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Category: Substance Use Disorders

Hot Topics: Spinal Surgery “Enhanced Recovery” Cuts Opioid Use

Jackie Werner Hot Topics in Research, Neurosurgery, Substance Use Disorders, Surgery, Uncategorized

Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution

Ali ZS, Flanders TM, Ozturk AK, et al. Enhanced recovery after elective spinal and peripheral nerve surgery: Pilot study from a single institution. Journal of Neurosurgery: Spine SPI. 2019:1-9. https://dx.doi.org/10.3171/2018.9.SPINE18681.

Enhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient’s surgical journey. The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.


The authors conducted a prospective cohort analysis comparing clinical outcomes of patients undergoing elective spine or peripheral nerve surgery after implementation of the ERAS protocol compared to a historical control cohort in a tertiary care academic medical center. Patients in the historical cohort (September–December 2016) underwent traditional surgical care. Patients in the intervention group (April–June 2017) were enrolled in a unique ERAS protocol created by the Department of Neurosurgery at the University of Pennsylvania. Primary objectives were as follows: opioid and nonopioid pain medication consumption, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary objectives were as follows: mobilization and ambulation status, Foley catheter use, need for straight catheterization, length of stay, need for ICU admission, discharge status, and readmission within 30 days.


A total of 201 patients underwent surgical care via an ERAS protocol and were compared to a total of 74 patients undergoing traditional perioperative care (control group). The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).


Implementation of this novel ERAS pathway safely reduces patients’ postoperative opioid requirements during hospitalization and 1 month postoperatively. ERAS results in improved postoperative mobilization and ambulation.

Hot Topics: Chronic Pain Lessened by Stimulating the Brain

Jackie Werner Hot Topics in Research, Neurology, Substance Use Disorders

Patients’ Experience With Opioid Tapering: A Conceptual Model With Recommendations for Clinicians

Ahn S, Prim JH, Alexander ML, McCulloch KL, Fröhlich F. Identifying and engaging neuronal oscillations by transcranial alternating current stimulation in patients with chronic low back pain: A randomized, crossover, double-blind, sham-controlled pilot study. The Journal of Pain. . https://doi.org/10.1016/j.jpain.2018.09.004

Clinical guidelines discourage prescribing opioids for chronic pain, but give minimal advice about how to discuss opioid tapering with patients. We conducted focus groups and interviews involving 21 adults with chronic back or neck pain in different stages of opioid tapering. Transcripts were qualitatively analyzed to characterize patients’ tapering experiences, build a conceptual model of these experiences, and identify strategies for promoting productive discussions of opioid tapering. Analyses revealed 3 major themes. First, owing to dynamic changes in patients’ social relationships, emotional state, and health status, patients’ pain and their perceived need for opioids fluctuate daily; this finding may conflict with recommendations to taper by a certain amount each month. Second, tapering requires substantial patient effort across multiple domains of patients’ everyday lives; patients discuss this effort superficially, if at all, with clinicians. Third, patients use a variety of strategies to manage the tapering process (eg, keeping an opioid stash, timing opioid consumption based on planned activities). Recommendations for promoting productive tapering discussions include understanding the social and emotional dynamics likely to impact patients’ tapering, addressing patient fears, focusing on patients’ best interests, providing anticipatory guidance about tapering, and developing an individualized tapering plan that can be adjusted based on patient response.

Perspective: This study used interview and focus group data to characterize patients’ experiences with opioid tapering and identify communication strategies that are likely to foster productive, patient-centered discussions of opioid tapering. Findings will inform further research on tapering and help primary care clinicians to address this important, often challenging topic.

Hot Topics: Ineffective Arthritis Drug Could Treat Opioid Addiction

Jackie Werner Hot Topics in Research, Substance Use Disorders

Slowly Signaling G Protein–Biased CB2 Cannabinoid Receptor Agonist LY2828360 Suppresses Neuropathic Pain with Sustained Efficacy and Attenuates Morphine Tolerance and Dependence

Lin X, Dhopeshwarkar AS, Huibregtse M, Mackie K, Hohmann AG. Slowly Signaling G Protein–Biased CB2 Cannabinoid Receptor Agonist LY2828360 Suppresses Neuropathic Pain with Sustained Efficacy and Attenuates Morphine Tolerance and Dependence. Mol Pharmacol. 2018;93:49-62; doi: 10.1124/mol.117.109355.

The CB2 cannabinoid agonist LY2828360 lacked both toxicity and efficacy in a clinical trial for osteoarthritis. Whether LY2828360 suppresses neuropathic pain has not been reported, and its signaling profile is unknown. In vitro, LY2828360 was a slowly acting but efficacious G protein–biased CB2 agonist, inhibiting cAMP accumulation and activating extracellular signal-regulated kinase 1/2 signaling while failing to recruit arrestin, activate inositol phosphate signaling, or internalize CB2 receptors. In wild-type (WT) mice, LY2828360 (3 mg/kg per day i.p. × 12 days) suppressed chemotherapy-induced neuropathic pain produced by paclitaxel without producing tolerance. Antiallodynic efficacy of LY2828360 was absent in CB2 knockout (KO) mice. Morphine (10 mg/kg per day i.p. × 12 days) tolerance developed in CB2KO mice but not in WT mice with a history of LY2828360 treatment (3 mg/kg per day i.p. × 12 days). LY2828360-induced antiallodynic efficacy was preserved in WT mice previously rendered tolerant to morphine (10 mg/kg per day i.p. × 12 days), but it was absent in morphine-tolerant CB2KO mice. Coadministration of LY2828360 (0.1 mg/kg per day i.p. × 12 days) with morphine (10 mg/kg per day × 12 days) blocked morphine tolerance in WT but not in CB2KO mice. WT mice that received LY2828360 coadministered with morphine exhibited a trend (P = 0.055) toward fewer naloxone-precipitated jumps compared with CB2KO mice. In conclusion, LY2828360 is a slowly signaling, G protein–biased CB2 agonist that attenuates chemotherapy-induced neuropathic pain without producing tolerance and may prolong effective opioid analgesia while reducing opioid dependence. LY2828360 may be useful as a first-line treatment in chemotherapy-induced neuropathic pain and may be highly efficacious in neuropathic pain states that are refractive to opioid analgesics.

Hot Topics: Frequent Vaping Encourages Smokers to Quit Tobacco

Jackie Werner Hot Topics in Research, Substance Use Disorders

The Relationship of E-Cigarette Use to Cigarette Quit Attempts and Cessation: Insights From a Large, Nationally Representative U.S. Survey

David T Levy, PhD, Zhe Yuan, MS, Yuying Luo, MS, David B Abrams, PhD; The Relationship of E-Cigarette Use to Cigarette Quit Attempts and Cessation: Insights From a Large, Nationally Representative U.S. Survey. Nicotine & Tobacco Research. https://doi.org/10.1093/ntr/ntx166

While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample.

Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use).

Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use.

Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships.

Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.

Hot Topics: Training Medical Students to Organize Needle Exchange Programs

Jackie Werner Hot Topics in Research, Substance Use Disorders

Students as effective harm reductionists and needle exchange organizers

Barbour K, McQuade M, Brown B. Students as effective harm reductionists and needle exchange organizers. Substance Abuse Treatment, Prevention, and Policy. 2017;12(15). http://dx.doi.org/10.1186/s13011-017-0099-0.

Needle exchange programs are safe, highly effective programs for promoting health among people who inject drugs. However, they remain poorly funded, and often illegal, in many places worldwide due to fear and stigma surrounding drug use. Continued advocacy, education, and implementation of new needle exchanges are thus essential to improve public health and reduce structural inequality.

We argue that students, and especially professional and graduate students, have the potential to play an important role in advancing harm reduction. Students benefit from the respect given to the professions they are training to enter, which gives them leverage to navigate the political hurdles often faced by needle exchange organizers, especially in areas that presently lack services. In addition, due to their relative simplicity, needle exchanges do not require much of the licensing, clinical knowledge, and infrastructure associated with more traditional student programs, such as student-run free medical clinics. Students are capable of learning harm reduction cultural approaches and techniques if they remain humble, open-minded, and seek the help of the harm reduction community. Consequently, students can generate tremendous benefits to their community without performing beyond their appropriate clinical limitations.

Students benefit from organizing needle exchanges by gaining applied experience in advocacy, organization-building, and political finesse. Working in a needle exchange significantly helps erode stigma against multiple marginalized populations. Students in health-related professions additionally learn clinically-relevant knowledge that is often lacking from their formal training, such as an understanding of structural violence and inequality, root causes of substance use, client-centered approaches to health services, and interacting with clients as peers, rather than through the standard hierarchical medical interaction.

We therefore encourage students to learn about and consider organizing needle exchanges during their training. Our experience is that students can be successful in developing sustainable programs which benefit their clients, the broader harm reduction movement, and themselves alike.