RESUMO
The persisting use of opioids following bariatric surgery has emerged as a prevalent complication, heightening the probability of opioid-related harm (ORM), such as opioid-related fatalities and prescription opioid use disorder (OUD). A comprehensive review of PubMed literature from 1990 to 2023 was conducted to pinpoint physiological influences on postoperative ORM. As a result, we found that patients undertaking bariatric operations often exhibit an inherently higher risk for substance use disorders, likely attributable to genetic predisposition and related neurobiological changes that engender obesity and addiction-like tendencies. Furthermore, chronic pain is a common post-bariatric surgery complaint, and the surgical type impacts opioid needs, with increased long-term opioid use after surgeries. Additionally, the subjective nature of pain perception in patients with obesity can distort pain reporting and the corresponding opioid prescription both before and after surgery. Furthermore, the postoperative alterations to the gastrointestinal structure can affect the microbiome and opioid absorption rates, resulting in fluctuating systemic exposure to orally ingested opioids. The prospect of ORM development post-bariatric surgery appears amplified due to a preexisting susceptibility to addictive habits, surgically induced pain, modified gut-brain interaction and pain management and the changed pharmacokinetics post-surgery. Further research is warranted to clarify these potential risk variables for ORM, specifically OUD, in the bariatric population.
RESUMO
Pharmacogenetics holds the promise of personalized medicine, resulting in higher effectiveness and fewer adverse effects. Yet, the clinical benefit of a pre-emptive pharmacogenetic test has not been demonstrated rigorously. Recently an open-label real-world implementation study has been published, in which patients were randomized to either genotype-informed treatment (based on a 12-gene pharmacogenetic panel) or standard treatment. The study shows that genotype-informed prescription of different types of medication, i.e., opioids, anticoagulants and antidepressants, leads to a 30% reduction of clinically relevant adverse effects. This result is promising and indicates that genotype-informed treatment improves medication safety. Unfortunately, the influence of genotype-informed treatment on the balance between effectiveness and adverse effects could not be assessed and cost-effectiveness data are pending. Hence, a pharmacogenetic panel and a DNA medication pass for everyone are on the horizon, but not yet there.
