Moeschler, Susan M.

Abstract Objective The opioid epidemic is a national public health emergency that requires a comprehensive approach to reduce opioid-related deaths. Proper and timely disposal of unused prescription opioids is one method to deter improper use of these medications and prevent overdose. The objective of this study was to understand how recommendations for disposing of unused prescription opioids, including both take-back programs and toilet disposal, are communicated to the public. Methods Two hundred sixty-three US newspaper articles published between January 1, 2014, and June 30, 2017, containing information on opioids and take-back programs were found using LexisNexis. Using content analysis, articles were coded for the presentation of and recommendation for opioid disposal practices, beliefs about environmental harm from toilet disposal, and additional strategies to reduce opioid supply. The entity responsible for the statement was also captured. Results Take-back programs were presented as a recommended disposal strategy for unused prescription opioids in 88.6% of coded articles. Toilet disposal was presented as a recommended disposal strategy for unused prescription opioids in 3.4% of articles and as harmful to the environment in 16.0% of articles. Individuals from health care, government, and law enforcement were primarily involved in discussing opioid disposal practices. Conclusions Although toilet disposal is recommended by the US Food and Drug Administration (FDA) for disposal of unused prescription opioids when a take-back program is not readily available, it was infrequently presented or recommended in news media articles. These results highlight the importance of improving communication of FDA guidelines for opioid disposal in the media, particularly by health care providers, government employees, and law enforcement officials.

The American Society of Anesthesiologists (ASA) Annual Meeting is the primary venue for anesthesiologists to present research, share innovations, and build networks. Herein, we describe gender representation for physician speakers at the Annual Meeting relative to the specialty overall. Details of ASA Annual Meeting presentations for individuals and panels were abstracted from the ASA archives for 2011–2016. Observed speaker gender composition was compared to expected composition based on the gender distribution of members of the ASA. There were 5167 speaker slots across 2025 presentations and panels. Of the speaker slots, 3874 were assigned to men and 1293 to women. Speaker slot gender composition was relatively consistent between 2011 and 2016 (annual percentage 22.3%–27.7% women, trend test P = .062). ASA membership composition of women increased slightly over the study period (24%–28%). The overall observed number of women in speaker slots over the study period did not differ significantly from what would be expected based on the ASA membership composition (25.0% observed versus 25.9% expected; P = .153). However, the percentage of single speakers who were women was significantly less than would be expected based on the ASA gender distribution (20.2% observed versus 25.9% expected; P < .001). Interestingly, for panels that included 2–5 anesthesiologists, single-gender panels were more common than would be expected by chance, with all-male panels predominating (all P < .01). The gender composition of speakers at the ASA Annual Meeting largely reflected gender composition within the specialty, although women were not overrepresented at any meeting. The predominance of single-gender panels and underrepresentation of women as single speakers is a potential target to improve gender representation.

Background. Cervical interlaminar epidural steroid injections (ESIs) are commonly performed procedures to treat painful cervical radiculopathy, but little is known about the systemic absorption and serum levels of steroids following injection. The primary objective of this study was to investigate the pharmacokinetics of fluoroscopy-guided cervical epidural-administered triamcinolone acetonide in a cohort of patients with cervical radicular pain seeking treatment in a pain medicine clinic.Methods. The study cohort included eight patients undergoing a fluoroscopically guided C7-T1 interlaminar ESI at a pain medicine specialty clinic. Blood was collected prior to the ESI and on days 1, 2, 4, 6, 8, 14, 21, 28, 35, and 42 following the injection. The sample extract was analyzed by tandem mass spectrometry.Results. The terminal elimination half-life of cervical epidural-administered triamcinolone in a noncompartmental analysis was 219 hours. In the noncompartmental analysis, peak triamcinolone concentrations of 5.4 ng/mL were detected within 22.1 hours after administration.Conclusions. The pharmacokinetics of cervical epidural-administered triamcinolone is consistent with our previous study of lumbar ESI, demonstrating that the elimination half-life is longer than that which has been reported following intravenous triamcinolone. The elimination half-life was shorter following cervical ESI than that which has been reported following lumbar ESI.

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.

AbstractObjectiveThe goal of this study was to determine the frequency and clinical indications associated with implantation of single vs. dual percutaneous lead spinal cord stimulator (SCS) systems and to look further into how these leads are utilized for treatment.Materials and MethodsA retrospective cohort analysis of all patients undergoing SCS implantation between January 2001 and December 2013 with a minimum of 2 years of clinical follow‐up was performed. Number of trial leads and implanted leads was recorded. For patients with dual‐lead systems, it was noted if and when the second lead was used, along with the clinical indication for lead activation.ResultsIn the 259‐patient cohort, 15.8% (n = 41) patients underwent placement of a single‐lead system, 83.0% (n = 215) underwent placement of a dual‐lead system, and 1.2% (n = 3) underwent placement of 3‐lead systems. Placement of dual‐lead systems was similar among all indication groups. Of those patients with a dual‐lead system in place, 88.1% utilized both leads and average time to programming of the second lead was 2.3 months. The most common reason to activate the second lead was inadequate stimulation coverage. Five of the 41 patients with single‐lead systems underwent an additional surgery to implant a second lead due to inadequate stimulation with 1 lead.ConclusionsTo our knowledge this is the first descriptive analysis of the frequency of single‐ and dual‐lead SCS systems. This report indicates that dual‐lead systems are most often placed and both leads are required for optimal patient therapy.

Abstract Objectives. Our purpose was to determine the incidence of surgical site infection (SSI) in cancer patients receiving an intrathecal drug delivery system (IDDS) and compare that rate with the incidence of SSI in the general population receiving an IDDS or spinal cord stimulator. We attempted to describe risk factors for SSIs in cancer patients treated with IDDS in terms of exposure to cancer treatments. Design. Retrospective review. Setting. Large tertiary care center. Patients. Cancer patients receiving an IDDS in 2006–2013. Methods. The incidence of SSI was determined according to the US Centers for Disease Control and Prevention definition. Medication regimens and current cancer treatment were investigated to identify immunocompromised patients during IDDS placement. Microbacteriology, treatment, and overall outcomes were investigated. Results. Sixty-four patients had an IDDS implanted in 2006–2013. SSI developed in four patients (6.2%). All four patients had received chemotherapy or radiotherapy within three months before implantation. Three of the three were receiving dexamethasone, and three of the four required explantation of the IDDS. Conclusion. The incidence of SSI was at the upper end of the published infection rates for IDDS. The risk of SSI may be increased in this population because of factors that alter the patient’s immune status, including concomitant corticosteroid use, radiotherapy near the SSI, and presence of immunomodulators. The identification and mitigation of certain risk factors for this population may prevent infection in future patients.

A recent publication reported the incidence of postdural puncture headache (PDPH) in conjunction with intrathecal drug delivery system (IDDS) implantation to be nearly 23 percent. Many patients responded to conservative measures but a percentage needed invasive treatment with an epidural blood patch (EBP). There is limited data to describe the technical details, success rates, and complications associated with EBP in this population. This study aims to provide a retrospective report of EBP for patients suffering from PDPH related to IDDS implantation. A chart review established a cohort of patients that required EBP in relation to a PDPH after IDDS implantation. This cohort was evaluated for demographic data as well as details of the EBP including technical procedural data, success rates, and complications. All patients received a trial of conservative therapy. Standard sterile technique and skin preparation were utilized with no infectious complications. The EBP was placed below the level of the IDDS catheter in 94% of procedures. Fluoroscopy was utilized in each case. The mean EBP volume was 18.6 cc and median time of EBP was day 7 after implant. There were no complications associated with EBP. EBP appears to be an effective intervention in this subset of PDPH patients.