Podcasts about opioid prescribing

Contributor: Aaron Lessen, MD Educational Pearls: How do we take care of kids in severe pain? There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated. These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl. Intranasal fentanyl has many advantages: Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after administration, and then becomes equivalent to other pain control options Total adverse effects were also lower with IN fentanyl, including low rates of nausea and vomiting To administer, use the IV formulation with an atomizer and spray into the nose; therefore, you do not need an IV line Dose is 1-2 micrograms per kilogram, can be redosed once at 10 minutes.  Don't forget about gabapentinoids for neuropathic pain, muscle relaxants for muscle spasms, and nerve blocks when appropriate. (Disclaimer: muscle relaxers have not been well studied in children) References Alsabri M, Hafez AH, Singer E, Elhady MM, Waqar M, Gill P. Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis. Pediatr Emerg Care. 2024 Oct 1;40(10):748-752. doi: 10.1097/PEC.0000000000003187. Epub 2024 Apr 11. PMID: 38713846. Bailey B, Trottier ED. Managing Pediatric Pain in the Emergency Department. Paediatr Drugs. 2016 Aug;18(4):287-301. doi: 10.1007/s40272-016-0181-5. PMID: 27260499. Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, Raval MV, Renny MH, Larson-Steckler B, Wexelblatt S, Wilder RT, Flinn SK. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics. 2024 Sep 30:e2024068752. doi: 10.1542/peds.2024-068752. Epub ahead of print. PMID: 39344439. Summarized by Jeffrey Olson, MS4 | Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Acknowledgement of Country//Headlines// Please note that the following clip may touch on themes including domestic violence, childhood sexual abuse, organised abuse, colonial violence, suicide, mental illness, self harm and drug use. If you need immediate support, you can call Lifeline 13 11 14, Suicide Callback Service 1300 659 467, 1800 RESPECT (1800 737 732) or LGBTQ peer support QLife 1800 184 527 (3pm - midnight). If you're a First Nations person who'd prefer mob only support, you can call 13 YARN (13 92 76) or Yarning Safe'n'Strong 1800 959 563.//We replay conversation between Amy Ciara, Jasmine McLennan and president of the Blue Knot Foundation, Dr Cathy Kezelman, during last Wednesday's special broadcast marking  Dissociative Identity Disorder Awareness Day and supported by 3CR's Brainwaves. In the following interview, Amy, Jasmine and Cathy explore the nuances of living with complex trauma and dissociative identity disorders, also known as DID.// Lebanese-Australian lawyer and first-time filmmaker Nicholas Hanna speaks with us about his recently-released documentary, 'The Last Sky', which provides critical insight into Israel's war on Gaza within a broader context of its aggression against the Palestinian and Lebanese people. The film, which was produced by Palestinian media producer and filmmaker Rihab Charida, focuses unique attention on the perspectives of Palestinian refugees in Lebanon during the genocide, bringing together footage recorded in the region by Hanna and Charida in both 2004 and 2024.// We listened to part 2 of Priya's conversation with Jinsella Kennaway, Co-Founder and Executive Director of UK-based Demilitarise Education, who joined us to unpack the organisation's work to equip organisers with tools in the fight to break the links in the military-industrial-academic complex. In today's segment, Jinsella continues our discussion about the Demilitarise Education Treaty, a foundational framework that provides a pathway for action for universities to publicly commit to and implement full demilitarisation across investments, research and teaching activities. Head to 3cr.org.au/thursday-breakfast to listen back to part 1, which aired last week.// Professor Alex Collie is an applied public health and social policy scholar at Monash University. His research and teaching focus on work injury rehabilitation, occupational health and social protection schemes for personal injury. He joins us to discuss the latest study published 06 Mar 25 "Early High-Risk Opioid Prescribing and Persistent Opioid Use in Australian Workers with Workers' Compensation Claims for Back and Neck Musculoskeletal Disorders or Injuries: A Retrospective Cohort Study" which raises concern about opioid prescribing to injured Australian workers.// SongsBetter Things - Kee'ahnCaged Bird - Miiesha//

Our panel of medical experts discusses this month's biggest health care headlines.

Researchers Identify Trajectories of Opioid Prescribing by Dentists in the United States By Today's RDH Research   Original article published on Today's RDH: https://www.todaysrdh.com/researchers-identify-trajectories-of-opioid-prescribing-by-dentists-in-the-united-states/   Need CE? Start earning CE credits today at https://rdh.tv/ce  Get daily dental hygiene articles at https://www.todaysrdh.com Follow Today's RDH on Facebook: https://www.facebook.com/TodaysRDH/ Follow Kara RDH on Facebook: https://www.facebook.com/DentalHygieneKaraRDH/ Follow Kara RDH on Instagram: https://www.instagram.com/kara_rdh/

How does opioid prescribing in the ED differ between races? Find out about this and more in today's PeerDirect Medical News Podcast.

In this episode of The Frontline, we have a special episode with the CDC discussing the most recent rendition of the opioid prescribing guidelines which focus on SUD prevention, pain management, and medication safety. I am joined by Dr. Kate Vlasica and Dr. Debbie Dowell. https://www.nejm.org/doi/full/10.1056/NEJMp2211040 https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm

Episode 65: Guidelines for Safe Prescribing of Controlled Substances Evaluation and Credit:  https://www.surveymonkey.com/r/MedChat65   Target AudienceThis activity is targeted toward primary care and geriatric healthcare providers and advanced providers. Statement of Need This activity will discuss the steps to safe prescribing of opioids for providers. In that chronic pain is commonly treated in the primary care office and back pain is one of top ten reasons patients visit health care providers, providers should be aware of how to safely prescribe controlled substances if selected as the treatment for these patients. Objectives At the conclusion of this offering, the participant will be able to: Describe the risks and benefits of prescribing and tapering controlled substances. Identify the key components of safe prescribing of controlled substances. ModeratorGregory E. Cooper, M.D., Ph.D. Chief of Adult Neurology Medical Director, Memory Center Norton Neuroscience Institute Norton Healthcare Louisville, Kentucky SpeakerKelly C. Cooper, M.D., MPH, FASAM Addiction Specialist Norton Behavioral Health Louisville, Kentucky Moderator, Speaker and Planner Disclosures  The planners, moderators and speakers of this activity do not have any relevant financial relationships to disclose.  Commercial Support  There was no commercial support for this activity.  Physician Credits Accreditation Norton Healthcare is accredited by the Kentucky Medical Association to provide continuing medical education for physicians. Designation Norton Healthcare designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nursing CreditsNorton Healthcare Institute for Education and Development is approved with distinction as a provider of nursing continuing professional development by the South Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. This continuing professional development activity has been approved for 0.75 contact hours. In order for nursing participants to obtain credits, they must claim attendance by attesting to the number of hours in attendance.   For more information related to nursing credits, contact Sally Sturgeon, DNP, RN, SANE-A, AFN-BC at (502) 446-5889 or sally.sturgeon@nortonhealthcare.org. HB1 / Prescribing Controlled SubstancesThe Kentucky Board of Medical Licensure has approved the podcast Guidelines for Safe Prescribing of Controlled Substances for .75 HB1 credit hours. ID# 0723-H.75-NHC2i Resources for Additional Study: The Impact of Increased Hydrocodone Regulation on Opioid Prescribing in an Urban Safety-Net Health Care System    https://pubmed.ncbi.nlm.nih.gov/31068400/ CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022 https://pubmed.ncbi.nlm.nih.gov/36327391/   Norton Healthcare, a not for profit health care system, is a leader in serving adult and pediatric patients throughout Greater Louisville, Southern Indiana, the commonwealth of Kentucky and beyond. Five Louisville hospitals provide inpatient and outpatient general care as well as specialty care including heart, neuroscience, cancer, orthopedic, women's and pediatric services. A strong research program provides access to clinical trials in a multitude of areas. More information about Norton Healthcare is available at NortonHealthcare.com.   Date of Original Release | March 2024; Information is current as of the time of recording. Course Termination Date | March 2027 Contact Information | Center for Continuing Medical, Provider and Nursing Education; (502) 446-5955 or cme@nortonhealthcare.org      

We delve into the complexities of opioid prescribing, pain management, and the opioid crisis with our guest, Richard A. Lawhern. As a patient advocate, Richard brings a unique perspective to the table. Join us as we discuss the discrepancies in data handling by organizations like the CDC, the implications of these discrepancies on public perception and policy decisions, and the role of patient advocacy in shaping discussions around pain management. Together, we'll explore the nuances of this critical issue and uncover the truths behind the numbers. Richard A. Lawhern is a patient advocate. He discusses the KevinMD article, "Uncovering the real story behind opioid prescriptions and deaths." Our presenting sponsor is Nuance, a Microsoft company. Do you spend more time on administrative tasks like clinical documentation than you do with patients? You're not alone. Clinicians report spending up to two hours on administrative tasks for each hour of care provided. Nuance, a Microsoft company, is committed to helping clinicians restore the balance with Dragon Ambient eXperience – or DAX for short. DAX is an AI-powered, voice-enabled solution that helps physicians cut documentation time in half. DAX Copilot combines proven conversational and ambient AI with the most advanced generative AI in a mobile application that integrates directly with your existing workflows. DAX Copilot can be easily enabled within the workflow of the Dragon Medical application to bring the power of ambient technology to more clinicians faster while leveraging the proven and powerful capabilities used by over 550,000 physicians. Explore DAX Copilot today. Visit https://nuance.com/daxinaction to see a 12-minute DAX Copilot demo. Discover clinical documentation that writes itself and reclaim your work-life balance. VISIT SPONSOR → https://nuance.com/daxinaction SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended GET CME FOR THIS EPISODE → https://earnc.me/voVkM6 Powered by CMEfy.

Editor in Chief Cecelia E. Schmalbach, MD, MSc, is joined by Associate Editor Michael J. Brenner, MD and Associate Editor and senior author John P. Dahl, MD, PhD, MBA for a discussion of the article “Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative,” which published in the February 2024 issue of Otolaryngology–Head and Neck Surgery. They discuss how the researchers were able to reduce the numbers of opioid doses given to pediatric patients after adenotonsillectomy through standardized processes for prescribing.  Click here to read the article.

Dr. Yun “Sherry” Wang is an Assistant Professor on the tenure track at Chapman University School of Pharmacy (CUSP). Her academic journey is built upon a foundation in Geospatial Science from Washington University in St. Louis, an exploration of Data Science at Monash University, and comprehensive Ph.D. training in Clinical Pharmacy. Since she arrived at Chapman in May 2021, she has established and led the "Patient Safety Lab," a research initiative driven by her profound interests in health service research and pharmacoepidemiology, with a special focus on substance users and chronic disease patients. The "Patient Safety Lab" is a collaborative effort that utilizes diverse real-world datasets to explore various projects, including "Opioid Prescribing and Overdose Deaths Before and During the COVID-19 Pandemic in California," "Utilization of Buprenorphine Treatments in California: A Real-World Assessment of X Waiver Holders and Prescribers," "Spatiotemporal Disparity Mapping of Buprenorphine Treatment," and "Treatment Adherence Disparities among Adolescents and Young Adults with Cancer." These multifaceted projects unite over ten dedicated faculty members and students, fostering collaboration beyond the boundaries of Chapman University. Dr. Wang's professional background encompasses a spectrum of disciplines, including machine learning, epidemiology, clinical pharmacy, health economics, and health service research across Asia, Australia, and the United States. Her contributions are evident through peer-reviewed publications in esteemed journals such as JAMA, Lancet, Clinical Infectious Disease, International Journal of Cardiology, Pharmacogenomics Journal, Drug and Alcohol Dependence, Pain Reports, and Neuroepidemiology. Her editorial role for the "Opioid Epidemic during the COVID-19 Pandemic" Special Issue of the journal Healthcare underscores her dedication to addressing the opioid crisis. Her research findings have garnered attention in ISPOR News Across Asia, Physician Weekly, and the COVID newsletter by the Washington State Department of Health. She received the American Association of Colleges of Pharmacy (AACP) New Investigator Award in 2022. Faculty profile: https://www.chapman.edu/our-faculty/sherry-yun-wang Google Scholar: https://scholar.google.com.au/citations?user=-RicqRIAAAAJ&hl=en

Disparities in ED & urgent care opioid prescribing randomized clinician feedback interventions by SAEM

Disparities in ED & urgent care opioid prescribing randomized clinician feedback interventions by SAEM

Demographic differences in opioid prescribing by patient race and ethnicity have been widely reported; Black and Hispanic patients receive lower rates and dosages of opioid prescriptions for the same conditions and reported pain level as white patients. At the same time, higher dosage opioid prescriptions have been associated with higher rates of new long-term opioid use and high-risk use, and opioid stewardship is being increasingly emphasized. Today we're talking aout a new study in this area with lead author Aidan Crowley: Disparities in Emergency Department and Urgent Care Opioid Prescribing Before and After Randomized Clinician Feedback Interventions.

Dr. Mark Olfson (Columbia University) discusses the links between opioid prescribing and suicide risk in the United States. Afterwards, AJP Editor-in-Chief Dr. Ned Kalin discusses how issues of substance use disorder draw together the rest of the June issue. Transcript Olfson interview [00:46] Geographic commuting areas [01:06] Opioid prescription measures [02:10] Rates of opioid prescription and suicide [03:27] Youngest age cohorts as outliers [04:19] Regional variations [04:57] Limitations [05:17] Clinical implications [05:55] What's next for your research? [06:21] Kalin interview [06:42] Olfson et al. [07:00] Vickers-Smith et al. [08:36] Rognli et al. [10:44] Garrison et al. [12:51] Be sure to let your colleagues know about the podcast, and please rate and review it on Apple Podcasts, Google Podcasts, Stitcher, Spotify, or wherever you listen to it. Subscribe to the podcast here. Listen to other podcasts produced by the American Psychiatric Association. Browse articles online. How authors may submit their work. Follow the journals of APA Publishing on Twitter. E-mail us at ajp@psych.org

Host David Johnson interviews Scott Metzger, MD, author of  A Shift Left: Revised Regulations for Opioid Prescribing in New Jersey.  The full article is published in the March 2023, Journal of Medical Regulation (JMR).    

Dr. Shannon Douglas grew up in the Omineca area of Northern BC and has been dog sledding in the Fort St James area since her youth. She now practices medicine in the same region and is the Medical Director for the Lakes Omineca region and loves the diversity of patients she cares for everyday. This region includes Vanderhoof, Fraser Lake, Fort St. James, Burns Lake, Southside and Granisle. Chronic pain is a debilitating, complex condition that effects >60,000 people within the Northern Health region, and many patients use opioids to manage their pain. In 2016-2017 it became apparent that that opioid prescribing for chronic pain was contributing to the  opioid overdose public health crisis. There was a need for improved processes for patients to access their medication in a way that was safe, timely, and evidence based. Dr. Douglas initiated an improvement project aimed at redefining the way chronic pain patients were supported in primary care. She worked together with the local interprofessional team to create a new pathway and screening process, that ensured prescription renewals became comprehensive care episodes. Changing the approach required self-reflection and challenging the status quo of 'the way it's always been done'. The project was successful, and patients really enjoyed the new approach, since getting medication can be really challenging for chronic pain patients. Ultimately the patients were able to manage their pain in a safe and supported way, and many were empowered to eventually transition away from opioids.

Lead Story: Opioid Prescribing and Suicide Risk in the United States The American Journal of Psychiatry Approximately 40% of overdose suicide deaths in the United States involve opioids. Because of their respiratory depression effects and narrow therapeutic window, opioids pose a greater risk than any other drug class of an intentional overdose proving to be lethal.  In this retrospective study of US commuting zone–level opioid prescriptions and mortality, regional decreases in opioid prescriptions were consistently associated with declines in total suicide deaths, including suicide overdose deaths involving opioids. For some opioid prescribing measures, negative associations were observed with unintentional overdose deaths involving opioids among younger people. Individual-level inferences are limited by the ecological nature of the analysis. Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

CME link for the Episode 20:   https://cmetracker.net/UTHSCSA/Publisher?page=pubOpen#/getCertificate/10092859     Episode 20: Safe Opioid Prescribing in Pediatrics   FACULTY: Hema Navaneethan, MD currently serves as the Medical Director Pediatric Supportive Care Services and the Pediatric Palliative Care Fellowship Director.   OVERVIEW: Pediatrics Now Host and Producer Holly Wayment talks with Hema Navaneethan, MD about safe opioid prescribing in pediatrics.   DISCLOSURES: Hema Navaneethan, MD has no financial relationships with ineligible companies to disclose.   The Pediatric Grand Rounds Planning Committee (Deepak Kamat, MD, PhD, Daniel Ranch, MD and Elizabeth Hanson, MD) has no financial relationships with ineligible companies to disclose.  Planning Committee member Steven Seidner, MD has disclosed he receives funding from Draeger Medical for the Clinical Study to Evaluate the Safety and Effectiveness of the Infinity Acute Care System Workstation Neonatal Care Babylog VN500 Device in High-Frequency Oscillatory Ventilation (HFOV) Mode in Extremely Low Birth Weight (ELBW) Neonates for which he is a co-principal investigator. The relevant financial relationships noted for Dr. Seidner have been mitigated.     The UT Health Science Center San Antonio and Deepak Kamat, MD course director and content reviewer for the activity, have reviewed all financial disclosure information for all speakers, facilitators, and planning committee members; and determined and resolved all conflicts of interests.   CONTINUING EDUCATION STATEMENTS: The presentation, Safe Opioid Prescribing in Pediatrics, has been designated by UT Health Science Center San Antonio for 1 credit of education in pain management and the prescription of opioids.   The UT Health Science Center San Antonio is accredited by the Accreditation Council for Continuing Medical Education to provide continuing education for physicians.   The UT Health Science Center San Antonio designates this live activity up to a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.   CREDITS: AMA PRA Category 1 Credits™ (1.00) Non-Physician Participation Credit (1.00) Pain Mgmt Prescription Opioids Credit (1.00) MOC 2 credit (1.00)  

Claudia and Bev discuss the updated CDC Guidelines with Dr. Sarah from Maryland. They answer the following questions: Is it an improvement? Are the 2022 Guidelines more or less restrictive? Will it help pain patients? Were limits from the 2016 Guidelines a misapplication or was it intentional? Did the CDC violate their own guidelines on how to create guidelines? Links from discussion: Telebriefing for updated CDC Guidelines Nov 9, 2022 CDC Guidelines for Prescribing Opioids for Chronic Pain - Dr. David Tauben UW TelePain - March 23, 2016 Dr. Jane Ballantyne - TelePain - What the New CDC Guideline Mean for Prescribers - April 27, 2022 Dr. Jane Ballantyne - Alternatives to Opioids - PDFNJ - March 30, 2023 2016 CDC Guidelines 2022 CDC Guidelines The Doctor Patient Forum's docket comment on 2022 CDC Guidelines Study by Dr. Jason Doctor - Effect of Prescriber Notifications on Patient's Fatal Overdose on Opioid Prescribing at 4-12 Months Have you been force tapered or have you lost your pain provider? Please fill out this survey Suicide hotline: 988 or 911 Disclaimer: The information that has been provided to you in this podcast is not to be considered legal or medical advice. --- Send in a voice message: https://podcasters.spotify.com/pod/show/the-doctor-patient-forum/message Support this podcast: https://podcasters.spotify.com/pod/show/the-doctor-patient-forum/support

As other countries move to restrict access to opioid drugs, New Zealand regulators have loosened the rules on how much can be prescribed at once. An amendment in November to the Misuse of Drugs Regulations would allow for three months' worth of the pain drugs to be prescribed, up from one months' worth. That's alarmed some medical professionals, who say they weren't fully consulted on the changes and it could increase the risk of harm and addiction. Kathryn speaks to former Royal College of GPs medical director, now Chair of General Practice New Zealand Bryan Betty about the pressure doctors can come under from patients over access to the drugs.

We speak with Mr. Jacob James Rich, who wrote an article in Reason Magazine - The Fight To Criminalize Opioid Prescribing - which provides a synopsis of his seminal work published in the Yale Law & Policy Review Inter Alia. We discuss the article in depth, gleaning important insights on how opioid data is mischaracterized to arrive at contrived narratives of physician over-prescribing. Mr. Jacob James Rich is a researcher at the Cleveland Clinic Center for Value-Based Care Research, a Ph.D. student at the Case Western Reserve University School of Medicine, and a policy analyst at Reason Foundation. https://reason.com/2023/02/10/the-fight-to-criminalize-opioid-prescribing/ https://ylpr.yale.edu/inter_alia/misinformed-misguided-prescription-abuse-prevention-act-response-delfino #opioid #epidemic #data #fallacy

Death Diaries is what I call the  research I did with Dr. Jason Doctor. We reviewed data on every single person who died of an unintentional medical overdose and compared the drugs on autopsy to what was prescribed to the person. This list of medications were diaries that lead to death.  The research changed my life as a doctor and how I prescribe medications. Dr. Jason Doctor is an Associate Professor in the School of Pharmacy and Faculty at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California. His research program centers on decision-making in healthcare. Dr. Doctor specializes in applying behavioral economic methods within health and medicine and current leads a multi-site federally-funded multi-site cluster randomized clinical trial that evaluates behavioral economic approaches to improve physician adherence to comparatively effective treatments.  In other federally-funded research, Dr. Doctor has developed Bayesian decision algorithms to identify errors in blood panels to improve patient diagnosis. He also maintains a research program in understanding preferences for health from a behavioral economic perspective. He has extended the quality-adjusted life year (QALY) preference model to accommodate preference for helping others in medical need (social preferences) and has developed mathematical representations in QALY calculations that accommodate cognitive limitations people have in abiding by rational principles in decision making. JAMA Letter: Effect of Prescriber Notification of Patient's Fatal Overdose on Opioid Prescribing

This episode is also available as a blog post: https://youarewithinthenorms.com/2023/01/23/from-pain-news-network-doctor-convicted-of-illegal-opioid-prescribing-imprisoned-before-sentencing/

Postoperative Restrictive Opioid Protocols and Durable Changes in Opioid Prescribing and Chronic Opioid Use JAMA Oncology This prospective cohort study investigated whether postsurgical acute pain using a restrictive opioid prescription protocol (ROPP) of 3 days or less after discharge would result in reduced opioid use. Mean opioid prescribing days decreased from a mean (SD) of 3.9 (4.5) days in the pre-ROPP group to 1.9 (3.6) days in the post-ROPP group (P 

Jack Flynn and Alex Gornitzky from CHOP and University of Michigan, respectively, join the show to discuss their recent article on the psychology of scoliosis bracing. The lightning round focuses on recent publications by Dr. Flynn with some controversies mixed in to give the guests a chance to "stir the pot." Your hosts are Carter Clement from Children's Hospital of New Orleans, Josh Holt from University of Iowa, and Craig Louer from Vanderbilt. The episode is sponsored by nView Medical. Music by A. A. Alto.   “Main Event” article:   Why Don't Adolescents Wear Their Brace? A Prospective Study Investigating Psychosocial Characteristics That Predict Scoliosis Brace Wear. Gornitzky et al. JPO Jan 2023. https://pubmed.ncbi.nlm.nih.gov/36194756/   Lightning (a.k.a. “Jumpin Jack Flash”) Round articles:   Lengthening Behavior of Magnetically Controlled Growing Rods in Early-Onset Scoliosis: A Multicenter Study. Heyer et al. JBJS Oct 2022. https://pubmed.ncbi.nlm.nih.gov/36367763/   Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment. Badin et al. JPO Nov-Dec 2022. https://pubmed.ncbi.nlm.nih.gov/36037438/   A Modern Day Timeline for In-Hospital Monitoring in Perfused, Pulseless Pediatric Supracondylar Humerus Fractures. Heyer et al. JPO Nov-Dec 2022. https://pubmed.ncbi.nlm.nih.gov/35980760/   Preoperative MRI Reliably Predicts Pedicle Dimensions on Intraoperative CT Images in Structural Main Thoracic Curves in Patients With Adolescent Idiopathic Scoliosis. Mitchell et al. Spine (Phila PA 1976) Sept 2022. https://pubmed.ncbi.nlm.nih.gov/35867611/   Early Knee Range of Motion Following Operative Treatment for Tibial Tubercle Avulsion Fractures Is Safe. Huang et al. JPO Oct 2022. https://pubmed.ncbi.nlm.nih.gov/35968996/   Getting the Message: The Declining Trend in Opioid Prescribing for Minor Orthopaedic Injuries in Children and Adolescents. Krakow et al. JBJS Jul 2022. https://pubmed.ncbi.nlm.nih.gov/35793795/   Complications following surgical treatment of adolescent idiopathic scoliosis: a 10-year prospective follow-up study. Hariharan et al. Spine Deformity Sept 2022. https://pubmed.ncbi.nlm.nih.gov/35488969/   Evidence Behind Upper Instrumented Vertebra Selection in Adolescent Idiopathic Scoliosis: A Systematic and Critical Analysis Review. Baghdadi et al. JBJS Reviews Sept 2021. https://pubmed.ncbi.nlm.nih.gov/35417439/   Better Patient Care Through Physician Extenders and Advanced Practice Providers. Milewski et al. JPO May-June 2022. https://pubmed.ncbi.nlm.nih.gov/35405696/   Thoracic Curve Correction Ratio: An Objective Measure to Guide against Overcorrection of a Main Thoracic Curve in the Setting of a Structural Proximal Thoracic Curve. Landrum et al. Journal of Clinical Medicine Mar 2022. https://pubmed.ncbi.nlm.nih.gov/35329871/   Benchmarking surgical indications for adolescent idiopathic scoliosis across time, region, and patient population: a study of 4229 cases. Heyer et al. Spine Deformity July 2022. https://pubmed.ncbi.nlm.nih.gov/35258846/   When Is an Isolated Olecranon Fracture Pathognomonic for Osteogenesis Imperfecta? VanEenenaam et al. JPO May-June 2022. https://pubmed.ncbi.nlm.nih.gov/35200208/   Unplanned Return to the Operating Room (UpROR) After Pediatric Diaphyseal Femoral Fractures. Baghdadi et al. JPO Feb 2022. https://pubmed.ncbi.nlm.nih.gov/34923506/   Awake serial body casting for the management of infantile idiopathic scoliosis: is general anesthesia necessary? LaValva et al. Spine Deformity Oct 2020. https://pubmed.ncbi.nlm.nih.gov/32383143/   Do Year-Out Programs Make Medical Students More Competitive Candidates for Orthopedic Surgery Residencies? Bram et al. Journal of Surgical Education Nov-Dec 2020. https://pubmed.ncbi.nlm.nih.gov/32505668/   Why Irrigate for the Same Contamination Rate: Wound Contamination in Pediatric Spinal Surgery Using Betadine Versus Saline. Cohen et al. JPO Nov-Dec 2020. https://pubmed.ncbi.nlm.nih.gov/33044376/   Mistakes Made and Lessons Learned: A Mid-Career Pediatric Orthopaedic Surgeon's Journey to Sustain Energy and Avoid Burnout. Flynn. JPO July 2020. https://pubmed.ncbi.nlm.nih.gov/32502065/

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/12/02/re-publishedhow-the-united-states-department-of-justice-and-the-dea-opioid-prescribing-guidelines-has-endangered-the-lives-of-white-people-when-doctors-are-pressured-patients-suffer-original/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/12/01/the-mis-guided-opioid-prescribing-guidelines-of-the-cdc-and-how-its-failed-pain-healthcare-around-the-world/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

AP correspondent Jackie Quinn reports on MED Opioid Guidelines CDC.

Host:     Timothy Morgenthaler, MD  @DrTimMorg Guests:  Helena Gazelka M.D., Consultant, Anesthesia-Pain Clinic, Mayo Clinic               Benjamin Lai, M.B., B.Ch., B.A.O., Consultant, Family Medicine, Mayo Clinic  @BenjaminLaiMD Drug overdose deaths have skyrocketed during the COVID-19 pandemic.  Many of the overdoses occur in people who were originally prescribed medications such as pain medications for acceptable clinical indications. A number of studies indicate that of those who began abusing opioids, a large number reported that their first opioid was from a prescription. Opioid abuse and addiction has become a crisis in the US and the need for standardized practices for prescribing is more important now than ever to avoid the terrible consequences of addiction. This podcast will share what Mayo Clinic is doing to reduce risks to patients, support physicians and standardize prescribing practices through an Opioid Stewardship program. Find out more about Mayo Clinic's Quality program at https://www.mayoclinic.org/about-mayo-clinic/quality/. Connect with us on Twitter or Facebook using #mayokeyintoquality or at: https://www.facebook.com/MayoClinic https://twitter.com/MayoClinic  

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/08/10/once-again-its-now-time-to-defund-and-eliminate-the-cdcs-failed-opioid-prescribing-guidelinescypt-3/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

With the opioid epidemic in America showing troubling trends, such as a steep rise in the number of opioid-related deaths during the pandemic, healthcare professionals face increased challenges to develop better opioid prescribing habits while maintaining quality care. On this episode of the Beyond Clinical Medicine Podcast, Dr. Robert Strauss, Chief Medical Training Officer, interviews Dr. Nathan Schlicher, Regional Medical Director of Quality Assurance and Associate Director of Litigation Support. Dr. Schlicher is the clinical lead for the Better Prescribing, Better Treatment program, a collaborative effort in Washington state to promote clinician-driven guidelines for improved opioid prescribing techniques.   Learn more about the Better Prescribing, Better Treatment program: https://wsma.org/better-prescribing

Moderator: James Rathmell, M.D. Participants: Eric Sun, M.D., Ph.D. and Daniel McIsaac, M.D., M.P.H. Articles Discussed: Surgeon Variation in Perioperative Opioid Prescribing and Medium or Long Term Opioid Utilization After Total Knee Arthroplasty: A Cross-Sectional Analysis Postoperative Opioid Prescribing: Finding the Balance Transcript

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/07/19/the-supreme-court-9-0-unanimous-on-medical-opioid-prescribing-ruan-khan-v-the-united-states-no-20-1410-so-say-we-all/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

In this episode, Antonia and Andrew discuss a selection of articles from the July 6, 2022 issue of JBJS, along with an added dose of entertainment and pop culture. Listen at the gym, on your commute, or whenever your case is on hold! Articles Discussed: Getting the Message: The Declining Trend in Opioid Prescribing for Minor Orthopaedic Injuries in Children and Adolescents, by Krakow et al. Tranexamic Acid Was Not Associated with Increased Complications in High-Risk Patients with Intertrochanteric Fracture, by Porter et al. Arthroscopic Versus Open Ankle Arthrodesis. A 5-Year Follow Up, by Abuhantash et al. Modular Fluted Tapered Stems for Periprosthetic Femoral Fractures. Excellent Results in 171 Cases, by Hannon et al. Histologic Differences in Human Rotator Cuff Muscle Based on Tear Characteristics, by Ruderman et al. Racial, Ethnic, and Gender Diversity in Academic Orthopaedic Surgery Leadership, by Meadows et al. Surgical Anatomy of the Radial Nerve at the Dorsal Region of the Humerus. A Cadaveric Study, by Welle et al. Internal Torsion of the Knee. An Embodiment of Lower-Extremity Malrotation in Patients with Patellar Instability, by Qiao et al. Transphyseal Distal Humeral Fractures. A 13-Times-Greater Risk of Non-Accidental Trauma Compared with Supracondylar Humeral Fractures in Children Less Than 3 Years of Age, by Crowe et al. Link: JBJS website: https://jbjs.org/issue.php Sponsor: This episode is brought to you by JBJS Clinical Classroom. Subspecialties: Basic Science Trauma Pediatrics Shoulder Sports Medicine Orthopaedic Essentials Hip Foot &

Controversies, Confusion, and the Future of Urologic Post-Operative Opioid Prescribing Reduction Strategies CME Available: https://auau.auanet.org/node/35160 Course Director: Jennifer Robles, MD, MPH Faculty: Chad Brummett, MD; Gregory Auffenberg, MD, MS; Hitya Abraham, MD; Kevan Sternberg, MD After participating in this activity, learners will be able to: 1. Identify at least one non-pharmaceutical method they can practically implement to manage post-operative pain and reduce post-operative opioid prescribing. 2. Discuss multi-modal pain control and identify at least two non-opioid medications which can be used to manage post-operative pain and reduce post-operative opioid prescribing.

Joint CNS-NANS Podcast: Opioid Prescribing in the Perioperative Period Moderator: Yeshar Eshraghi Faculty: Traci Speed

We discuss trends in the comments that have appeared in response to the draft version of the updated clinical practice guidelines for prescribing opioids for chronic pain. Richard A. Lawhern, PhD, is a technically trained non-physician with 20 years of experience in peer-to-peer patient support groups for chronic pain patients. His work and commentaries have been published or featured at the US Trigeminal Neuralgia Association, The American Council on Science and Health, The Journal of Medicine of the National College of Physicians, the National Institutes for Neurological Disorder and Stroke, among others.

Jeff talks with Executive Director of PROP, Kat Marriott, PhD. Kat's sister, Sarah, was prescribed Opioids to manage chronic pain and soon became dependent. In 2016, after a several-year battle with addiction, Sarah died from overdose. Kat combined her professional experience with her personal passion for addressing the Opioid Epidemic. She now works with PROP (Physicians and Health Professionals for Responsible Opioid Prescribing) to bring awareness to the Opioid Crisis and provide education on Responsible Opioid Prescribing.Follow Kat & PROP:https://www.linkedin.com/in/kat-marriott-692b5111/https://twitter.com/supportprophttps://www.linkedin.com/company/physicians-for-responsible-opioid-prescribing/www.supprotprop.org

Jeff talks with Executive Director of PROP, Kat Marriott, PhD. Kat's sister, Sarah, was prescribed Opioids to manage chronic pain and soon became dependent. In 2016, after a several-year battle with addiction, Sarah died from overdose. Kat combined her professional experience with her personal passion for addressing the Opioid Epidemic. She now works with PROP (Physicians and Health Professionals for Responsible Opioid Prescribing) to bring awareness to the Opioid Crisis and provide education on Responsible Opioid Prescribing.Follow Kat & PROP:https://www.linkedin.com/in/kat-marriott-692b5111/https://twitter.com/supportprophttps://www.linkedin.com/company/physicians-for-responsible-opioid-prescribing/www.supprotprop.org

Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: Top Court Sets Jan. 7 Oral Argument in Vaccine Mandate Appeals. Landmark Tort Claim by Spouse of COVID Infected Worker Affirmed. DCA Clarifies IFPA "First-to-File" Rule in Published Decision. WCAB Panel Rejects Claim of CRPS Total Disability. Lien Claimant Must Meet CCP 473 Criteria for Relief From Default. Secret Service Says Cost of COVID-relief Funds Fraud is $100 Billion. Marketers of Beverly Hills Surgery Companies Guilty of $355M Fraud. Mileage Rate Will Increase to 58.5 Cents Per Mile in 2022. RAND Study Shows 21% Decline in Opioid Prescribing. Global TPA Market to Reach $514.98 Billion by 2030.

Dr. Sue Sgambati, COPIC's medical director and a colorectal surgeon, joins Dr. Zacharias to talk about her personal experience in balancing the professional responsibility to treat pain with concerns over opioid addiction. Dr. Sgambati reviews the historical background of key factors that contributed to the overprescribing of opioids and what she saw and learned in her own practice. She then talks about the value of using tools such as a state's prescription drug monitoring program, opioid risk assessment tools, and guidelines published by organizations such as the CDC. Dr. Sgambati also addresses alternatives to opioids that are being used, the challenges of having conversations with patients about opioids and how to document these, and the availability of naloxone to counter overdoses. Email: wnlpodcast@copic.com

OnePath is your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. Hosted by MetroHealth Department of Opioid Safety educator Libbey Pelaia, OnePath is an immersive, engaging series that shares practical advice, hard data, and personal anecdotes of those working to combat the opioid epidemic on a daily basis — from software developers and policy makers to emergency doctors and clinical psychologists. Our first episode premieres Tuesday, Feburary 23rd. In the meantime, please subscribe, rate, and share to help spread the word.

View the show notes in Google Docs here: http://bit.ly/3bFS43j Gonorrhea Updates Gonorrhea Treatment and Care. Centers for Disease Control and Prevention Website. https://www.cdc.gov/std/gonorrhea/treatment.htm. Published December 14, 2020. Accessed January 11, 2021. CDC No Longer Recommends Oral Drug for Gonorrhea Treatment. Centers for Disease Control and Prevention. https://www.cdc.gov/nchhstp/newsroom/2012/gctx-guidelines-pressrelease.html. Published August 9, 2012. Accessed January 11, 2021. Recurrent UTI Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2019). American Urological Association. https://www.auanet.org/guidelines/recurrent-uti?fbclid=IwAR1TwSTQNHv8PDWLfW7WjsDan46D_9b6Qs1ptJxaXr6YFnDpBeptpW3BY. Published 2019. Accessed January 11, 2021. Combo Ibuprofen and Acetaminophen / Pain Advil® Dual Action. GSK Expert Portal. https://www.gskhealthpartner.com/en-us/pain-relief/brands/advil/products/dual-action/?utmsource=google&utmmedium=cpc&utmterm=ibuprofen+acetaminophen&utmcampaign=GS+-+Unbranded+Advil+DA+-+Alone+-+PH. Accessed January 11, 2021. FDA approves GSK's Advil Dual Action with Acetaminophen for over-the-counter use in the United States. GSK. https://www.gsk.com/en-gb/media/press-releases/fda-approves-gsk-s-advil-dual-action-with-acetaminophen-for-over-the-counter-use-in-the-united-states/. Published March 2, 2020. Accessed January 11, 2021. Tanner T, Aspley S, Munn A, Thomas T. The pharmacokinetic profile of a novel fixed-dose combination tablet of ibuprofen and paracetamol. BMC clinical pharmacology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906415/. Published July 5, 2010. Accessed January 11, 2021. Searle S, Muse D, Paluch E, et al. Efficacy and Safety of Single and Multiple Doses of a Fixed-dose Combination of Ibuprofen and Acetaminophen in the Treatment of Postsurgical Dental Pain: Results From 2 Phase 3, Randomized, Parallel-group, Double-blind, Placebo-controlled Studies. The Clinical journal of pain. https://pubmed.ncbi.nlm.nih.gov/32271183/. Published July 2020. Accessed January 11, 2021. 1000 mg versus 600/650 mg Acetaminophen for Pain or Fever: A Review of the Clinical Efficacy. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK373467/. Published June 17, 2016. Accessed January 11, 2021. Motov S. Is There a Limit to the Analgesic Effect of Pain Medications? Medscape. https://www.medscape.com/viewarticle/574279. Published June 17, 2008. Accessed January 11, 2021. Motov, Sergey. Faculty Forum: A Practical Approach to Pain Management. YouTube. https://www.youtube.com/watch?v=lJSioPsGw3A. The Center for Medical Education. Published December 2, 2020. Accessed January 1, 2021. Wuhrman E, Cooney MF. Acute Pain: Assessment and Treatment. Medscape. https://www.medscape.com/viewarticle/735034_4. Published January 3, 2011. Accessed January 11, 2021. Social Pain Dewall CN, Macdonald G, Webster GD, et al. Acetaminophen reduces social pain: behavioral and neural evidence. Psychological science. https://pubmed.ncbi.nlm.nih.gov/20548058/. Published June 14, 2010. Accessed January 11, 2021. Mischkowski D, Crocker J, Way BM. From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Social cognitive and affective neuroscience. https://pubmed.ncbi.nlm.nih.gov/27217114/. Published May 5, 2016. Accessed January 11, 2021. Other / Recurrent liner notes Center for Medical Education. https://courses.ccme.org/. Accessed January 11, 2021. Roberts M, Roberts JR. The Proceduralist. https://www.theproceduralist.org/. Accessed January 11, 2021. The Procedural Pause by James R. Roberts, MD, & Martha Roberts, ACNP, PNP. Emergency Medicine News. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx. Accessed January 11, 2021. The Skeptics' Guide to Emergency Medicine. sgem.ccme.org. https://sgem.ccme.org/. Accessed January 11, 2021. Trivia Question: Send answers to 2viewcast@gmail.com Please note that you must answer the 2 part question to win a copy of the EMRA Pain Guide. “What controversial drug was given a black box warning for prolonged QT and torsades in 2012 and now has been declared by WHICH organization to be an effective and safe treatment use for nausea, vomiting, headache and agitation?” Practical Pain Management in Acute Care Setting Handout Sergey Motov, MD @painfreeED • Pain is one of the most common reasons for patients to visit the emergency department and other acute care settings. Due to the extensive number of visits related to pain, clinicians and midlevel providers should be aware of the various options, both pharmacological and nonpharmacological, available to treat patients with acute pain. • As the death toll from the opioid epidemic continues to grow, the use of opioids in the acute care setting as a first-line treatment for analgesia is becoming increasingly controversial and challenging. • There is a growing body of literature that is advocating for more judicious use of opioids and well as their prescribing and for broader use of non-pharmacological and non-opioid pain management strategies. • The channels/enzymes/receptors targeted analgesia (CERTA) concept is based on our improved understanding of the neurobiological aspect of pain with a shift from a symptom-based approach to pain to a mechanistic approach. This targeted analgesic approach allows for a broader utilization of synergistic combinations of nonopioid analgesia and more refined and judicious (rescue) use of opioids. These synergistic combinations result in greater analgesia, fewer side effects, lesser sedation, and shorter LOS. (Motov et al 2016) General Principles: Management of acute pain in the acute care setting should be patient-centered and pain syndrome-specific by using multimodal approach that include non-pharmacological modalities and pharmacological ones that include non-opioid and opioid analgesics. Assessment of acute pain should be based on a need for analgesics to improve functionality, rather than patients-reported pain scores. Brief pain inventory short form BPI-SF is better than NRS/VAS as it assesses quantitative and qualitative impact of pain (Im et al 2020). ED clinicians should engage patients in shared decision-making about overall treatment goals and expectations, the natural trajectory of the specific painful condition, and analgesic options including short-term and long-term benefits and risks of adverse effects. If acute pain lasting beyond the expected duration, complications of acute pain should be ruled out and transition to non-opioid therapy and non-pharmacological therapy should be attempted. Non-Pharmacologic Therapies • Acute care providers should consider applications of heat or cold as well as specific recommendations regarding activity and exercise. • Music therapy is a useful non-pharmacologic therapy for pain reduction in acute care setting (music-assisted relaxation, therapeutic listening/musical requests, musical diversion, song writing, and therapeutic singing (Mandel 2019). • The use of alternative and complementary therapies, such as acupuncture, guided imagery, cognitive-behavioral therapy, and hypnosis have not been systemically evaluated for use in the Acute care setting including ED. (Dillan 2005, Hoffman 2007) • In general, their application may be limited for a single visit, but continued investigation in their safety and efficacy is strongly encouraged. • Practitioners may also consider utilization of osteopathic manipulation techniques, such as high velocity, low amplitude techniques, muscle energy techniques, and soft tissue techniques for patients presenting to the acute care setting with pain syndromes of skeletal, arthroidal, or myofascial origins. (Eisenhart 2003) Opioids • Acute Care providers are uniquely positioned to combat the opioid epidemic by thoughtful prescribing of parenteral and oral opioids in inpatient setting and upon discharge, and through their engagement with opioid addicted patients in acute care setting. • Acute Care providers should make every effort to utilize non-pharmacological modalities and non-opioid analgesics to alleviate pain, and to use opioid analgesics only when the benefits of opioids are felt to outweigh the risks. (not routinely) • When opioids are used for acute pain, clinicians should combine them with non-pharmacologic and non-opioid pharmacologic therapy: Yoga, exercise, cognitive behavioral therapy, complementary/alternative medical therapies (acupuncture); NSAID's, Acetaminophen, Topical Analgesics, Nerve blocks, etc. • When considering opioids for acute pain, Acute Care providers should involve patients in shared decision-making about analgesic options and opioid alternatives, risks and benefits of opioid therapies, and rational expectations about the pain trajectory and management approach. • When considering opioids for acute pain, acute care providers should counsel patients regarding serious adverse effects such as sedation and respiratory depression, pruritus and constipation, and rapid development of tolerance and hyperalgesia. • When considering administration of opioids for acute pain, acute care providers should make every effort to accesses respective state's Prescription Drug Monitoring Program (PDMP). The data obtained from PDMP's to be used to identify excessive dosages and dangerous combinations, identify and counsel patients with opioid use disorder, offer referral for addiction treatment. • PDMPs can provide clinicians with comprehensive prescribing information to improve clinical decisions around opioids. However, PDMPs vary tremendously in their accessibility and usability in the ED, which limits their effectiveness at the point of care. Problems are complicated by varying state-to-state requirements for data availability and accessibility. Several potential solutions to improving the utility of PDMPs in EDs include integrating PDMPs with electronic health records, implementing unsolicited reporting and prescription context, improving PDMP accessibility, data analytics, and expanding the scope of PDMPs. (Eldert et al, 2018) • Parenteral opioids when used in titratable fashion are effective, safe, and easily reversible analgesics that quickly relieve pain. • Acute care clinicians should consider administering these analgesics for patients in acute pain where the likelihood of analgesic benefit is judged to exceed the likelihood of harm. • Parenteral opioids must be titrated regardless of their initial dosing regimens (weight-based or fixed) until pain is optimized to acceptable level (functionality status) or side effects become intolerable. • When parenteral opioids are used, patients should be engaged in shared-decision making regarding the route of administration, as repetitive attempts of IV cannulation and intramuscular injections are associated with pain. In addition, intramuscular injections are associated with unpredictable absorption rates, and complications such as muscle necrosis, soft tissue infection and the need for dose escalation. (Von Kemp 1989, Yamanaka 1985, Johnson 1976) • Morphine sulfate provides better balance of analgesic efficacy and safety among all parenteral opioids. a. Dosing regimens and routes: b. IV: 0.05-0.1mg/kg to start, titrate q 10-20 min c. IV: 4-6 mg fixed, titrate q 10-20 min d. SQ: 4-6 mg fixed, titrate q 20 min e. Nebulized: 0.2 mg/kg or 10-20 mg fixed, repeat q 15-20 min f. PCA: prone to dosing errors g. IM: should be avoided (pain, muscle fibrosis, necrosis, increase in dosing requirements) • Hydromorphone should be avoided as a first-line opioid due to significant euphoria and severe respiratory depression requiring naloxone reversal. Due to higher lipophilicity, Hydromorphone use is associated with higher rates of euphoria and subsequent development of addiction. Should hydromorphone be administered in higher than equi-analgesic morphine milligram equivalents, close cardiopulmonary monitoring is strongly recommended. Dosing h. IV: 0.2-0.5 mg initial, titrate q10-15 min i. IM: to be avoided (pain, muscle fibrosis, necrosis, increase in dosing requirements) j. PCA: prone to dosing errors (severe CNS and respiratory depression) k. Significantly worse AE profile in comparison to Morphine l. Equianalgesic IV conversion (1 mg HM=8mg of MS) m. Overprescribed in >50% of patients n. Inappropriately large dosing in EM literature: 2 mg IVP o. Abuse potential (severely euphoric due to lipophilicity) • Fentanyl is the most potent opioid, short-acting, requires frequent titration. Dosing: p. IV: 0.25-0.5 μg/kg (WB), titrate q10 min q. IV: 25-50 μg (fixed), titrate q10 min r. Nebulization: 2-4 μg/kg, titrate q20-30 min s. IN: 1-2 μg/kg, titrate q5-10min t. Transbuccal: 100-200μg disolvable tablets u. Transmucosal: 15-20 mcg/kg Lollypops • Opioids in Renal Insufficiency/Renal Failure Patients-requires balance of ORAE with pain control by starting with lower-than-recommended doses and slowly titrate up the dose while extending the dosing interval. (Dean 2004, Wright 2011) • Opioid-induced pruritus is centrally mediated process via μ-opioid receptors as naloxone, nalbuphine reverse it, and can be caused by opioids w/o histamine release (Fentanyl). Use ultra-low-dose naloxone of 0.25 -1 mcg/kg/hr with NNT of 3.5. (Kjellberg 2001) • When intravascular access is unobtainable, acute care clinicians should consider utilization of intranasal (fentanyl), nebulized (fentanyl and morphine), or transmucosal (rapidly dissolvable fentanyl tablets) routes of analgesic administration for patients with acute painful conditions. • Breath actuated nebulizer (BAN): enclosed canister, dual mode: continuous and on-demand, less occupational exposures. a. Fentanyl: 2-4 mcg//kg for children, 4 mcg/kg for adults: titration q 10 min up to three doses via breath-actuated nebulizer (BAN): systemic bioavailability of 50-60% of IV route. (Miner 2007, Furyk 2009, Farahmand 2014) b. Morphine: 10-20 mg g10 min up to 3 doses via breath-actuated nebulizer (BAN)-Systemic bioavailability (concentration) of 30-35% of IV Route. (Fulda 2005, Bounes 2009, Grissa 2015) c. Intranasal Fentanyl: IN via MAD at 1-2 mcg/kg titration q 5 min (use highly concentrated solution of 100mcg/ml for adults and 50 mcg/ml for children)- systemic bioavailability of 90% of IV dosing. (Karisen 2013, Borland 2007, Saunders 2010, Holdgate 2010) d. IN route: shorter time to analgesia, titratable, comparable pain relief to IV route, minimal amount of side effects, similar rates of rescue analgesia, great patients and staff satisfaction. Disadvantages: requires highly concentrated solutions that not readily available in the ED, contraindicated in facial/nasal trauma. Oral Opioids • Oral opioid administration is effective for most patients in the acute care setting, however, there is no appreciable analgesic difference between commonly used opioids (oxycodone, hydrocodone and morphine sulfate immediate release (MSIR). • When oral opioids are used for acute pain, the lowest effective dose and fewest number of tablets needed should be prescribed. In most cases, less than 3 days' worth are necessary, and rarely more than 5 days' worth are needed. • If painful condition outlasts three-day supply, re-evaluation in health-care facility is beneficial. Consider expediting follow-up care if the patient's condition is expected to require more than a three-day supply of opioid analgesics. • Only Immediate release (short-acting) formulary are to be prescribed in the acute care setting and at discharge. • Clinicians should not administer or prescribe long-acting, extended-release, or sustained-release opioid formulations, which include both oral and transdermal (fentanyl) medications in the acute care setting. These formulations are not indicated for acute pain and carry a high risk of overdose, particularly in opioid-naïve patients. • Acute care providers should counsel patients about safe medication storage and disposal, as well as the consequences of failure to do this; potential for abuse and misuse by others (teens and young adults), and potential for overdose and death (children and teens). • Oxycodone is no more effective than other opioids (hydrocodone, MSIR). Oxycodone has highest potential for abuse, misuse and diversion as well as increased risks of overdose, addiction and death. Oxycodone should be avoided as a first-line oral opioid for acute pain. ( Strayer 2016) • If still prescribed, lowest dose (5mg) in combination with acetaminophen (lowest dose of 325 mg) should be considered as it associated with less abuse and diversion (in theory). Potential for acetaminophen overdose exist though with combination. • Hydrocodone is three times more prescribed than oxycodone, but three times less used for non-medical purpose. Combo with APAP (Vicodin)-Use lowest effective dose for hydrocodone and APAP (5/325). (Quinn 1997, Adams 2006) • Immediate release morphine sulfate (MSIR) administration is associated with lesser degree of euphoria and consequently, less abuse potential (Wightman 2012). ED providers should consider prescribing Morphine Sulfate Immediate Release Tablets (MSIR) (Wong 2012, Campos 2014) for acute pain due to: o Similar analgesic efficacy to Oxycodone and Hydrocodone o Less euphoria (less abuse potential) o Less street value (less diversion) o More dysphoria in large doses o Less abuse liability and likeability • Tramadol should not be used in acute care setting and at discharge due to severe risks of adverse effects, drug-drug interactions, and overdose. There is very limited data supporting better analgesic efficacy of tramadol in comparison to placebo, or better analgesia than APAP or Ibuprofen. Tramadol dose not match analgesic efficacy of traditional opioids. (Juurlink 2018, Jasinski 1993, Babalonis 2013) • Side effects are: o Seizures o Hypoglycemia o Hyponatremia o Serotonin syndrome o Abuse and addiction • Codeine and Codeine/APAP is a weak analgesic that provides no better pain relief than placebo. Codeine must not be administered to children due to: o dangers of the polymorphisms of the cytochrome P450 iso-enzyme: o ultra-rapid metabolizers: respiratory depression and death o poor metabolizers: absent or insufficient pain relief • Transmucosal fentanyl (15 and 20 mcg/kg lollypops) has an onset of analgesia in 5 to 15 minutes with a peak effect seen in 15 to 30 minutes (Arthur 2012). • Transbuccal route can be used right at the triage to provide rapid analgesia and as a bridge to intravenous analgesia in acute care setting. (Ashburn 2011). A rapidly dissolving trans-buccal fentanyl (100mcg dose) provides fast pain relief onset (median 10 min), great analgesics efficacy, minimal need for rescue medication and lack of side effects in comparison to oxycodone/acetaminophen tablet (Shear 2010) • Morphine Milligram Equivalent (MME) is a numerical standard against which most opioids can be compared, yielding a comparison of each medication's potency. MME does not give any information of medications efficacy or how well medication works, but it is used to assess comparative potency of other analgesics. • By converting the dose of an opioid to a morphine equivalent dose, a clinician can determine whether a cumulative daily dose of opioids approaches an amount associated with increased risk of overdose and to identify patients who may benefit from closer monitoring, reduction or tapering of opioids, prescribing of naloxone, and other measures to reduce risk of overdose. • Opioid-induced hyperalgesia: o opioid-induced hyperalgesia (OIH) is a rare syndrome of increasing pain, often accompanied by neuroexcitatory effects, in the setting of increasing opioid therapy. o Morphine is by far the most common opiate implicated in OIH. Hydromorphone and oxycodone, members of the same class of opiate as morphine (phenanthrenes), can also cause OIH. Fentanyl, a synthetic opioid in the class of phenylpiperidine, is less likely to precipitate OIH. Existing data suggests that OIH is caused by multiple opioid-induced changes to the central nervous system including: -Activation of N-methyl-D-aspartate (NMDA) receptors -Inhibition of the glutamate transporter system -Increased levels of the pro-nociceptive peptides within the dorsal root ganglia -Activation of descending pain facilitation from the rostral ventromedial medulla -Neuroexcitatory effects provoked by metabolites of morphine and hydromorphone • OIH can be confused with tolerance as in both cases patients report increased pain on opioids. The two conditions can be differentiated based on the patient's response to opioids. In tolerance, the patient's pain will improve with dose escalation. In OIH, pain will worsen with opioid administration. This paradoxical effect is one of the hallmarks of the syndrome. Non-opioid analgesics • Acetaminophen is indicated for management of mild to moderate pain and as a single analgesic and has modest efficacy at most. Addition of Acetaminophen to Ibuprofen does not provide better analgesia for patients with acute low back pain. The greatest limitation to the use of intravenous (IV) versus oral acetaminophen is the nearly 100-fold cost differential, which is likely not justified by any marginal improvement in pain relief. Furthermore, IV APAP provide faster onset of analgesia only after an initial dose. (Yeh 2012, Serinken 2012) • NSAIDs should be administered at their lowest effective analgesic doses both in the ED and upon discharge and should be given for the shortest appropriate treatment course. Caution is strongly advised when NSAIDs are used in patients at risk for renal insufficiency, heart failure, and gastrointestinal hemorrhage, as well as in the elderly. Strong consideration should be given to topical NSAID's in managing as variety of acute and chronic painful Musculo-skeletal syndromes. The analgesic ceiling refers to the dose of a drug beyond which any further dose increase will not result in additional analgesic efficacy. Thus, the analgesics ceiling for ibuprofen is 400 mg per dose (1200 mg/24 h) and for ketorolac is 10 mg per dose (10 mg/24 h). These doses are less than those often prescribed for control of inflammation and fever. When it comes to equipotent doses of different NSAIDs, there is no difference in analgesic efficacy. • Ketamine, at sub-dissociative doses (also known as low-dose ketamine or analgesic dose ketamine) of 0.1 to 0.4 mg/kg, provided effective analgesia as a single agent or as an adjunct to opioids (reducing the need for opioids) in the treatment of acute traumatic and nontraumatic pain in the ED. This effective analgesia, however, must be balanced against high rates of minor adverse side effects (14%–80%), though typically short-lived and not requiring intervention. In addition to IV rout, ketamine can be administered via IN,SQ, and Nebulized route. • Local anesthetics are widely used in the ED for topical, local, regional, intra-articular, and systemic anesthesia and analgesia. Local anesthetics (esters and amides) possess analgesic and anti-hyperalgesic properties by non-competitively blocking neuronal sodium channels. o Topical analgesics containing lidocaine come in patches, ointments, and creams have been used to treat pain from acute sprains, strains, and contusions as well as variety of acute inflammatory and chronic neuropathic conditions, including postherpetic neuralgia (PHN), complex regional pain syndromes (CRPS) and painful diabetic neuropathy (PDN). o UGRA used for patients with lower extremity fractures or dislocations (eg, femoral nerve block, fascia iliaca compartment block) demonstrated significant pain control, decreased need for rescue analgesia, and first-attempt procedural success. In addition, UGRA demonstrated few procedural complications, minimal need for rescue analgesia, and great patient satisfaction. o Analgesic efficacy and safety of IV lidocaine has been evaluated in patients with renal colic and acute lower back pain. Although promising, this therapy will need to be studied in larger populations with underlying cardiac disease before it can be broadly used. o knvlsd • Antidopaminergic and Neuroleptics are frequently used in acute care settings for treatment of migraine headache, chronic abdominal pain, cannabis-induced hyperemesis. • Anti-convulsant (gabapentin and pregabalin) are not recommended for management of acute pain unless pain is of neuropathic origin. Side effects, particularly when combined with opioids (potentiation of euphoria and respiratory depression), titration to effect, and poor patients' compliance are limiting factors to their use. (Peckham 2018) References: Chang HY, Daubresse M, Kruszewski SP, et al. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med 2014;32(5):421–31. Green SM. There is oligo-evidence for oligoanalgesia. Ann Emerg Med 2012;60: 212–4. Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med. 2017 Feb;35(2):337-341. Smith RJ, Rhodes K, Paciotti B, Kelly S,et al. Patient Perspectives of Acute Pain Management in the Era of the Opioid Epidemic. Ann Emerg Med. 2015 Sep;66(3):246-252 Meisel ZF, Smith RJ. Engaging patients around the risks of opioid misuse in the emergency department. Pain Manag. 2015 Sep;5(5):323-6. Wightman R, Perrone J. (2017). Opioids. In Strayer R, Motov S, Nelson L (Eds.), Management of Pain and Procedural Sedation in Acute Care. http://painandpsa.org/opioids/ Motov S, Nelson L, Advanced Concepts and Controversies in Emergency Department Pain Management. Anesthesiol Clin. 2016 Jun;34(2):271-85. doi: 10.1016/j.anclin.2016.01.006. Ducharme J. Non-opioid pain medications to consider for emergency department patients. Available at: http://www.acepnow.com/article/non-opioid-painmedications- consider-emergency-department-patients/. 2015. Wightman R, Perrone J, Portelli I, et al. Likeability and Abuse Liability of Commonly Prescribed Opioids. J Med Toxicol. September 2012. doi: 10.1007/s12181-012-0263-x Zacny JP, Lichtor SA. Within-subject comparison of the psychopharmacological profiles of oral oxycodone and oral morphine in non-drug-abusing volunteers. Psychopharmacology (Berl) 2008 Jan;196(1):105–16. Hoppe JA, Nelson LS, Perrone J, Weiner SG, Prescribing Opioids Safely in the Emergency Department (POSED) Study Investigators. Opioid Prescribing in a Cross Section of US Emergency Departments. Ann Emerg Med. 2015;66(3):253–259. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010; 56(1):19–23 Weiner SG, Griggs CA, Mitchell PM, et al. Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department. Ann Emerg Med 2013;62(4):281–9. Greenwood-Ericksen MB, Poon SJ, Nelson LS, Weiner SG, et al. Best Practices for Prescription Drug Monitoring Programs in the Emergency Department Setting: Results of an Expert Panel. Ann Emerg Med. 2016 Jun;67(6):755-764 Patanwala AE, Keim SM, Erstad BL. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother 2010;44(11):1800–9. Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med 2005; 46:362–7. Birnbaum A, Esses D, Bijur PE, et al. 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Patient Satisfaction and Benefits of Music Therapy Services to Manage Stress and Pain in the Hospital Emergency Department. J Music Ther. 2019 May 10;56(2):149-173. Piatka C, Beckett RD. Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review. Acad Emerg Med. 2020 Feb;27(2):148-160. Tzabazis A, Kori S, Mechanic J, Miller J, Pascual C, Manering N, Carson D, Klukinov M, Spierings E, Jacobs D, Cuellar J, Frey WH 2nd, Hanson L, Angst M, Yeomans DC. Oxytocin and Migraine Headache. Headache. 2017 May;57 Suppl 2:64-75. doi: 10.1111/head.13082. PMID: 28485846. Yeh YC, Reddy P. Clinical and economic evidence for intravenous acetaminophen. Pharmacotherapy 2012;32(6):559–79. Serinken M, Eken C, Turkcuer I, et al. Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blinded controlled trial. Emerg Med J 2012;29(11):902–5. Wright JM, Price SD, Watson WA. NSAID use and efficacy in the emergency department: single doses of oral ibuprofen versus intramuscular ketorolac. Ann Pharmacother 1994;28(3):309–12. Turturro MA, Paris PM, Seaberg DC. Intramuscular ketorolac versus oral ibuprofen in acute musculoskeletal pain. Ann Emerg Med 1995;26(2):117–20. Catapano MS. The analgesic efficacy of ketorolac for acute pain [review]. J Emerg Med 1996;14(1):67–75 Dillard JN, Knapp S. Complementary and alternative pain therapy in the emergency department. Emerg Med Clin North Am 2005; 23:529–549. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol 2007;26:1–9. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc 2003;103:417–421.

Researchers dialed down the default number of opioids in two hospitals’ prescription systems—and doctors ended up prescribing fewer pills. Christopher Intagliata reports.

Each year, the Canadian Society for Internal Medicine (CSIM) Annual Meeting features a presentation of the “Top 5 Papers” in internal medicine. From the papers that had been discussed on The Rounds Table between November 2016 and October 2017, we selected 5 that we felt were particularly influential and presented them as the “Top 5 ...The post Top 5 Papers (Part 2): Challenging Asthma Diagnoses, Natriuretic Guided Therapy for Heart Failure, and Opioid Prescribing Patterns appeared first on Healthy Debate.

Each year, the Canadian Society for Internal Medicine (CSIM) Annual Meeting features a presentation of the “Top 5 Papers” in internal medicine. From the papers that had been discussed on The Rounds Table between November 2016 and October 2017, we selected 5 that we felt were particularly influential and presented them as the “Top 5 ... The post Top 5 Papers (Part 2): Challenging Asthma Diagnoses, Natriuretic Guided Therapy for Heart Failure, and Opioid Prescribing Patterns appeared first on Healthy Debate.

Contrast-induced nephropathy is cited as the third most common cause of iatrogenic acute kidney injury. In the Emergency Department, physicians must balance diagnosing life-threatening conditions using emergent imaging with the risk of potential harm caused by exposure to IV contrast. Recent studies, including the one discussed by Lauren in this episode, challenge the proposed causal ... The post REPLAY: Emergent Realizations – Contrast-Induced Nephropathy & Opioid Prescribing Patterns appeared first on Healthy Debate.

Contrast-induced nephropathy is cited as the third most common cause of iatrogenic acute kidney injury. In the Emergency Department, physicians must balance diagnosing life-threatening conditions using emergent imaging with the risk of potential harm caused by exposure to IV contrast. Recent studies, including the one discussed by Lauren in this episode, challenge the proposed causal ...The post REPLAY: Emergent Realizations – Contrast-Induced Nephropathy & Opioid Prescribing Patterns appeared first on Healthy Debate.

Contrast-induced nephropathy is cited as the third most common cause of iatrogenic acute kidney injury. In the Emergency Department, physicians must balance diagnosing life-threatening conditions using emergent imaging with the risk of potential harm caused by exposure to IV contrast. Recent studies, including the one discussed by Lauren in this episode, challenge the proposed causal ...The post Emergent Realizations: Contrast-Induced Nephropathy & Opioid Prescribing Patterns appeared first on Healthy Debate.

Contrast-induced nephropathy is cited as the third most common cause of iatrogenic acute kidney injury. In the Emergency Department, physicians must balance diagnosing life-threatening conditions using emergent imaging with the risk of potential harm caused by exposure to IV contrast. Recent studies, including the one discussed by Lauren in this episode, challenge the proposed causal ... The post Emergent Realizations: Contrast-Induced Nephropathy & Opioid Prescribing Patterns appeared first on Healthy Debate.