed to be on them at some dosage, because I have a prescription, and then I’m also augmenting that. And then all the prescriptions run out, and I’m now just taking 30 mil oxys that I’ve bought whenever I decide I can do [it].”

As he was still able to fulfill his daily responsibilities, including his twice-weekly podcast, he thought everything was under control. But then he started lying: “And I hate it, and I’m lying to other people. And I know I have to quit. But my tolerance is going up so quickly that I’m now in a situation where I’m taking, you know, eight 30s a day, and I know that’s an amount that’s going to result in a pretty bad withdrawal. And I start getting really scared, and I’m starting to feel really lonely. And I just have this enormous secret.”

Monica eventually called him out, and he came clean to her and Kristen. He immediately gave his pills to his wife and Monica to titrate down, began to go to AA meetings, and underwent withdrawal symptoms: “I’m sweating bullets; I’m jerky; my back kills. It’s terrible.”

Shepard went on to apologize to his friends, family, and his fans for deceiving them. He felt it was his responsibility to come forward and be honest about his struggles in the hope that others can also come forward and get the help they need.

Prescription Opioids

Prescription opioids can be used to treat moderate-to-severe pain and are often prescribed following surgery or injury, or for health conditions such as cancer.

In recent years, there has been a dramatic increase in the acceptance and use of prescription opioids for the treatment of chronic, non-cancer pain, such as back pain or osteoarthritis, despite serious risks and the lack of evidence about their long-term effectiveness.

According to the CDC:

  • More than 168 million opioid prescriptions were dispensed to American patients in 2018
  • There is a wide variation of opioid prescription rates across states; healthcare providers in the highest prescribing state, Alabama, wrote almost three times as many of these