Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a disease faced by civilian and military survivors who have experienced trauma.  The disease can greatly effect a person’s quality of life so a lot research is being done regarding pharmacotherapy after serious physical injury and other traumatic events to prevent PTSD from occurring.  Some drugs, including opioids, may decrease memory formation, and therefore the fear associated with the memory, if administered as part of trauma care.

This study involved 696 injured U.S. military personnel who did not have a traumatic brain injury.  The participants’ records were collected including their medication records from the combat trauma registry and their diagnosis of PTSD from the personnel system, which was then verified through medical records.  The results of the study showed that the use of morphine was significantly associated with a lower risk of PTSD.  61% of patients that were diagnosed with PTSD received morphine while 76% of the patients who were not diagnosed with PTSD received morphine.  This difference was statistically significant.

PTSD is a serious issue for returning military members.  I believe that more steps should be taken to prevent PTSD as the disease can reduce quality of life and lead to other problems including depression, anxiety, etc.  Since this is an acute usage of the medication, there should be little worry of abuse.  However, more research should be done since opioids are a common allergenic so other options, including those listed in the article, should be explored.

Holbrook TL, Galarneau MR, Dye JL, et al. Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder. N Engl J Med. 2010;362(2):110-17.

http://www.nejm.org/doi/full/10.1056/NEJMoa0903326#t=article

Ultra-Low Doses of Opioids May Treat Suicidal Thoughts

Suicide leads to over 1 million deaths worldwide every year and is preceded by suicidal thoughts, although it is only rarely that suicidal thoughts lead to a completed suicide. Given the prevalence of suicide, the treatment of suicidal thoughts should be an important task for healthcare providers. However, there are currently no short term, medication based treatments for suicidal thoughts that can be easily administered independently in an outpatient setting and which can be effective for a wide range of patients. Therefore, one study was designed to test the effectiveness of very low doses of the opioid buprenorphine in quickly treating suicidal thoughts.

The study followed 88 patients selected from the populations of four medical centers in Israel. Participants were selected based on their suffering from clinically significant suicidal ideation and could not have a history of opioid abuse. 57 patients received buprenorphine treatment while 31 received a placebo, and both groups had their amount of suicidal thoughts as well as their likelihood to commit suicide measured over the course of four weeks. At the end of the study, patients in the buprenorphine group had a significant decrease in suicidal thoughts compared to the placebo group, although this group also exhibited an increased number of side effects, particularly fatigue, nausea, dry mouth, and constipation. At the end of the study, both groups were slowly tapered off of their medications, and no participant in either group reported feeling withdrawal symptoms. This study suggests that buprenorphine may be an effective short term treatment of suicidal thoughts. Although it is important to treat suicidal thoughts, is doing so by increasing the number of prescribed opioids the most effective method of doing this?

 

Yovell Y, Bar G, Mashiah M. Ultra-low-dose buprenorphine as a time-limited treatment for severe suicidal ideation: a randomized controlled trial. Am J Psychiatry. DOI:10.1176/appi.ajp.2015.15040535

Major Causes of Injury Death and the Life Expectancy Gap between the United States and other High-Income Countries

Drug overdose is becoming an increasingly more prevalent problem that health care providers, especially pharmacists, must work together to prevent. Currently, drug poisoning is the leading cause of injury-related deaths in the United States. This study looks at the differences in the major causes of injury-related deaths between the Unites States and other high-income countries including Italy, Denmark, Finland, United Kingdom, and more. In the US, drug poisonings were the third leading cause of injury-related death for men and the first leading cause for women, compared to the second as well for men and second for women in all of the other countries. Even though the causes of death were ranked similarly to each other in the US and in other countries, the rates themselves differ significantly. In men, the rate per 100,000 population was 16.1 in the US versus only 2.7 in the other countries. For women, the rate was 10.1 in the US versus 1.6 in other countries.

This study is really interesting to me because we have talked about drug overdose-related deaths specifically in the Pittsburgh area and Allegheny County. Through work and community health sites, I have worked with patients who are working through addiction, particularly opioid addiction. I wonder if this increase in overdoses is due to higher prescribing rates of opioids, more illegal access to them, or due to another class of drugs entirely. What are your thoughts on this issue? Can you think of any possible solutions to this problem that we will face in our careers as pharmacists?

Citation: Fenelon A, Chen LH, Baker SP. Major causes of injury death and the life expectancy gap between the United States and other high-income countries. JAMA. 2016; 315:609-611.

http://jama.jamanetwork.com.pitt.idm.oclc.org/article.aspx?articleid=2488300

Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion

Pleural effusion is a condition in which fluid collects between tissues lining the lung and chest.  This condition can be painful and may lead to infection.  It can often be treated with antibiotics or diuretics, but sometimes it is necessary to physically deplete the space between the tissue via a surgical procedure known as pleurodesis.  This randomized clinical trial compared the efficacy of pain treatment for the procedure between opioids, which are the current go-to treatment, and NSAIDs.

NSAIDs had previously been avoided for this type of procedure due to fear that they might decreases the efficacy of pleurodesis; however, this study found that not only did the NSAIDs result in similar pain scores, but they also resulted in noninferior pleurodesis efficacy.  These results demonstrate that NSAIDs are essentially equivalent to opioids in effective pain management following pleurodesis, while also not negatively affecting the efficacy of pleurodesis itself.

These results offer an interesting and favorable pain management option. The growing incidence rates of opioid abuse and opioid-related death have led health professionals to look for other viable pain management options when possible.  Recently, an emergency department in New York successfully attempted to run a whole shift without giving opioids to patients (http://www.ashpintersections.org/2016/02/pharm-d-m-d-team-successfully-enacts-opioid-free-ed-shift/).

Personally, I am excited to see the results of this clinical trial.  I believe we will need to begin looking for other viable methods of pain management following surgery or injury to combat the growing opioid epidemic in the US.  Hospitals can begin to use this kind of data to try prescribing alternative medications such as NSAIDs when safe.  Although NSAIDs come with their own set of problems and are especially unsafe in older patients, there are many cases in which it could be a superior option to opioids.

Do you think it is feasible to significantly reduce prescription and usage of opioids for pain management, or do you believe will it be near impossible to make this transition in the near future?

Rahman NM, Pepperell J, Rehal S, et al. Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial. JAMA. 2015;314:2641-2653.

http://jama.jamanetwork.com/article.aspx?articleid=2478201