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- Emergency department procedural sedation: the London experience. [JOURNAL ARTICLE]
- Eur J Emerg Med 2014 Sep 12.
The aim of this study was to develop a procedural sedation guideline and an audit tool to identify the medications chosen, the incidence of predefined adverse events and the factors associated with their occurrence.We performed a prospective observational study using a standardized proforma. We obtained data on patient demographics, the procedure performed, the drugs used and the dosages and predefined adverse events. Our target population was adult patients attending three urban UK teaching hospital Emergency Departments (EDs) over a 12-month period. We included all patients who were to undergo procedural sedation in the ED.Data were obtained on 414 patients. The majority of procedures were reductions of fractures and dislocations (89%). Midazolam was the sedative agent used most commonly (45%), and morphine was the most frequently used analgesic agent (36%). Overall 10% of sedations involved predefined complications (95% confidence interval: 7.1-12.9). There were no cases of airway obstruction requiring intervention; no patients showed clinical evidence of aspiration and no patient required intubation. Procedural success was 96%. Propofol was associated with fewer adverse events (95% confidence interval: 0.024-0.572), as well as higher procedural success.Procedural sedation and analgesia can be safely and effectively performed in the ED by appropriately trained emergency physicians.
- Carbamazepine Potentiates the Effectiveness of Morphine in a Rodent Model of Neuropathic Pain. [JOURNAL ARTICLE]
- PLoS One 2014; 9(9):e107399.
Approximately 60% of morphine is glucuronidated to morphine-3-glucuronide (M3G) which may aggravate preexisting pain conditions. Accumulating evidence indicates that M3G signaling through neuronal Toll-like receptor 4 (TLR4) may be central to this proalgesic signaling event. These events are known to include elevated neuronal excitability, increased voltage-gated sodium (NaV) current, tactile allodynia and decreased opioid analgesic efficacy. Using an in vitro ratiometric-based calcium influx analysis of acutely dissociated small and medium-diameter neurons derived from lumbar dorsal root ganglion (DRG), we observed that M3G-sensitive neurons responded to lipopolysaccharide (LPS) and over 35% of these M3G/LPS-responsive cells exhibited sensitivity to capsaicin. In addition, M3G-exposed sensory neurons significantly increased excitatory activity and potentiated NaV current as measured by current and voltage clamp, when compared to baseline level measurements. The M3G-dependent excitability and potentiation of NaV current in these sensory neurons could be reversed by the addition of carbamazepine (CBZ), a known inhibitor of several NaV currents. We then compared the efficacy between CBZ and morphine as independent agents, to the combined treatment of both drugs simultaneously, in the tibial nerve injury (TNI) model of neuropathic pain. The potent anti-nociceptive effects of morphine (5 mg/kg, i.p.) were observed in TNI rodents at post-injury day (PID) 7-14 and absent at PID21-28, while administration of CBZ (10 mg/kg, i.p.) alone failed to produce anti-nociceptive effects at any time following TNI (PID 7-28). In contrast to either drug alone at PID28, the combination of morphine and CBZ completely attenuated tactile hyperalgesia in the rodent TNI model. The basis for the potentiation of morphine in combination with CBZ may be due to the effects of a latent upregulation of NaV1.7 in the DRG following TNI. Taken together, our observations demonstrate a potential therapeutic use of morphine and CBZ as a combinational treatment for neuropathic pain.
- Ambulatory Percutaneous Nephrolithotomy: What is the Rate of Re-admission? [JOURNAL ARTICLE]
- J Endourol 2014 Sep 15.
Purpose: Tubeless Percutaneous Nephrolithotomy (PCNL) has gained popularity in an attempt to decrease morbidity and accelerate discharge. Recently, ambulatory tubeless PCNL has been reported. However, there is no data regarding re-admission rates of patients who had ambulatory PCNL. Therefore, the aim of this study was to assess rates of Emergency Department (ED) visits and re-admissions post-ambulatory PCNL. Patients and Methods: A retrospective chart-review of all ambulatory PCNL cases at two institutions between March 2007 and December 2013 was performed. Pre-operative, intra-operative and post-operative data were collected including the amount of narcotics used, length of hospital stay, post-operative complications, returns to ED and re-admissions. Results: Fifty patients underwent ambulatory PCNL, including two bilateral cases, making up a total of 52 renal units. All patients were discharged home on the same day with a mean hospital stay of 208.32±73.43 minutes. The mean narcotic requirement was 41.13± 46.76 mg of oral morphine equivalents. Six patients (12%) returned to the ED within 7 days including 4 patients who were discharged; 3 with stent colic and one with wound cellulitis. Only 2 patients (4%) were readmitted; one with multi-resistant E. coli and one with uncomplicated stent colic. Overall stone-free rate was 90.4%. There were no major complications, while 8 patients (16%) developed low grade (I-II) Clavien complications. Conclusion: Ambulatory PCNL is safe in highly selected patients with a stone-free rate of 90% and re-admission rate of 4%. Prospective studies comparing standard PCNL to ambulatory PCNL are warranted.
- P-52slow-release oral morphine (srom) as further medication in opioid subtitution treatment (ost): results from a registration study. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i63.
Since 50 years oral methadone is the gold standard in OST. However, some of the heroin dependent patients refrain from this kind of treatment due to different reasons (e.g. no injections, limited well-being, excessive sweating). Additionally the prolongation of the QTc poses a clinical problem in double diagnosed patients as many medications that are necessary in the treatment of these patients, add to the QTc prolongation. Unconfirmed reports from different countries suggested that SROM could be a useful addition to the in Switzerland already registered substitution medications methadone, diamorphine, and buprenorphine. In order to test this assumption we conducted a prospective, multi-dose, open label, non-inferiority, cross-over study in a bi-national, multicentre setting over 11 weeks, in which methadone and SROM were compared (ITT population n = 276). Beyond this time-point, the participants were observed another 25 weeks. Main results were: The proportion of heroin-positive urine samples and retention rates under SROM was equal to the ones under methadone. The mean QTc-interval under methadone was significantly longer than that under SROM. Higher treatment satisfaction, fewer cravings for heroin, and lower mental stress were reported by patients under SROM. More Details will be presented. SROM is now registered in Switzerland as an OST medication.
- P-37oxycodone misuse. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i60.
Oxycodone was first developed in Germany in 1916 in attempt to offer an alternative to existing opioids such as morphine, codeine and heroin. It was hoped that the introduction of Oxycodone would provide a more effective pain treatment and reduce the risk of dependencies developing. The Victorian Alcohol and Drug Association recognised an alarming increase in the amount of Oxycodone prescribed in the last 15 years. Oxycodone related deaths have increased concurrently from four deaths in 2000 to a staggering ninety seven deaths in 2009. The rate of opioid type prescriptions including Oxycodone per person aged 15-54 from 1995-2003 has increased across all jurisdictions within Australia. Turning Point Alcohol and Drug Centre conducted research for Ambo Project, which looked at recording all ambulance attendances for patients specifically with drug and alcohol concerns. While the number of call outs by the Melbourne Metropolitan Ambulance for 'other opioids' was relatively low compared with alcohol, the concerns lies within the growth margin of attendances. An enormous increase of 20.6% in just 1 year. The increased trends in prescribing Oxycodone has bought about further health issues including harms related to injecting Oxycodone. The Addiction Medicine Unit at Monash Medical Centre; Monash Health, audited the amount of reported IV Oxycodone user in comparison to the reported number of infective endocarditis during 2010 and 2011.
- Or11-1attenuation of opiate withdrawals by co-administration of nalbuphine in opiate dependent rats. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i48.
Nalbuphine is a kappa-opiate agonist and Mu-opiate partial antagonist, stimulates kappa- receptors & antagonizes the acute reinforcing/rewarding effects of morphine and has been widely used as an analgesic or an adjuvant with morphine. The present study evaluated the effect of nalbuphine in opiate dependent rats.Male adult Wistar albino rats (170-175gms, N = 164) were made physically dependent by administrating increasing dose of morphine over a period of 5 days (5-25 mg/kg, b.i.d., i.p.) followed by single dose of morphine on the 6th day. Withdrawals were precipitated with naloxone (1mg/kg, i.p.), 4 hours after last morphine injection. Somatic signs of withdrawals were scored by using the global Gellert-Holtzman rating scale. Nalbuphine was co-administered acutely and chronically in variable doses (0.1, 0.3, 1.0, 3.0 mg/kg, i.p.) with morphine and saline in experimental and control group respectively.Animals pretreated with acute dose of nalbuphine did not produce any effect on the global withdrawal scale, whereas a significant decrease on the global withdrawal scale was observed with chronic co-administration of nalbuphine.These findings suggest that nalbuphine might be useful as pharmacological adjuncts in the treatment of opiate addiction (Supported by Indian Council of Medical Research, Govt. of India, New Delhi).
- Sy42-1ats use in malaysia - an overview. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i35.
The trend of ATS use in Malaysia has increased markedly in recent years. In 2011 methamphetamine overtook morphine for the first time as the number two drug of abuse in Malaysia. Although the transmission of HIV through needle sharing in Malaysia has declined significantly in the last decade, it remains high relative to other countries in the region.The source of ATS in Malaysia has also seen an increase in locally manufactured drugs and an increase in the amount of methamphetamines seized between 2009-2011. The types of ATS users in Malaysia include individuals who use ATS to increase pleasure and performance during sexual activity, sex workers who use these drugs to enhance their performance, people who are involved services or industries where high performance is expected, and in the drug abusing population who use ATS as one of the drugs used to seek pleasure. Complications of ATS abuse including paranoia, cardiovascular, neurological and behavioural problems resulting in higher incidence of blood borne virus transmission due to unprotected sex and injecting drug use. The trend is worrying, as treatment for ATS addiction and abuse is more complex than the more commonly prescribed treatments in opiate addiction that is readily available in Malaysia.
- Sy37-1lessons learned from a comparison of evidence-based research in pregnant opioid-dependent women. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i31.
Lessons learned in research and treatment of opioid dependence demonstrate the need to include pregnant women in clinical trials.Two double-blind, double-dummy, randomized controlled trials comparing buprenorphine and methadone in opioid-dependent pregnant women were conducted. In both studies, participants received voucher-based incentives for attendance and completion of study assessments. In the MOTHER trial, participants additionally received escalating voucher incentives for drug-free urine samples. Neonatal abstinence syndrome was treated with oral morphine solution based on standardized modified Finnegan scores.After a mean treatment period of 13.79 weeks in the Pilot study (PS, n = 18) and 20.78 weeks in the MOTHER-trial (MT, n = 41), respectively (p < 0.001), PS patients delivered at mean doses of 14.00mg buprenorphine/52.50mg methadone and MT participants at 13.44mg buprenorphine/63.68mg methadone. Nonsignificant differences regarding dropout rates were found (22% in PS versus 10% in MT), but dropout was significantly earlier in the MT (p = 0.013). Significantly higher rates of concomitant consumption of opioids and benzodiazepines occurred in the PS compared with the MT (p < 0.001), however, with no significant differences in neonatal data between both settings.Early treatment enrolment combined with contingency management contributes to reduced illicit drug use throughout pregnancy, surprisingly without influencing neonatal outcome parameters.
- Sy01-2bending the curve of opioid analgesic abuse in the United States. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i3.
Abuse of prescription drugs is the leading cause of accidental death in the United States. In response, hundreds of federal, state and local interventions have been implemented. We describe trends in the diversion and abuse of prescription opioids using data through 2013.We used 5 different programs from the Researched Abuse, Diversion and Addiction Related Surveillance (RADARS) System to describe trends in diversion and abuse of 6 opioid analgesics: oxycodone, hydrocodone, hydromorphone, fentanyl, morphine, and tramadol. The programs include law enforcement agencies, poison centers, substance abuse treatment centers and college students.RADARS System programs reported large increases in opioid diversion and abuse rates from 2002 to 2010, but then rates flattened or decreased 2011 through 2013. Poison Center fatality rates also rose and fell with a similar pattern.Considered with other data sources, it seems possible that the long period of increasing prescription opioid abuse may be abating. The reasons for this observation are unclear but generate several alternatives that could affect the public policy debate regarding prescription opioid analgesics.
- Sy15-4prescription opioids in southern europe: france. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i15.
Prescription opioid misuse in an increasing public health in many countries. The objective is to assess the prevalence of prescription opioid misuse in four European countries. Data from France are presented.Cross-sectional study. The rates of prescription drug misuse have been assessed using patient self-report at treatment program intake. Patients have been asked to self-report the use of use and injection history for European-market prescription opioids, prescription stimulants, and heroin, during the past 30-day. Also, basic demographic information, treatment history, and health care worker status have been recorded.In France, a final sample of 144 subjects (77% males; 38,9years old) was recruited. The were 62,5% in treatment for heroin dependence; the rest (7) has as a main drug buprenorphine, codeine, methadone, morphine, fentanyl and tramadol. The main opioid abused drug during the last month was heroin, followed by buprenorphine, codeine, methadone and morphine. Those previously in treatment endorsed significantly less drugs, and less past 30-day use of buprenorphine. Buprenorphine is the preferred first line medication for French opioid rehabilitation patients.Preliminary data show that besides heroin, there is a concomitant abuse of prescription opioids. The knowledge of drug use patterns can provide useful information to develop effective prevention and treatment.