286 Enhanced recovery after cesarean (ERAC) delivery with local bupivacaine wound infusion
Melissa M. MasaracchiaCristina WoodMichael V. ZaretskyWenru ZhouZhaoxing PanM J Gonzalez HernandezFranklin Chow
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Hydromorphone
Concurrent administration of oxycodone and phenytoin may cause, through induction of CYP3A4 enzymes, decreased analgesic effects of oxycodone. However, no descriptions of this interaction exist. A patient who was on oxycodone for chronic back pain was admitted to the hospital. Five days after initiating fosphenytoin, the patient experienced a dramatic escalation in his pain and lack of response to oxycodone breakthrough doses. Changing oxycodone to hydromorphone resulted in significantly improved analgesia. Concurrent use of fosphenytoin and oxycodone may increase the conversion of oxycodone to inactive metabolites, resulting in decreased analgesia. This may be avoided using hydromorphone, morphine, or oxymorphone.
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In morphine intoxication cases, forensic toxicologists are frequently confronted with the question of if the individual was opioid-tolerant or opioid-naïve, which can be investigated by hair analysis. However, interpretation of results can be challenging. Here, we report on hair testing for morphine and its metabolite hydromorphone following morphine intoxication without tolerance and upon chronic use. Two consecutive hair samples were collected after a non-fatal intoxication. Analysis comprised short hair segments and their initial wash water solutions. In the intoxications, morphine and hydromorphone levels were 3.3 to 56 pg/mg and at maximum 9.8 pg/mg, respectively. Both levels and hydromorphone to morphine ratios were significantly lower compared to chronic morphine use. In the non-fatal intoxication, the highest hydromorphone to morphine ratio was obtained in the segment corresponding to the time of intoxication. Morphine ratios of wash to hair were significantly higher in the intoxications compared to chronic use, being indicative of sweat/sebum contamination. We recommend including the analysis of hydromorphone and the initial wash solution in cases of morphine intoxications. Our study demonstrates that hydromorphone to morphine ratios can help in distinguishing single from chronic morphine use and in estimating the period of exposure when a consecutive hair sample can be collected in survived intoxications.
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The aim of this systematic review is to evaluate the scientific evidence for the efficacy and side effects of hydromorphone in the management of moderate to severe cancer pain. Randomized and non-randomized clinical trials, reporting data on efficacy and/or side effects of hydromorphone, were identified. Thirteen eligible studies, involving 1208 patients, were selected. Seven studies compared hydromorphone with other opioids (five with morphine, one with oxycodone and one with fentanyl and buprenorphine) and five of them were randomized controlled trials (RCTs). Most of the studies were conducted on patients already receiving opioid treatment, often at stabilized doses, and most had methodological limitations. The RCTs comparing hydromorphone with morphine and oxycodone showed similar analgesic results, while the comparison of side effects showed minor differences, not consistent across studies. Due to clinical and methodological heterogeneity of the studies, a meta-analysis was not performed. In conclusion there is evidence to support the efficacy and tolerability of hydromorphone for moderate to severe cancer pain as an alternative to morphine and oxycodone, while there is no evidence to demonstrate its superiority or inferiority in comparison with morphine as the first choice opioid for the same indication.
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Abstract Study Objective The US is experiencing an epidemic of opioid overdoses which may be at least partially due to an over-reliance on opioid analgesics in the treatment of chronic non-cancer pain and subsequent escalation to heroin or illicit fentanyl. As Texas was reported to be among the lowest in the US for opioid use and misuse, further examination of this state is warranted. Study Design This study was conducted to quantify prescription opioid use in Texas. Data Source Data was obtained from the publically available US Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) which monitors controlled substances transactions from manufacture to commercial distribution. Measurement and Main Results Data for 2006-2017 from Texas for ten prescription opioids including eight primarily used to relieve pain (codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, oxymorphone) and two (buprenorphine and methadone) for the treatment of an Opioid Use Disorder (OUD) were examined. The change in Morphine Mg Equivalent (MME) of all opioids (+23.3%) was only slightly greater than the state’s population gains (21.1%). Opioids used to treat an OUD showed pronounced gains (+90.8%) which were four-fold faster than population growth. Analysis of individual agents revealed pronounced elevations in codeine (+387.5%), hydromorphone (+106.7%), and oxycodone (+43.6%) and a reduction in meperidine (−80.3%) in 2017 relative to 2006. Methadone in 2017 accounted for a greater portion (39.5%) of the total MME than hydrocodone, oxycodone, morphine, hydromorphone, oxymorphone, and meperidine, combined. There were differences between urban and rural areas in the changes in hydrocodone and buprenorphine. Conclusions Collectively, these findings indicate that continued vigilance is needed in Texas to appropriately treat pain and an OUD while minimizing the potential for prescription opioid diversion and misuse. Texas may lead the US in a return to pre opioid crisis prescription levels.
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Abstract A middle-aged woman with recent cervical diskectomy with spinal fusion at C3-C4 suffered a mechanical fall with bilateral upper extremity paresthesia requiring admission but no surgical intervention. Patient was seen by orthopedic service and was recommended to continue using Aspen collar and oxycodone for pain. Following discharge, a drug urine screen test was performed, and showed positive for oxycodone by immunoassay. Confirmatory urine test by liquid chromatography-tandem mass spectrometry (LC-MS/MS) showed detectable oxycodone, oxymorphone and hydromorphone. In patients treated with opioid therapy for chronic pain, urine drug monitoring is an important tool to ensure that patients are adhering to the prescribed medication. Hydrocodone and hydromorphone are not metabolites of oxycodone. However, hydrocodone can be present in oxycodone preparations with an estimated impurity of <1%. Hydrocodone can be metabolized into hydromorphone, although, there is no literature reporting detectable hydromorphone in patients’ urine with prescribed oxycodone only. This case resulted in a quality improvement project where we evaluated the detection of hydrocodone and hydromorphone in positive oxycodone urine samples using LC-MS/MS. We analyzed 322 oxycodone positive urine samples. Twenty-one samples (6%) had detectable hydrocodone and/or hydromorphone below 100 ng/mL. Twelve out of the 21 were from patients taking no opioid medication other than oxycodone in the last week, with 33.3% showing detectable hydromorphone and 75% for hydrocodone below 100 ng/dL. The calculated hydrocodone/oxycodone (HC/OC) and hydromorphone/oxycodone (HM/OC) ratios were on average 0.26% HC/OC = 0.26% (0.05-0.69% SD 0.002; HM/OC = 0.26% (0.18-0.37% SD 0.001)] each (<1%). Patients taking oxycodone and other opioids had ratios >1% [HC/OC = 168% (3-563% SD 2.53; HM/OC = 699% (1.09-6585% SD 15.96)] and had higher detected levels (>100 ng/mL). Pain management can be very challenging; therefore, laboratory testing provides an objective assessment of drug exposure and adherence to treatment. Cut-off values for considering positive the detection of hydrocodone and hydromorphone may change the interpretation of the drug urine tests in patients with prescribed oxycodone. Using higher cutoff (100 ng/mL) and the ratios HC/OC and HM/OC (<1%) may be useful to determine that the detection of these components is due to impurity of oxycodone formulation.
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