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Journal articles on the topic 'Opioid-tolerant'

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Published: 10 December 2022
Last updated: 28 January 2023

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1

Gulur, Padma, and Amanda H. Nelli. "The Opioid-Tolerant Patient: Opioid Optimization." Journal of Arthroplasty 35, no. 6 (June 2020): S50—S52. http://dx.doi.org/10.1016/j.arth.2020.01.001.

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2

Lee, PharmD, Stephanie, Vineet Tatla, PharmD, Sorin Buga, MD, and Doreen Pon, PharmD, BCOP, BCPS. "Comparing the safety and efficacy of intravenous naloxone administration in opioid-naive and opioid-tolerant hospitalized oncology patients." Journal of Opioid Management 18, no. 6 (November 1, 2022): 497–502. http://dx.doi.org/10.5055/jom.2022.0744.

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Objective: To compare naloxone doses and clinical outcomes after emergency opioid reversal in opioid-naïve and opioid-tolerant inpatients.Design: Cross-sectional, retrospective chart review.Setting: Comprehensive cancer center.Patients: In-patients who received ≥1 dose of intravenous naloxone for emergency opioid reversal between 2014 and 2018.Methods: Patients were classified as opioid-tolerant based on opioid dosing history ≥60 morphine milligram equivalents/day for ≥7 consecutive days prior to naloxone administration. Response to naloxone was based on documentation of improvement in respiratory rate to 10 breaths/min or improved response to stimuli.Outcomes: Naloxone doses and clinical outcomes after naloxone administration.Results: Ninety-three naloxone episodes (58 opioid-naive and 35 opioid-tolerant) in 80 unique patients were included. No differences between opioid-naïve and opioid-tolerant groups were found for naloxone mean starting doses (0.14 mg vs 0.19 mg, p = 0.35), total doses (0.50 mg vs 0.32 mg, p = 0.07), and response rates (74.1 percent vs 77.1 percent, p = 0.81). Naloxone adverse reactions were more frequent in the opioid-tolerant group than the opioid-naïve group (opioid withdrawal symptoms (OWSs): 14.3 percent vs 0 percent; increase in pain: 20 percent vs 8.6 percent, p = 0.002).Conclusions: In opioid-tolerant patients, naloxone total doses required and response rates were similar to opioid-naïve patients. Use of opioid dosing history to identify potentially opioid-dependent patients should be considered prior to naloxone administration to guide dosing and reduce the risk for precipitating OWSs.
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3

Gulur, Padma. "Opioid Tolerance – A Predictor of Increased Length of Stay and Higher Readmission Rates." Pain Physician 4;17, no. 4;7 (July 14, 2014): E503—E507. http://dx.doi.org/10.36076/ppj.2014/17/e503.

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The increasing use of opioids to manage pain in the United States over the last decade has resulted in a subset of our population developing opioid tolerance. While the management of opioid tolerant patients during acute episodes of care is well known to be a challenge amongst health care providers, there is little in the literature that has studied opioid tolerance as a predictor of outcomes. We conducted a review on all admissions to Massachusetts General Hospital over a period of 6 months, from January 2013 to June 2013, and identified opioid tolerant patients at admission using the FDA definition of opioid tolerance. To compare risk adjusted groups, we placed opioid tolerant patients and control patients into groups determined by expected length of stay of less than 2 days, 2 to 5 days, 5 to 10 days, and greater than 10 days. Opioid tolerant patients were then compared to the control for outcomes measures including observed length of stay and readmission rates. Our results show that all opioid tolerant patients have a significantly longer length of stay and a greater 30 day all cause readmission rate than the control group (P < 0.01). This trend was found in the first 3 risk adjusted groups, but not in the fourth group where expected length of stay was greater than 10 days. The opioid tolerant population is at risk given the poorer outcomes and higher health care costs associated with their care. It is imperative that we identify opportunities for improvement and delineate specific pathways for the care of these patients. Key words: Opioid tolerance, opioid tolerant patient population, opioid tolerant patients, readmission rates, length of stay
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4

Sazuka, Shoichiro, and Toshiya Koitabashi. "Tapentadol is effective in the management of moderate-to-severe cancer-related pain in opioid-naïve and opioid-tolerant patients: a retrospective study." Journal of Anesthesia 34, no. 6 (July 9, 2020): 834–40. http://dx.doi.org/10.1007/s00540-020-02821-8.

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Abstract Purpose Tapentadol is a dual-acting mu-opioid receptor agonist and noradrenaline reuptake inhibitor with non-inferior analgesic efficacy to oxycodone and better gastrointestinal tolerability than full mu-opioid receptor agonists. Tapentadol is approved for cancer pain in Japan; however, real-world evidence on tapentadol’s effectiveness and safety for cancer-related pain in Japan is limited. Methods This retrospective study evaluated the effectiveness, safety, and tolerability of tapentadol (by patient type—opioid-naïve and opioid-tolerant) in 84 patients with moderate-to-severe cancer pain at Ichikawa General Hospital between September 2014 and August 2016. Results Almost 93% of patients achieved clinically relevant pain relief within 4 days (median). Over 90% of patients with neuropathic pain or mixed pain and all patients with nociceptive pain were responders. Pain intensity significantly decreased from baseline through to the end of maintenance period in opioid-naïve and opioid-tolerant patients. No patients discontinued tapentadol due to serious adverse events. No opioid-naïve patients experienced nausea or vomiting during tapentadol treatment. Only three opioid-tolerant patients experienced nausea which was considered to be related to tapentadol. Conclusion Tapentadol is effective and well tolerated in opioid-naïve and opioid-tolerant patients with cancer pain of varying pathophysiology, including those with nociceptive and/or neuropathic components. Tapentadol may be considered for first-line use in moderate-to-severe cancer-related pain.
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5

Richards, John R., Irina N. Richards, Gal Ozery, and Robert W. Derlet. "Droperidol Analgesia for Opioid-Tolerant Patients." Journal of Emergency Medicine 41, no. 4 (October 2011): 389–96. http://dx.doi.org/10.1016/j.jemermed.2010.07.005.

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6

Simpson, GK, and M. Jackson. "Perioperative management of opioid-tolerant patients." BJA Education 17, no. 4 (April 2017): 124–28. http://dx.doi.org/10.1093/bjaed/mkw049.

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7

Lin, Chih-Peng, Kai-Hsiang Kang, Tzu-Hung Lin, Ming-Yueh Wu, Houng-Chi Liou, Woei-Jer Chuang, Wei-Zen Sun, and Wen-Mei Fu. "Role of Spinal CXCL1 (GROα) in Opioid Tolerance." Anesthesiology 122, no. 3 (March 1, 2015): 666–76. http://dx.doi.org/10.1097/aln.0000000000000523.

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Abstract Background: The pivotal role of glial activation and up-regulated inflammatory mediators in the opioid tolerance has been confirmed in rodents but not yet in humans. Here, the authors investigated the intraspinal cytokine and chemokine profiles of opioid-tolerant cancer patients; and to determine if up-regulated chemokines could modify opioid tolerance in rats. Methods: Cerebrospinal fluid samples from opioid-tolerant cancer patients and opioid-naive subjects were compared. The cerebrospinal fluid levels of tumor necrosis factor-alpha, CXCL1, CXCL10, CCL2, and CX3CL1 were assayed. The rat tail flick test was utilized to assess the effects of intrathecal CXCL1 on morphine-induced acute antinociception and analgesic tolerance. Results: CXCL1 level in cerebrospinal fluid was significantly up-regulated in the opioid-tolerant group (n = 30, 18.8 pg/ml vs. 13.2 pg/ml, P = 0.02) and was positively correlated (r2 = 0.49, P &lt; 0.01) with opioid dosage. In rat experiment, after induction of tolerance by morphine infusion, the spinal cord CXCL1 messenger RNA was up-regulated to 32.5 ± 11.9-fold. Although CXCL1 infusion alone did not affect baseline tail-flick latency, the analgesic efficacy of a single intraperitoneal injection of morphine dropped significantly on day 1 to day 3 after intrathecal infusion of CXCL1. After establishing tolerance by intrathecal continuous infusion of morphine, its development was accelerated by coadministration of CXCL1 and attenuated by coadministration of CXCL1-neutralizing antibody or CXCR2 antagonist. Conclusions: CXCL1 is up-regulated in both opioid-tolerant patients and rodents. The onset and extent of opioid tolerance was affected by antagonizing intrathecal CXCL1/CXCR2 signaling. Therefore, the CXCL1/CXCR2 signal pathway may be a novel target for the treatment of opioid tolerance.
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8

Bourne, Nicola. "Managing Acute Pain in Opioid Tolerant Patients." Journal of Perioperative Practice 18, no. 11 (November 2008): 498–503. http://dx.doi.org/10.1177/175045890801801105.

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Managing acute pain in opioid tolerant patients can be a significant challenge. This article will provide an overview of the terminology used when managing acute pain in these patients. This understanding is essential to ensure adequate pain relief while avoiding opioid withdrawal. It is also crucial that these patients are identified and that sufficient peri- and postoperative pain management plans are formulated. This article will present an overview of the terms tolerance, physical dependence and addiction. The literature on the management of acute pain in opioid tolerant patients will be considered. Finally an audit that explores and compares the practises of a group of London hospitals, with regard to managing post-surgical pain in opioid-dependent patients will be discussed.
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9

Schulz, Rüdiger, Eva Seidl, and Albert Herz. "Opioid dependence in the guinea-pig myenteric plexus is controlled by non-tolerant and tolerant opioid receptors." European Journal of Pharmacology 110, no. 3 (April 1985): 335–41. http://dx.doi.org/10.1016/0014-2999(85)90561-8.

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10

Wilson, Jennifer LC, Patricia A. Poulin, Robert Sikorski, Howard J. Nathan, Monica Taljaard, and Catherine Smyth. "Opioid Use among Same-Day Surgery Patients: Prevalence, Management and Outcomes." Pain Research and Management 20, no. 6 (2015): 300–304. http://dx.doi.org/10.1155/2015/897491.

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OBJECTIVES: To determine whether the prevalence of opioid use among patients requiring elective same-day admission (SDA) surgery is greater than the 2.5% prevalence found in the general population. Secondary objectives were to assess compliance with expert recommendations on acute pain management in opioid-tolerant patients and to examine clinical outcomes.METHODS: A retrospective review of 812 systematically sampled adult SDA surgical cases between April 1, 2008 and March 31, 2009 was conducted.RESULTS: Among 798 eligible patients, 148 (18.5% [95% CI 15.9% to 21.2%]) were prescribed opioids, with 4.4% prescribed long-acting opioids (95% CI 3.0% to 5.8%). Use of opioids was most prevalent among orthopedic and neurosurgery patients. Among the 35 patients on long-acting opioids who had a high likelihood of being tolerant, anesthesiologists correctly identified 33, but only 13 (37%) took their usual opioid preoperatively while 22 (63%) had opioids continued postoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered preoperatively in 18 (51%), 15 (43%) and 18 (51%) cases, respectively, while ketamine was used in 15 (43%) patients intraoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered postoperatively in 31 (89%), 15 (43%) and 17 (49%) of the cases, respectively. No differences in length of stay, readmissions and emergency room visits were found between opioid-tolerant and opioid-naïve patients.CONCLUSION: Opioid use is more common in SDA surgical patients than in the general population and is most prevalent within orthopedic and neurosurgery patients. Uptake of expert opinion on the management of acute pain in the opioid tolerant patient population is lacking.
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11

Moss, Laurence M., Marijke Hyke Algera, Robert Dobbins, Frank Gray, Stephanie Strafford, Amy Heath, Monique van Velzen, et al. "Effect of sustained high buprenorphine plasma concentrations on fentanyl-induced respiratory depression: A placebo-controlled crossover study in healthy volunteers and opioid-tolerant patients." PLOS ONE 17, no. 1 (January 27, 2022): e0256752. http://dx.doi.org/10.1371/journal.pone.0256752.

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Background Opioid-induced respiratory depression driven by ligand binding to mu-opioid receptors is a leading cause of opioid-related fatalities. Buprenorphine, a partial agonist, binds with high affinity to mu-opioid receptors but displays partial respiratory depression effects. The authors examined whether sustained buprenorphine plasma concentrations similar to those achieved with some extended-release injections used to treat opioid use disorder could reduce the frequency and magnitude of fentanyl-induced respiratory depression. Methods In this two-period crossover, single-centre study, 14 healthy volunteers (single-blind, randomized) and eight opioid-tolerant patients taking daily opioid doses ≥90 mg oral morphine equivalents (open-label) received continuous intravenous buprenorphine or placebo for 360 minutes, targeting buprenorphine plasma concentrations of 0.2 or 0.5 ng/mL in healthy volunteers and 1.0, 2.0 or 5.0 ng/mL in opioid-tolerant patients. Upon reaching target concentrations, participants received up to four escalating intravenous doses of fentanyl. The primary endpoint was change in isohypercapnic minute ventilation (VE). Additionally, occurrence of apnea was recorded. Results Fentanyl-induced changes in VE were smaller at higher buprenorphine plasma concentrations. In healthy volunteers, at target buprenorphine concentration of 0.5 ng/mL, the first and second fentanyl boluses reduced VE by [LSmean (95% CI)] 26% (13–40%) and 47% (37–59%) compared to 51% (38–64%) and 79% (69–89%) during placebo infusion (p = 0.001 and < .001, respectively). Discontinuations for apnea limited treatment comparisons beyond the second fentanyl injection. In opioid-tolerant patients, fentanyl reduced VE up to 49% (21–76%) during buprenorphine infusion (all concentration groups combined) versus up to 100% (68–132%) during placebo infusion (p = 0.006). In opioid-tolerant patients, the risk of experiencing apnea requiring verbal stimulation following fentanyl boluses was lower with buprenorphine than with placebo (odds ratio: 0.07; 95% CI: 0.0 to 0.3; p = 0.001). Interpretation Results from this proof-of-principle study provide the first clinical evidence that high sustained plasma concentrations of buprenorphine may protect against respiratory depression induced by potent opioids like fentanyl.
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12

Cooney, Maureen F., and Kathleen Broglio. "Acute Pain Management in Opioid-tolerant Individuals." Journal for Nurse Practitioners 13, no. 6 (June 2017): 394–99. http://dx.doi.org/10.1016/j.nurpra.2017.04.016.

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13

McDonald, D., C. Camilleri, D. Davis, and C. Martin. "Postoperative pain management for opioid tolerant patients." Journal of Pain 14, no. 4 (April 2013): S83. http://dx.doi.org/10.1016/j.jpain.2013.01.670.

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14

Viscomi, Christopher, and Jared K. Pearson. "Perioperative Management of the Opioid-Tolerant Patient." Advances in Anesthesia 27, no. 1 (January 2009): 25–54. http://dx.doi.org/10.1016/j.aan.2009.07.004.

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15

Bie, Bihua, and Zhizhong Z. Pan. "Increased Glutamate Synaptic Transmission in the Nucleus Raphe Magnus Neurons from Morphine-Tolerant Rats." Molecular Pain 1 (January 1, 2005): 1744–8069. http://dx.doi.org/10.1186/1744-8069-1-7.

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Currently, opioid-based drugs are the most effective pain relievers that are widely used in the treatment of pain. However, the analgesic efficacy of opioids is significantly limited by the development of tolerance after repeated opioid administration. Glutamate receptors have been reported to critically participate in the development and maintenance of opioid tolerance, but the underlying mechanisms remain unclear. Using whole-cell voltage-clamp recordings in brainstem slices, the present study investigated chronic morphine-induced adaptations in glutamatergic synaptic transmission in neurons of the nucleus raphe magnus (NRM), a key supraspinal relay for pain modulation and opioid analgesia. Chronic morphine significantly increased glutamate synaptic transmission exclusively in one class of NRM cells that contains μ-opioid receptors in a morphine-tolerant state. The adenylyl cyclase activator forskolin and the cAMP analog 8-bromo-cAMP mimicked the chronic morphine effect in control neurons and their potency in enhancing the glutamate synaptic current was significantly increased in neurons from morphine-tolerant rats. MDL12330a, an adenylyl cyclase inhibitor, and H89, a protein kinase A (PKA) inhibitor, reversed the increase in glutamate synaptic transmission induced by chronic morphine. In addition, PMA, a phorbol ester activator of protein kinase C (PKC), also showed an increased potency in enhancing the glutamate synaptic current in these morphine-tolerant cells. The PKC inhibitor GF109203X attenuated the chronic morphine effect. Taken together, these results suggest that chronic morphine increases presynaptic glutamate release in μ receptor-containing NRM neurons in a morphine-tolerant state, and that the increased glutamate synaptic transmission appears to involve an upregulation of both the cAMP/PKA pathway and the PKC pathway. This glutamate-mediated activation of these NRM neurons that are thought to facilitate spinal pain transmission may contribute to the reduced opioid analgesia during opioid tolerance.
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16

de Leon-Casasola, Oscar, and Anthony Yarussi. "Pathophysiology of opioid tolerance and clinical approach to the opioid-tolerant patient." Current Review of Pain 4, no. 3 (June 2000): 203–5. http://dx.doi.org/10.1007/s11916-000-0080-9.

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17

Emery, Michael J., Chase C. Groves, Timothy N. Kruse, Chen Shi, and Gregory W. Terman. "Ventilation and the Response to Hypercapnia after Morphine in Opioid-naive and Opioid-tolerant Rats." Anesthesiology 124, no. 4 (April 1, 2016): 945–57. http://dx.doi.org/10.1097/aln.0000000000000997.

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Abstract Background Opioid-related deaths are a leading cause of accidental death, with most occurring in patients receiving chronic pain therapy. Respiratory arrest is the usual cause of death, but mechanisms increasing that risk with increased length of treatment remain unclear. Repeated administration produces tolerance to opioid analgesia, prompting increased dosing, but depression of ventilation may not gain tolerance to the same degree. This study addresses differences in the degree to which chronic morphine (1) produces tolerance to ventilatory depression versus analgesia and (2) alters the magnitude and time course of ventilatory depression. Methods Juvenile rats received subcutaneous morphine for 3 days (n = 116) or vehicle control (n = 119) and were then tested on day 4 following one of a range of morphine doses for (a) analgesia by paw withdraw from heat or (b) respiratory parameters by plethysmography–respirometry. Results Rats receiving chronic morphine showed significant tolerance to morphine sedation and analgesia (five times increased ED50). When sedation was achieved for all animals in a dose group (lowest effective doses: opioid-tolerant, 15 mg/kg; opioid-naive, 3 mg/kg), the opioid-tolerant showed similar magnitudes of depressed ventilation (−41.4 ± 7.0%, mean ± SD) and hypercapnic response (−80.9 ± 15.7%) as found for morphine-naive (−35.5 ± 16.9% and −67.7 ± 15.1%, respectively). Ventilation recovered due to tidal volume without recovery of respiratory rate or hypercapnic sensitivity and more slowly in morphine-tolerant. Conclusions In rats, gaining tolerance to morphine analgesia does not reduce ventilatory depression effects when sedated and may inhibit recovery of ventilation.
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18

Rozen, MD, Dima, and Noah P. DeGaetano, MD. "Perioperative management of opioid-tolerant chronic pain patients." Journal of Opioid Management 2, no. 6 (November 1, 2006): 353. http://dx.doi.org/10.5055/jom.2006.0052.

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Opioids occupy a position of unsurpassed clinical utility in the treatment of many types of painful conditions. In recent years there has been a noticeable shift regarding the use of opioids for the treatment of both benign and malignancy-related pain. As acceptance of the prescribing of opioids for chronically painful conditions has grown, many more opioid-tolerant patients are presenting for surgical procedures. It is therefore imperative that practicing anesthesiologists become familiar with currently available opioid formulations, including data regarding drug interactions and side effects, in order to better plan for patients’ perioperative anesthetic needs and management. Unfortunately, there is a lack of scientifically rigorous studies in this important area, and most information must be derived from anecdotal reports and the personal experience of anesthesiologists working in this field. In this review, we shall discuss current chronic pain management and the impact of opioid use and tolerance on perioperative anesthetic management.
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19

Schug, Stephan A. "Acute pain management in the opioid-tolerant patient." Pain Management 2, no. 6 (November 2012): 581–91. http://dx.doi.org/10.2217/pmt.12.57.

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20

Bourne, Nicola. "Acute pain management in the opioid-tolerant patient." Nursing Standard 25, no. 12 (November 24, 2010): 35–39. http://dx.doi.org/10.7748/ns.25.12.35.s50.

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Bourne, Nicola. "Acute pain management in the opioid-tolerant patient." Nursing Standard 25, no. 12 (November 24, 2010): 35–39. http://dx.doi.org/10.7748/ns2010.11.25.12.35.c8112.

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22

Mancini, Robert, and Mark Filicetti. "Pain management of opioid-tolerant patients undergoing surgery." American Journal of Health-System Pharmacy 67, no. 11 (June 1, 2010): 872–75. http://dx.doi.org/10.2146/ajhp090408.

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23

Owen, Emily, Julianne Yeary, Nicholas Pauley, Blake Robbins, Jacob Keeperman, and Evan Schwarz. "985: ANALGOSEDATION IN OPIOID-NAIVE VERSUS TOLERANT PATIENTS." Critical Care Medicine 48, no. 1 (January 2020): 472. http://dx.doi.org/10.1097/01.ccm.0000633476.04802.65.

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24

Cooney, Maureen F. "Management of Postoperative Pain in Opioid-Tolerant Patients." Journal of PeriAnesthesia Nursing 30, no. 5 (October 2015): 436–43. http://dx.doi.org/10.1016/j.jopan.2015.08.006.

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25

Gordon, Deb, Charles E. Inturrisi, J. Eric Greensmith, Timothy J. Brennan, Layne Goble, and Robert D. Kerns. "Perioperative Pain Management in the Opioid-Tolerant Individual." Journal of Pain 9, no. 5 (May 2008): 383–87. http://dx.doi.org/10.1016/j.jpain.2008.01.331.

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26

Rogers, Ada G. "The use of methadone in opioid-tolerant patients." Journal of Pain and Symptom Management 3, no. 1 (1988): 45. http://dx.doi.org/10.1016/0885-3924(88)90137-6.

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27

Dykstra, Linda A., Mitchell J. Picker, and Kelly R. Powell. "Opioid agonists/antagonists in morphine-tolerant squirrel monkeys." Pharmacology Biochemistry and Behavior 36, no. 3 (July 1990): 639–44. http://dx.doi.org/10.1016/0091-3057(90)90269-n.

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28

Patch III, Richard K., Jason S. Eldrige, Susan M. Moeschler, and Matthew J. Pingree. "Dexmedetomidine as Part of a Multimodal Analgesic Treatment Regimen for Opioid Induced Hyperalgesia in a Patient with Significant Opioid Tolerance." Case Reports in Anesthesiology 2017 (2017): 1–5. http://dx.doi.org/10.1155/2017/9876306.

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Acute postoperative pain in patients with opioid tolerance creates a significant management challenge for anesthesiologists and pain medicine physicians. A multimodal approach is key; however other factors can complicate management such as opioid induced hyperalgesia. We present the case of a patient on large amounts of intrathecal opioids for chronic pain syndrome with opioid induced hyperalgesia after an exploratory laparotomy. Dexmedetomidine was utilized successfully as part of a controlled multimodal analgesic plan and should be a consideration for opioid tolerant patients experiencing opioid induced hyperalgesia.
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Larochelle, MD, MPH, Marc R., Noelle M. Cocoros, DSc, MPH, Jennifer Popovic, DVM, MA, Elizabeth C. Dee, MPH, Cynthia Kornegay, PhD, Jing Ju, PharmD, PhD, and Judith A. Racoosin, MD, MPH. "Opioid tolerance and urine drug testing among initiates of extended-release or long-acting opioids in Food and Drug Administration's Sentinel System." Journal of Opioid Management 13, no. 5 (September 1, 2017): 315. http://dx.doi.org/10.5055/jom.2017.0407.

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Objective: A risk evaluation and mitigation strategy for extended-release and long-acting (ER/LA) opioid analgesics was approved by the Food and Drug Administration in 2012. Our objective was to assess frequency of opioid tolerance and urine drug testing for individuals initiating ER/LA opioid analgesics.Design: Retrospective cohort study.Setting: Sentinel, a distributed database with electronic healthcare data on >190 million predominantly commercially insured members.Patients, participants: Members under age 65 initiating ER/LA opioid analgesics between January 2009 and December 2013.Main outcome measure(s): We examined the proportion of opioid-tolerantonly ER/LA opioid analgesic initiates meeting tolerance criteria: receipt of ≥30 mg oxycodone equivalents per day in 7 days prior to the first opioid-tolerant-only dispensing. We separately examined the proportion of new users of extended-release oxycodone (ERO) and other ER/LA opioid analgesics with a claim for a urine drug test in the 30 days prior to, and separately for the 183 days after, dispensing.Results: We identified 79,824 ERO, 7,343 extended-release hydromorphone, and 91,778 transdermal fentanyl opioid-tolerant-only episodes. Tolerance criteria were met in 64 percent of ERO, 64 percent of extended-release hydromorphone and 40 percent of transdermal fentanyl episodes. We identified 210,581 incident ERO and 311,660 other ER/LA opioid analgesic episodes. Use of urine drug testing for ERO compared with other ER/LA opioid analgesics was: 4 percent vs 14 percent respectively in the 30 days prior to initiation and 9 percent vs 23 percent respectively in the 183 days following initiation.Conclusions: These results suggest potential areas for improving appropriate ER/LA opioid analgesic prescribing practices.
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Wenzel, John T., Eric S. Schwenk, Jaime L. Baratta, and Eugene R. Viscusi. "Managing Opioid-Tolerant Patients in the Perioperative Surgical Home." Anesthesiology Clinics 34, no. 2 (June 2016): 287–301. http://dx.doi.org/10.1016/j.anclin.2016.01.005.

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31

Patanwala, Asad E., Donna L. Jarzyna, Michael D. Miller, and Brian L. Erstad. "Comparison of Opioid Requirements and Analgesic Response in Opioid-Tolerant versus Opioid-Naïve Patients After Total Knee Arthroplasty." Pharmacotherapy 28, no. 12 (December 2008): 1453–60. http://dx.doi.org/10.1592/phco.28.12.1453.

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32

Lin, Rongbo, Sunzhi Lin, Shuitu Feng, Qingyi Wu, Jianqian Fu, Fang Wang, Hui Li, et al. "Comparing Patient-Controlled Analgesia Versus Non-PCA Hydromorphone Titration for Severe Cancer Pain: A Randomized Phase III Trial." Journal of the National Comprehensive Cancer Network 19, no. 10 (October 2021): 1148–55. http://dx.doi.org/10.6004/jnccn.2020.7699.

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Background: Opioid titration is necessary to achieve rapid, safe pain relief. Medication can be administered via patient-controlled analgesia (PCA) or by a healthcare provider (non-PCA). We evaluated the efficacy of intravenous PCA versus non-PCA hydromorphone titration for severe cancer pain (≥7 at rest on the 11-point numeric rating scale [NRS]). Patients and Methods: Patients with severe cancer pain were randomized 1:1 to PCA or non-PCA titration, stratified by opioid-tolerant or opioid-naïve status. The PCA pump was set to no continuous dose, with a hydromorphone bolus dose 10% to 20% of the total previous 24-hour equianalgesic (for opioid-tolerant patients) or 0.5 mg (for opioid-naïve patients). For the non-PCA group, the initial hydromorphone bolus dose was identical to that in the PCA group, with the subsequent dose increased by 50% to 100% (for NRS unchanged or increased) or repeated at the current dose (for NRS 4–6). Hydromorphone delivery was initiated every 15 minutes (for NRS ≥4) or as needed (for NRS ≤3). The primary endpoint was time to successful titration (TST; time from first hydromorphone dose to first occurrence of NRS ≤3 in 2 consecutive 15-minute intervals). Results: Among 214 patients (PCA, n=106; non-PCA, n=108), median TSTs (95% CI) were 0.50 hours (0.25–0.50) and 0.79 hours (0.50–1.42) for the PCA and non-PCA groups, respectively (hazard ratio [HR], 1.64; 95% CI, 1.23–2.17; P=.001). TSTs in opioid-tolerant patients were 0.50 hours (0.25–0.75) and 1.00 hours (0.50–2.00) for the PCA and non-PCA groups, respectively (HR, 1.92; 95% CI, 1.32–2.78; P=.003); in opioid-naive patients, TST was not significantly different for the PCA versus non-PCA groups (HR, 1.35; 95% CI, 0.88–2.04; P=.162). Pain score (median NRS; interquartile range) over 24 hours was significantly lower in the PCA group (2.80; 2.15–3.22) than in the non-PCA group (3.00; 2.47–3.53; P=.020). PCA administration produces significantly higher patient satisfaction with pain control than non-PCA administration (P<.001). Conclusions: Intravenous hydromorphone titration for severe cancer pain was achieved more effectively with PCA than with non-PCA administration.
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Cuthbert, Colleen Ann, Yuan Xu, Devon J. Boyne, Shiying Kong, Brenda R. Hemmelgarn, and Winson Y. Cheung. "Patient level factors associated with chronic opioid use in cancer patients." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): 11580. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.11580.

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11580 Background: Opioid prescribing in oncology is increasingly scrutinized given public health concerns about chronic opioid use, misuse, and harms. We aimed to evaluate patient reported pain scores, mental health indicators, prior opioid use, and number of opioid prescribers as potential risk factors for chronic opioid use in a large Canadian province. Methods: This was a population-based cohort study using administrative health data of patients in Alberta, Canada, diagnosed between Jan 2016 and Jan 2017, and completed a prospective comprehensive symptom survey within +/- 60 days of diagnosis. Patients were divided into two groups: chronic opioid use (COU) (defined as continuous prescriptions for opioids for at least 90 days post diagnosis) and non-chronic opioid use (NCOU). Logistic regression models were used to evaluate factors associated with COU. Results: We included 694 patients. Most had breast (20%), colorectal (13%), and lung (33%) cancers. There were no differences in mean age (65 years) or gender (50% female) between the groups. In total, 32% had moderate to high pain scores at diagnosis. Of the 14% with COU, 79% were opioid naïve at diagnosis. Those in the COU group were more often diagnosed with advanced stage of disease (66% vs 40%), had lung cancer (47%), and were opioid tolerant at diagnosis (defined as > 90 days of continuous opioids within 1 year prior to their diagnosis) (21% vs 3%). In comparison, 64% of COU versus 27% of NCOU had moderate to severe pain scores at diagnosis (p < 0.001). COU had significantly higher anxiety and depression scores at diagnosis versus NCOU (p = 0.004). Among patients with COU, morphine equivalent daily doses increased from 27.3 (pre-diagnosis) to 65.1 (post-diagnosis). Irrespective of treatment type or stage, those who had moderate to high pain scores, were opioid tolerant at diagnosis, or had multiple prescribers were at greater risk for COU (see Table). Conclusions: Specific patient groups were at increased risk of COU and should be the focus of adaptive prescribing approaches to ensure that opioid use is appropriate. [Table: see text]
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Samolsky Dekel, MD, PhD, MA, Boaz Gedaliahu, Marco Tomasi, MD, Alessio Vasarri, MD, Alberto Gori, MD, Marco Adversi, MD, Anna Castagnoli, MD, GianFranco Di Nino, MD, and Rita Maria Melotti, MD. "Opioid titration with sustained-release oxycodone and immediate-release morphine for moderate/severe cancer pain: A pilot assessment of the CoDem protocol." Journal of Opioid Management 10, no. 1 (January 1, 2014): 29. http://dx.doi.org/10.5055/jom.2014.0189.

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Objectives: Opioid titration is the first challenging stage for rapid control of moderate/severe cancer pain. Evidence shows that sustained-release formulations may be used for opioid titration. We set a pilot assessment of the efficacy and tolerability of our in-house protocol (continuous and on demand opioids [CoDem]) of the association of sustained-release oxycodone and immediate-release morphine as rescue dose for opioid titration/rotation in opioid-naïve (NAOP, n = 13), tolerant to weak (WOP, n = 20), or strong opioids (STOP, n = 44) in-patients with moderate/severe cancer pain.Methods: Observational and retrospective analysis of cancer in-patients treated for ≥7 days with the CoDem protocol.Outcome measures: Pain intensity (patients self-reported pain with numerical rating scale [NRS] under static [NRSs] and dynamic [NRSd] conditions), amount of drug consumption, opioid adverse effects, and patient satisfaction.Efficacy endpoints: In more than 50 percent of the patients and in <72 hours, steady NRSs and NRSd score reduction of at least two points, NRSs ≤ 3 and NRSd ≤4; and mean daily morphine consumption < mean of one rescue dose and t1:t6 ratio of mean oxycodone daily dose < 1:2.Results: Endpoints were reached within 24 hours both within the sample and subgroups. Only NAOP patients reached NRSd ≤ 4 endpoint within 48 hours. Against moderate and transient adverse effects, most patients (84.4 percent) found pain treatment to be good or excellent.Conclusions: The CoDem protocol was shown to be effective and reasonably tolerated for titration for moderate/severe cancer pain relief in both opioid-naïve or opioid-tolerant cancer in-patients. This pilot assessment warrants prospective and comparative studies with larger samples for more generalized results.
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Webster, MD, Lynn R., John Messina, PharmD, Fang Xie, PhD, and Srinivas Nalamachu, MD. "Effect of fentanyl buccal tablet on pain-related anxiety: A 4-week open-label study among opioid-tolerant patients with chronic and breakthrough pain." Journal of Opioid Management 7, no. 4 (January 15, 2018): 297–308. http://dx.doi.org/10.5055/10.5055/jom.2011.0071.

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Objective: To evaluate the effect of fentanyl buccal tablet (FBT) on pain-related anxiety in opioid-tolerant patients with chronic pain and breakthrough pain (BTP).Design: This study consisted of a screening visit, open-label titration period, and 4-week open-label treatment period.Setting: Thirty-one US study centers.Patients: Opioid-tolerant adults with chronic, persistent pain experiencing 1-4 BTP episodes per day at baseline. Two hundred eighteen patients were enrolled in this study; 180 completed the titration period; and 169 completed the treatment period.Intervention: Patients were treated with FBT (100-800 g) for BTP episodes for 4 weeks while continuing their around-the-clock opioid regimens.Main outcome measures: Change from baseline in the Pain Anxiety Symptoms Scale (PASS) total score at the final visit.Results: Based on a mean baseline PASS total score of 82.6, study patients had a high level of anxiety; 92 patients (42 percent) had a history of anxiety disorders. The change from baseline in PASS total score was not statistically significant (mean change, −1.6; p = 0.322). Numerical improvements were reported in some secondary measures (eg, Beck Depression Inventory total score [mean change, −1.1; p = 0.038]) and categorical measures (eg, Pain Flare Treatment Satisfaction, Patient Assessment of Function, and Clinician Assessment of Patient Function ratings). FBT was generally well tolerated, with no serious adverse events related to study drug.Conclusions: Four weeks of treatment with FBT did not reduce anxiety to a clinically meaningful extent, although improvement was reported in several secondary measures of functioning. Further research is needed to assess the impact of treatment for BTP on anxiety symptoms in opioid-tolerant patients with BTP.
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36

West, Amy, Mallory Fiorenza, and James Kasiewicz. "1584: COMPARISON OF ANALGESIA REQUIREMENTS IN OPIOID-TOLERANT VS OPIOID-NAÏVE CHEST WALL INJURY PATIENTS." Critical Care Medicine 44, no. 12 (December 2016): 471. http://dx.doi.org/10.1097/01.ccm.0000510257.96809.5b.

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37

Benoliel, J. J., S. Bourgoin, E. Collin, A. Mauborgne, M. Pohl, M. H. Thiébot, M. Hamon, and F. Cesselin. "Opioid control of the spinal release of cholecystokinin (CCK) in morphine-tolerant and non-tolerant rats." Regulatory Peptides 54, no. 1 (November 1994): 23–24. http://dx.doi.org/10.1016/0167-0115(94)90370-0.

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38

Young, Ronald F., and V. Israel Chambi. "Pain relief by electrical stimulation of the periaqueductal and periventricular gray matter." Journal of Neurosurgery 66, no. 3 (March 1987): 364–71. http://dx.doi.org/10.3171/jns.1987.66.3.0364.

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✓ Pain relief following stimulation of the periaqueductal gray matter (PAG) or periventricular gray matter (PVG) in man has been ascribed to stimulation-induced release of endogenous opioid substances. Forty-five patients were studied and followed for at least 1 year after placement of chronic stimulating electrodes in the PAG or PVG to determine if pain relief due to stimulation could be ascribed to an endogenous opioid mechanism. Three criteria were assessed: 1) the development of tolerance to stimulation; 2) the possibility of cross-tolerance to morphine; and 3) reversibility of stimulation-induced pain relief by the opiate antagonist naloxone. Sixteen patients (35.6%) developed tolerance to stimulation, that is, they obtained progressively less effective pain relief. Twelve (44.4%) of 27 patients undergoing stimulation of the thalamic sensory relay nuclei for treatment of chronic pain (a presumably non-opioid mechanism) also developed tolerance. Morphine sulfate was administered in a blind, placebo-controlled protocol to 10 patients who had become tolerant to PAG-PVG stimulation and none showed evidence of cross-tolerance. Fifteen of 19 patients, already tolerant to morphine at the time of PAG-PVG electrode implantation, experienced excellent pain relief by stimulation, also indicating a lack of cross-tolerance. Twenty-two patients who experienced excellent pain relief from chronic PAG-PVG stimulation received intravenous naloxone in a double-blind, placebo-controlled protocol. Pain intensity as assessed by the visual analog scale was increased to the same degree by both placebo and naloxone. Eight patients showed no increase in pain intensity with either placebo or naloxone. Although tolerance to PAG-PVG stimulation developed in these patients, the frequency of tolerance was similar to that seen in patients undergoing thalamic sensory nuclear stimulation. Since the latter technique presumably relieves pain by a non-opioid mechanism, the development of tolerance to PAG-PVG stimulation does not, in itself, confirm an opioid mechanism. Cross-tolerance between PAG-PVG stimulation and morphine was not seen and cross-tolerance to PAG-PVG stimulation in patients already tolerant to morphine was rare. The pain-relieving effect of PAG-PVG stimulation was reversed to an approximately equal degree by naloxone and placebo. The authors do not believe that, in most patients, pain relief elicited by PAG-PVG stimulation depends on an endogenous opioid mechanism. It appears that other, non-opioid mechanisms are primarily responsible for such pain relief.
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Kest, Benjamin, Shirzad Jenab, and Charles E. Inturrisi. "Levels of Delta-Opioid Receptor mRNA in Morphine-Tolerant Mice." Analgesia 1, no. 3 (January 1, 1995): 195–200. http://dx.doi.org/10.3727/107156995819564257.

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40

Chazan, RN, Shoshana, Margaret P. Ekstein, MD, Nissim Marouani, MD, and Avi A. Weinbroum, MD. "Ketamine for acute and subacute pain in opioid-tolerant patients." Journal of Opioid Management 4, no. 3 (January 30, 2018): 173. http://dx.doi.org/10.5055/jom.2008.0023.

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Prolonged acute pain, especially that of oncologic neurological origin, is at times difficult to control; it is seldom entirely alleviated by opioids. We report eight patients with severe pain, three of whom suffered from new onset oncologic metastatic bone pain, others had previous pain syndromes and presented with exacerbation of pain. Pain was associated with hyperalgesia and allodynia phenomena in two patients and with phantom pain in a third one. Tolerance to opioids had developed, and high IV doses of morphine, meperidine or fentanyl, and patient-controlled intravenous and epidural analgesia were insufficient. Several patients became dependent on opioids and could not be weaned from assisted ventilation.Pain was controlled with decreasing adjunct doses of ketamine. Within 5-10 days of ketamine and opioid protocols, pain was controlled and after an additional 5-7 days, ketamine could be stopped and pain controlled on oral regimens compatible with outpatient care.Ketamine is an efficient adjuvant analgesic for intractable severe pain, caused by metastasis, trauma, chronic ischemia, or central neuropathic pain. It is effective even when mega doses of IV, epidural, or oral opioids prove ineffective and when signs of tolerance have developed.
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Brennan, Timothy J., Richard C. Lennertz, and Sinyoung Kang. "Are Opioid-tolerant Patients Resistant to Local Anesthetic Nerve Blockade?" Anesthesiology 125, no. 4 (October 1, 2016): 625–26. http://dx.doi.org/10.1097/aln.0000000000001240.

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42

Coluzzi, Flaminia, Francesca Bifulco, Arturo Cuomo, Mario Dauri, Claudio Leonardi, Rita Maria Melotti, Silvia Natoli, Patrizia Romualdi, Gennaro Savoia, and Antonio Corcione. "The challenge of perioperative pain management in opioid-tolerant patients." Therapeutics and Clinical Risk Management Volume 13 (September 2017): 1163–73. http://dx.doi.org/10.2147/tcrm.s141332.

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43

Huxtable, C. A., L. J. Roberts, A. A. Somogyi, and P. E. Macintyre. "Acute Pain Management in Opioid-Tolerant Patients: A Growing Challenge." Anaesthesia and Intensive Care 39, no. 5 (September 2011): 804–23. http://dx.doi.org/10.1177/0310057x1103900505.

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44

Gelot, Agathe, Bernard Francés, Anne Roussin, Jean-Philippe Latapie, and Jean-Marie Zajac. "Anti-opioid efficacy of Neuropeptide FF in morphine-tolerant mice." Brain Research 808, no. 2 (October 1998): 166–73. http://dx.doi.org/10.1016/s0006-8993(98)00665-9.

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45

Mahathanaruk, Marchyarn, James Hitt, and Oscar A. de LeonCasasola. "Perioperative Management of the Opioid Tolerant Patient for Orthopedic Surgery." Anesthesiology Clinics 32, no. 4 (December 2014): 923–32. http://dx.doi.org/10.1016/j.anclin.2014.08.009.

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46

Vocci, Frank J., Robert P. Schwartz, Monique E. Wilson, Michael S. Gordon, Timothy W. Kinlock, Terrence T. Fitzgerald, Kevin E. O’Grady, and Jerome H. Jaffe. "Buprenorphine dose induction in non-opioid-tolerant pre-release prisoners." Drug and Alcohol Dependence 156 (November 2015): 133–38. http://dx.doi.org/10.1016/j.drugalcdep.2015.09.001.

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47

Shah, Samir, Shruti Kapoor, and Brian Durkin. "Analgesic management of acute pain in the opioid-tolerant patient." Current Opinion in Anaesthesiology 28, no. 4 (August 2015): 398–402. http://dx.doi.org/10.1097/aco.0000000000000218.

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48

Zhang, Y., P. A. Stolz, D. Y. Shirachi, and R. M. Quock. "Reduced antinociceptive responsiveness to hyperbaric oxygen in opioid-tolerant mice." European Journal of Pain 18, no. 7 (January 6, 2014): 1032–39. http://dx.doi.org/10.1002/j.1532-2149.2013.00448.x.

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49

Tobias, Joseph D. "Opioid Withdrawal Presenting as Stridor." Journal of Intensive Care Medicine 12, no. 2 (March 1997): 104–6. http://dx.doi.org/10.1177/088506669701200205.

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Following the prolonged administration of opioids for sedation in the PICU, tolerance and physical dependency may occur. In patients who have become tolerant, physical signs of withdrawal may occur when these agents are discontinued. The actual signs and symptoms of withdrawal vary from patient to patient, but the majority of the literature documents problems such as hyperactivity of the sympathetic nervous system included tachycardia, hypertension, diaphoresis, and tremulousness. The author presents two patients who developed symptoms of upper airway obstruction, including stridor, as the major manifestation of opioid withdrawal. Operative inspection of the airway with rigid bronchoscopy and direct laryngoscopy demonstrated no airway abnormalities. Reinstitution of opioid therapy resulted in a prompt resolution of symptoms and a more gradual tapering of the opioid dose prevented recurrence of the problem.
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Eden, Brenda, Brian Gilley, and Jennifer Neff. "Implementation of Evidence-Based Guidelines and PCA Order Sets for Opioid Naïve and Opioid Tolerant Patients." Pain Management Nursing 10, no. 1 (March 2009): e2. http://dx.doi.org/10.1016/j.pmn.2008.11.005.

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