Poisoning of companion animals resulting from exposure to analgesics intended for human use is a frequent and clinically relevant problem in veterinary practice, usually associated with administration without professional supervision. This can induce severe systemic toxicity. Diagnostic confirmation can be particularly challenging in cases presenting with nonspecific clinical signs or when conventional biological samples are unavailable. This case report describes the innovative use of earwax as a non-invasive biological matrix for toxicological confirmation in veterinary medicine. A 9-year-old male mixed-breed dog was admitted following a traumatic accident and subsequent administration by its owner of a human medication containing acetaminophen and codeine. Clinical evaluation revealed lethargy, hypersalivation, hyporexia, dehydration, and neurological abnormalities. Laboratory findings demonstrated neutrophilic leukocytosis and marked increases in hepatic enzyme activities, consistent with acute hepatocellular injury. Toxicological investigation using headspace gas chromatography-mass spectrometry detected acetaminophen-related signatures in an earwax sample, supporting suspected exposure to the drug. Intensive treatment was promptly initiated and included fluid therapy, antidotal treatment with N-acetylcysteine, opioid antagonism, analgesia, and supportive care. The patient showed progressive clinical improvement, with complete resolution of clinical signs and full recovery. This case highlights the significant risks of administering human medications to companion animals and underscores the need to improve owner awareness of self-medication practices. Furthermore, it demonstrates the diagnostic potential of earwax as a non-invasive biological matrix for toxicological confirmation, expanding the range of complementary diagnostic tools available for veterinary toxicology and supporting improved clinical decision-making in cases of suspected pharmaceutical intoxication.

Acetaminophen is a good choice for analgesia, and fever reduction in nursing mothers. Amounts in milk are much less than doses usually given to infants. Adverse effects in breastfed infants appear to be rare.

The causality between codeine and acute pancreatitis has not yet been fully deciphered in medical literature. Codeine-induced pancreatitis is a rare entity and the underlying mechanism of action mediated by codeine has not been completely elucidated. One plausible theory is that codeine increases the pressure of the sphincter of Oddi (SOD), which results in spasms and subsequently acute pancreatitis ensues. Codeine-induced pancreatitis has a predilection for patients with a previous surgical history of cholecystectomy. We herein present a case of a 74-year-old male patient presenting for severe epigastric pain radiating to the back after codeine intake for tension headache. His past surgical history was pertinent for a previous cholecystectomy that was done 3 years ago after which he reported no biliary-related symptoms. Upon detailed anamnesis, the patient reported that his pain was directly preceded by the intake of an analgesic medication for his tension headache. The painkiller consisted of 500 mg of acetaminophen, 8 mg of codeine and 30 mg of caffeine. CT scan of the abdomen and pelvis was performed and revealed a prominent pancreatic head with surrounding edema suggestive of acute pancreatitis. Codeine-induced pancreatitis is an uncommon entity. However, it has been documented in medical literature with a preponderance to patients who underwent previous cholecystectomy. Multiple pathophysiological elements come into play, such as decreased bile storage capacity and aberrant nervous wiring at the level of the SOD muscularity. These alterations result in increased SOD pressure and acute pancreatitis ensues. Nonetheless, this article should trigger future studies to further elucidate the causality between codeine and acute pancreatitis.

Due to the invasive nature of craniotomy, effective postoperative pain management is essential in pediatric neurosurgical patients, yet standardized guidelines remain limited. This scoping review evaluated postoperative analgesic strategies in children undergoing craniotomy to identify effective approaches and assess opioid-sparing techniques. Twenty-four studies met inclusion criteria, including five case reports/series and nineteen retrospective or prospective investigations, comprising 1,567 patients with a mean reported age of 6.3 years. Opioids were the most frequently used analgesics (70.7%), most commonly morphine and codeine, while non-opioid regimens including NSAIDs/acetaminophen, sedatives, local anesthetic infiltration, and regional nerve blocks were used. Overall clinical improvement was reported in 61.7% of patients, with similar outcomes between single-agent and multimodal regimens. Randomized trials showed scheduled non-opioid therapy, nerve blocks, and local anesthetic techniques reduced pain scores and opioid requirements without increased complications. Current evidence supports multimodal, opioid-minimizing strategies with opioids reserved for breakthrough pain, although further studies are needed.

BACKGROUND: Formulating a tailored clinical practice guideline is imperative for each country, necessitated by the refined considerations of medication availability, accessibility, and affordability. Hence, in this study, we aimed to investigate the clinical practice guidelines regarding acute and postoperative dental pain and customize them in prescribing analgesics for Iranian general dentists. METHODS: The study employed a two-phase approach; a qualitative customization of dental pain management guidelines and a cross-sectional analytic phase. The qualitative phase involved assembling a panel of specialists and adapting existing guidelines to create customized flowcharts, along with a review of literature regarding relative guidelines. In the cross-sectional analytic phase, two questionnaires (one for each flowchart) were designed to build a consensus-based final guideline for Iranian dentists. Participants provided insights through questionnaires, assessing relevance and clarity. The Scale content validity index (S-CVI) and item content validity index (I-CVI) were assessed, with a threshold of 0.79 considered acceptable. RESULTS: Our search initially identified 763 articles and guidelines. After screening, 36 studies provided recommended strategies for acute dental and post-operative pain management. According to these studies and the available regimens in Iran, pain management was outlined in two flowcharts, A and B, addressing mild, moderate and severe pain levels. The lowest Item-level content validity index (I-CVI) was 0.93 and all items showed acceptable agreement regarding content validity. Scale-level content validity index (S-CVI) values reached 0.99 for flowchart A and B., indicating strong consensus among experts. Also, since all items showed acceptable agreement and were above the threshold value, the S-CVI/UA for the relevance and clarity in both flowcharts A and B were 100% among all experts in our study. CONCLUSIONS: Acetaminophen and ibuprofen are the drug of choice for dental pain. For more intense dental and post-operative dental pains a combination of these two drugs or their combination with opioids is recommended. In Iran, the only available opioid is codeine 10–20 mg that is combined with acetaminophen 300–325 mg, which is prescribed for severe dental pains. Naproxen can also be an effective alternative to ibuprofen.

Reports of associations between use of specific analgesic medications and specific structural birth defects are inconsistent and difficult to translate for clinical guidelines and informed decision-making. To overcome this challenge, this study examines associations between use of specific analgesics and severity of structural birth defects, using a novel approach based on survival rates. We recorded average 12-month survival rates reported in the literature for specific birth defects and applied those rates to birth defects in the National Birth Defects Prevention Study (1997-2011) to create severity groups: < 95% survival (n = 20,229), < 70% survival (n = 2936), and ≥ 95% survival (6911). Maternal uses of specific analgesic medications during the month before through the first 3 months of pregnancy (periconception) were compared between non-malformed controls (n = 11,614) and severity groups with odds ratios (aOR) and 95% confidence intervals (CI) adjusted for race/ethnicity, maternal education, pre-pregnancy body mass index, maternal periconceptional alcohol use, exposure to known teratogens, infant sex, and study site. Use of acetaminophen as a single component product or in combination with cough/cold agents was not associated with any of the birth defect severity groups. Elevated aORs in relation to risks of < 70% survival birth defects were observed for use of acetaminophen in combination with aspirin and caffeine, hydrocodone, codeine, or propoxyphene (aOR range: 1.46-2.00) and for hydrocodone alone (OR: 2.45). aORs remained elevated for the < 95% group except for acetaminophen plus codeine (OR 1.07). aORs for each severity group in association with use of acetaminophen combined with oxycodone approximated the null and those for ibuprofen, naproxen, and aspirin ranged between 1.15 and 1.28. In consideration of severity of birth defects, our findings indicate both safer and riskier analgesic medication options are available.

BACKGROUND: Dihydrocodeine is metabolized by the liver and subsequently excreted by the kidneys following oral administration. Consequently, individuals with renal impairment are susceptible to drug buildup, heightening the likelihood of harmful effects, including central nervous system depression and reversible delirium. CASE PRESENTATION: A 70-year-old male patient undergoing maintenance peritoneal dialysis fell into a coma one week after taking acetaminophen and Dihydrocodeine Tartrate (a compound preparation of acetaminophen and dihydrocodeine, called Lu Gai Ke). This compound formulation contained 500 mg of acetaminophen and 10 mg of dihydrocodeine. MANAGEMENT: We conducted additional laboratory tests and imaging studies for this patient. The preliminary diagnosis is metabolic encephalopathy caused by an overdose of dihydrocodeine. Following an 8-hour automated peritoneal dialysis (APD) session, the patient experienced a brief period of lucidity. The patient ultimately achieved complete neurological recovery following treatment with naloxone (administered intermittently) and supportive dialysis. OUTCOME: This case demonstrates that automated peritoneal dialysis can partially clear the metabolites of dihydrocodeine from the bodies of patients undergoing maintenance peritoneal dialysis. However, specific antidotes remain the primary measure for treating opioid poisoning. CONCLUSION: Codeine-like opioids are best avoided in end-stage renal disease; safer analgesics and prompt naloxone availability are strongly recommended.

Mortality rates in individuals suffering from acute kidney injury (AKI) are notably high. The association between the administration of oxycodone-acetaminophen and the onset of AKI remains elusive. We explored the connection between the use of oxycodone-acetaminophen and the development of AKI among hospitalized patients with fractures in the lower limbs. We employed the Critical Care Medical Information Mart (Simulation) IV database and studied the occurrence of AKI in individuals with fractures of the lower extremities. Information on the administration of oxycodone and acetaminophen during the 48 hours following hospitalization was collected. The logistic regression approach was used to analyze the outcomes between the 2 groups, with several models adjusted simultaneously. The reliability of the results was evaluated by conducting both stratified and sensitivity analyses. We conducted a retrospective cohort study involving 2801 patients with lower extremity fractures, including 339 oxycodone-acetaminophen users and 2462 non-users. The overall rate of AKI was 65.6% (1844/2801). The rate for non-users was 64.6% (1591/2462), whereas it was 74.6% (253/339) for non-users. After controlling for confounding variables, the use of oxycodone-acetaminophen was linked to a 38% increased risk of AKI (hazard ratio = 1.38, 95% confidence interval = 1.02-1.87, P < .038). Subgroup analyses revealed similar patterns of association, with all interaction P-values >.05. The use of oxycodone-acetaminophen within 48 hours of hospitalization may increase the risk of AKI in patients with lower extremity fractures. However, further randomized controlled trials are needed to elucidate this relationship.

Background: Accurate classification of intentional death as suicide is essential to target prevention measures appropriately. Unfortunately, manner of death (MOD) for many opioid-related fatalities are unclassified in the United States, and in Maryland, as many as 82% of overdose deaths are classified as undetermined manner. Aims: For opioid-related fatalities in Maryland, leverage death certificate data to develop a model for identifying suicide as MOD among those classified as undetermined by the medical examiner. Method: Demographic and toxicology data were used to develop a classification model for opioid-related deaths where MOD was known, and then applied to a cohort where MOD was undetermined to estimate the likelihood that the intent was suicide. Results: Antidepressants, neuroleptics, oxycodone, benzodiazepines, and acetaminophen were more common in deaths classified as suicide while fentanyl, cocaine, and morphine were more common among accidental deaths. Our classification model correctly identified suicide cases 82% of the time (PPV = 0.82; AUC = 0.90) and expanded the number of suicide cases by 43% when applied to undetermined deaths. Limitations: The accuracy and completeness of death records. Conclusions: Data from standard autopsies can be used to detect additional suicide deaths with good statistical precision. Incorporating clinical information could enhance predictive accuracy and improve classification.