Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN).

PURPOSE: Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. METHODS: We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. RESULTS: The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). CONCLUSIONS: Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Association of periprocedural intravenous morphine use on clinical outcomes in ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention: Systematic review and meta-analysis.

OBJECTIVES: To conduct a systematic review and meta-analysis of studies examining the impact of periprocedural intravenous morphine on clinical outcomes in patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). BACKGROUND: Morphine analgesia may reduce the absorption of co-prescribed P2Y12 antagonists attenuating platelet inhibition. The impact of periprocedural intravenous morphine on clinical outcomes in patients undergoing PCI for STEMI is not well defined. METHODS: Analysis of the electronic databases of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Web of Science and ClinicalTrials.gov for association of peri-PCI intravenous morphine use with in-hospital or 30-day myocardial infarction (MI) (primary outcome) and in-hospital or 30-day mortality. RESULTS: A total of 11 studies were included for systematic review. One study was a randomized controlled trial, 10 were observational studies. Five studies including 3,748 patients were included in meta-analysis of in-hospital or 30-day MI. Within this group, patients were treated concurrently with ticagrelor (n = 2,239), clopidogrel (n = 1,256) and prasugrel (n = 253). There was no significant association of in-hospital or 30-day MI with intravenous morphine (odds ratio 1.88; 95% confidence interval [CI] 0.87-4.09; I2 0%). Across seven studies and 5,800 patients, no increased risk of mortality at the same composite time endpoint was evident (odds ratio 0.70; 95% CI 0.40-1.23; I2 19%). CONCLUSIONS: Periprocedural intravenous morphine administration was not associated with adverse short-term clinical outcomes in patients undergoing primary PCI for STEMI. Further randomized trial data are needed to evaluate the pharmacologic interaction between morphine and P2Y12 antagonists with clinical outcomes.

Trend and Economic Burden of Intravenous Narcotic Analgesic Utilization in Major Vascular Interventions in the United States.

BACKGROUND: The use of IV narcotic analgesics (IVNA) within the context of vascular procedures is not fully described. We sought to evaluate the burden of IVNA including narcotic analgesia-related adverse drug events (NARADE), associated mortality and hospitalization cost in open and endovascular vascular procedures, and to compare it with nonnarcotic analgesia (IVNNA). METHODS: Retrospective cross-sectional study in hospitals participating in Premier database (2009-2015). Logistic regression analysis was implemented to report the risks of NARADE and in-hospital mortality. Negative binomial regression was used to assess length of stay and generalized linear modeling was used to estimate the hospitalization cost. RESULTS: A total of 171,473 patients were identified. NARADE occurred in 6.2% of the cohort. NARADE group was similar in gender and race but was slightly older (median age 71 vs. 70; P < 0.001). After risk-adjustment, NARADE risk was higher in patients who received IVNA-alone in carotid and lower extremity revascularization (LER) [OR (odds ratio) (95% confidence interval [CI]): 1.17 (1.02-1.34) and 1.31 (1.14-1.50)] or combined with IVNNA [OR (95% CI): 1.34 (1.13-1.59) and 1.81 (1.54-2.13)], respectively. Patients receiving aortic repair benefited from the use of IVNA + IVNNA [OR (95% CI): 0.82 (0.69-0.98)]. Occurrence of NARADE doubled the LOS, amplified mortality risk and increased cost in all domains. NARADE increased the odds of mortality by 24.3, 6.5 (4.9-8.68) and 16.6 times and added $5,368, $12,737 and $11,349 to the cost of carotid, aortic and LER interventions, respectively. In contrast, IVNNA was not associated with NARADE risk, increased LOS or cost and showed a survival benefit in patients undergoing open aortic repair [aOR (95% CI): 0.52 (0.36-0.75)]. CONCLUSIONS AND RELEVANCE: The use of opioid-based narcotics had increased the risk of NARADE, resources utilization and NARADE-related mortality. Yet the use of nonopioid-based analgesic was safe, did not increase the cost and reduced mortality in open AA repair. This entices shifting the paradigm toward exploring nonopioid-based analgesia options in order to replace or minimize opioid requirements.

Mortality After Discontinuation of Primary Care-Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study.

BACKGROUND: Despite known risks of using chronic opioid therapy (COT) for pain, the risks of discontinuation of COT are largely uncharacterized. OBJECTIVE: To evaluate mortality, prescription opioid use, and primary care utilization of patients discontinued from COT, compared with patients maintained on opioids. DESIGN: Retrospective cohort study of patients with chronic pain enrolled in an opioid registry as of May 2010. PARTICIPANTS: Patients with chronic pain enrolled in the opioid registry of a primary care clinic at an urban safety-net hospital in Seattle, WA. MAIN OUTCOMES AND MEASURES: Discontinuation from the opioid registry was the exposure of interest. Pre-specified main outcomes included mortality, prescription and primary care utilization data, and reasons for discontinuation. Data was collected through March 2015. KEY RESULTS: The study cohort comprised 572 patients with a mean age of 54.9 ± 10.1 years. COT was discontinued in 344 patients (60.1%); 254 (73.8%) discontinued patients subsequently filled at least one opioid prescription in Washington State, and 187 (54.4%) continued to visit the clinic. During the study period, 119 (20.8%) registry patients died, and 21 (3.7%) died of definite or possible overdose: 17 (4.9%) discontinued patients died of overdose, whereas 4 (1.75%) retained patients died of overdose. Most patients had at least one provider-initiated reason for COT discontinuation. Discontinuation of COT was associated with a hazard ratio for death of 1.35 (95% CI, 0.92 to 1.98, p = 0.122) and for overdose death of 2.94 (1.01-8.61, p = 0.049), after adjusting for age and race. CONCLUSIONS: In this cohort of patients prescribed COT for chronic pain, mortality was high. Discontinuation of COT did not reduce risk of death and was associated with increased risk of overdose death. Improved clinical strategies, including multimodal pain management and treatment of opioid use disorder, may be needed for this high-risk group.

Opioid-related deaths and previous care for drug use and pain relief in Sweden.

AIM: In 2006-2014, the rate of drug-related deaths, typically opioid poisonings, more than doubled in Sweden. Opioid prescriptions for pain control or opioid agonist therapy also increased. In this retrospective study, we compared death rates between individuals whose first recorded contact with prescribed opioids was for pain control and individuals that had received substance use disorder (SUD) treatment before their first recorded opioid prescription. METHODS: We included 2834 forensically examined individuals (ages 15-64 years) that died of poisoning in Sweden in 2006-2014. For each death we acquired data on previous opioid prescriptions and SUD treatments. We compared three study groups: pain control (n = 788); a SUD treatment group (n = 1629); and a group with no prescription for pain control or SUD treatment (n = 417). RESULTS: Overall fatal poisonings increased from 2.77 to 7.79 (per 100,000 individuals) from 2006 to 2014 (relative 181% increase). Fatal poisoning increased from 2006 to 2014 by 269% in the pain control group (0.64 to 2.36 per 100,000) and by 238% in the SUD treatment group (1.35 to 4.57 per 100,000). Heroin-related deaths remained constant; consequently, the increase was likely attributable to prescription opioids. CONCLUSION: A rapid increase in deaths attributable mainly to prescription opioids for pain control, was reported previously in the United States. Our study indicated that increased access to prescription opioids might contribute to higher death rates also in Sweden among patients seeking pain control and individuals with an established SUD; however, deaths related to prescription opioids mainly occurred among those with SUDs.

Palliative radiotherapy utilization within a regional Australian palliative care unit.

BACKGROUND: Palliative radiotherapy has been demonstrated to be efficacious for symptom management in advanced malignancy however there are limited data investigating its use for inpatient palliative care patients. The aim of the current paper was to evaluate the utilization of radiotherapy amongst patients admitted to a regional Australian palliative care unit (PCU). METHODS: A retrospective cohort study was undertaken involving all Barwon Health PCU patients who received radiotherapy whilst an inpatient. A range of clinico-demographic, radiotherapy-specific and outcome measures were evaluated. Changes in opioid consumption were used as a surrogate for radiotherapy effectiveness. Demographic variables were analyzed descriptively and Wilcoxon Signed Rank Tests were used to compare opioid consumption before and after radiotherapy at time points one week, two weeks and three weeks. RESULTS: Sixty episodes of radiotherapy were provided to 51 PCU patients during the study period with 54 admissions included in the final analysis. Pain management was the commonest reason for radiotherapy treatment and most courses were multi-fractionated. Using the proportion of patients whose opioid dose decreased following radiotherapy as a marker for response, response rates ranged from 32-42%. Fortyeight percent of patients died during their PCU admission and the median survival from radiotherapy commencement was 36 days. CONCLUSIONS: A small proportion of all patients admitted to PCU received radiotherapy. Almost half of patients died during their admission and radiotherapy response rates were lower than have been reported for all-comers. More research is needed to optimize the stratification of PCU patients for radiotherapy.

The Effects of Perioperative Regional Anesthesia and Analgesia on Cancer Recurrence and Survival After Oncology Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Potentially, perioperative regional anesthesia and analgesia (RA) could influence the outcomes of patients with cancer. The aim of this systematic review and meta-analysis was to evaluate the effects of perioperative RA on survival and cancer recurrence after oncologic surgery. METHODS: The authors searched computerized databases (from inception to December 2014) and reference lists and considered all studies comparing the effects of RA on cancer recurrence or overall survival with that of general anesthesia (GA). Risk estimates were pooled to determine the effects of RA on risks of cancer recurrence and mortality. Twenty eligible studies were included. RESULTS: Perioperative RA use was associated with improved overall survival (Hazard ratio [HR] = 0.84, 95% CI, 0.75 - 0.94; I =41%), but not with reduced cancer recurrence (HR=0.91, 95% CI, 0.70 - 1.18; I=83%). CONCLUSIONS: Our meta-analysis suggests that RA may improve overall survival but not reduce cancer recurrence after oncologic surgery.

A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned.

An epidemic of morbidity and mortality has swept across the United States related to the use of prescription opioids for chronic noncancer pain. More than 100,000 people have died from unintentional overdose, making this one of the worst manmade epidemics in history. Much of health care delivery in the United States is regulated at the state level; therefore, both the cause and much of the cure for the opioid epidemic will come from state action. We detail the strong collaborations across executive health care agencies, and between those public agencies and practicing leaders in the pain field that have led to a substantial reversal of the epidemic in Washington State.

Harms of prescription opioid use in the United States.

BACKGROUND: Consumption levels of prescription opioids (POs) have increased substantially worldwide, particularly the United States. An emerging perspective implicates increasing consumption levels of POs as the primary system level driving factor behind the observed PO-related harms. As such, the present study aimed to assess the correlations between consumption levels of POs and PO-related harms, including non-medical prescription opioid use (NMPOU), PO-related morbidity and PO-related mortality. FINDINGS: Pearson's product-moment correlations were computed using published data from the United States (2001 - 2010). Consumption levels of POs were extracted from the technical reports published by the International Narcotics Control Board, while data for NMPOU was utilized from the National Survey on Drug Use and Health. Additionally, data for PO-related morbidity (substance abuse treatment admissions per 10,000 people) and PO-related mortality (PO overdose deaths per 100,000 people) were obtained from published studies. Consumption levels of POs were significantly correlated with prevalence of NMPOU in the past month (r =0.741, 95% CI =0.208-0.935), past year (r =0.638, 95% CI =0.014-0.904) and lifetime (r =0.753, 95% CI =0.235-0.938), as well as average number of days per person per year of NMPOU among the general population (r =0.900, 95% CI =0.625-0.976) and NMPOU users (r =0.720, 95% CI =0.165-0.929). Similar results were also obtained for PO-related morbidity and PO-related mortality measures. CONCLUSION: These findings suggest that reducing consumption levels of POs at the population level may be an effective strategy to limit PO-related harms.

A systematic review of the influence of opioids on advanced cancer patient survival.

PURPOSE OF REVIEW: Many health professionals still believe that opioids shorten the lifespan of patients. This situation implies that the ethical doctrine of double effect is often invoked to justify their use in extreme circumstances. The objective of this study is to revise the evidence existing in the recently published literature regarding the effect on patient survival of opioid used to control disease symptoms. RECENT FINDINGS: A review of the scientific literature regarding the effects of opioids on symptom control and survival does not provide any evidence that there is an association between these two variables. SUMMARY: The studies revised have not shown that the use of opioids for symptom control in advanced disease stages or in the last days of life has any effect on patient survival. Similarly, survival was not influenced by either the use of higher or lower doses of opioids, or by the practice of administering a double dose at night.

Epidural technique for postoperative pain: gold standard no more?

Epidural analgesia is a well-established technique that has commonly been regarded as the gold standard in postoperative pain management. However, newer, evidence-based outcome data show that the benefits of epidural analgesia are not as significant as previously believed. There are some benefits in a decrease in the incidence of cardiovascular and pulmonary complications, but these benefits are probably limited to high-risk patients undergoing major abdominal or thoracic surgery who receive thoracic epidural analgesia with local anaesthetic drugs only. There is increasing evidence that less invasive regional analgesic techniques are as effective as epidural analgesia. These include paravertebral block for thoracotomy, femoral block for total hip and knee arthroplasty, wound catheter infusions for cesarean delivery, and local infiltration analgesia techniques for lower limb joint arthroplasty. Wound infiltration techniques and their modifications are simple and safe alternatives for a variety of other surgical procedures. Although pain relief associated with epidural analgesia can be outstanding, clinicians expect more from this invasive, high-cost, labour-intensive technique. The number of indications for the use of epidural analgesia seems to be decreasing for a variety of reasons. The decision about whether to continue using epidural techniques should be guided by regular institutional audits and careful risk-benefit assessment rather than by tradition. For routine postoperative analgesia, epidural analgesia may no longer be considered the gold standard.