Latest news with #opioiduse
Medscape
4 days ago
- General
- Medscape
Fact or Fiction: Postoperative Pain Management
Effective postoperative pain management is crucial for enhancing patient recovery and reducing complications. Guidelines emphasize a multimodal approach, integrating pharmacologic and nonpharmacologic strategies to address the complex nature of postoperative pain. This includes using regional anesthesia techniques, non-opioid analgesics, and complementary therapies tailored to individual patient needs. Such comprehensive strategies aim to minimize opioid consumption and associated adverse effects, thereby promoting better outcomes. Persistent opioid use is reported in up to 10% of opioid-naive patients more than 90 days after surgery. Among those discharged with opioid prescriptions, approximately 70% retain a supply at home — and of that, 90% is stored insecurely. A recent study published in JAMA found that spinal surgery, older age, longer hospital stay, history of substance use disorder, and previous opioid discontinuation before surgery were associated with new-onset persistent opioid use after surgery. These findings underscore the importance of minimizing opioid exposure in the perioperative period. Learn more about opioid abuse. The FLACC scale is a validated tool recommended for assessing postoperative pain in children 2 months to 19 years of age. However, it may be less suitable for evaluating procedural pain. In preverbal or nonverbal children with cognitive impairments, standard FLACC assessments can be less reliable. In such cases, the revised FLACC scale, which incorporates individualized behavioral cues, may offer a more accurate assessment. Learn more about pain assessment. Combined guidelines from the World Society of Emergency Surgery, Global Alliance for Infection in Surgery, Italian Society of Anesthesia, Analgesia, and Resuscitation, and the American Association for the Surgery of Trauma recommend multimodal analgesia, rather than the use of a single class of drugs, to manage postoperative pain. This approach enhances pain relief and helps reduce opioid consumption as well as adverse effects associated with a single drug class. In the absence of contraindications, acetaminophen, gabapentinoids, and nonsteroidal anti-inflammatory drugs are recommended as components of multimodal anesthesia. A step-up strategy that incorporates major opioid drugs when necessary should be employed. The Centers for Disease Control and Prevention similarly recommends a multimodal approach in their opioid prescribing guidelines. Learn more about perioperative medication management. IV administration provides the most rapid onset of analgesia but does not offer superior pain control compared to the oral route. As such, IV analgesics should be reserved for situations where oral administration is not feasible, as in cases of gastrointestinal dysfunction. Postoperative pain management guidelines concur that the oral route is the preferred route of postoperative analgesic administration. Learn more about local and regional anesthesia. Guidelines state that the TAP block is both a safe and effective approach to managing postoperative pain. Abdominal wall blocks serve as an effective component of multimodal analgesia, contributing to opioid-sparing strategies. TAP blocks have been shown to significantly reduce pain scores at 12 hours postoperatively. For laparoscopic abdominal procedures, a rectus sheath block may be considered an appropriate alternative to a TAP block within a multimodal analgesia plan. Learn more about the TAP block.
Medscape
16-05-2025
- Health
- Medscape
‘Legal Morphine' — The Rise of Kratom and 7-OH in the US
Interest in kratom in the United States has soared in the past decade, with estimates ranging as high as 16 million users and more than $2 billion in retail sales. The recent surge in use and increasing availability of products containing the potent kratom metabolite 7-hydroxymitragynine (7-OH) has some experts sounding the alarm over the addictive qualities of the drug, which acts on opioid receptors in the brain. 'People feel that it may be a good treatment for opioid use disorder [OUD] when they are going through withdrawal, which is only partially true and not all that evidence-based,' Petros Levounis, MD, professor and chair, Department of Psychiatry, and associate dean at Rutgers New Jersey Medical School, Newark, New Jersey, told Medscape Medical News . Evidence also suggests that rather than treating addiction and symptoms of withdrawal, the use of kratom may lead to addiction and withdrawal symptoms on its own. 'Perhaps even more concerning is that people start using kratom in a general sense — like it's going to help them with all kinds of nonspecific discomfort. Whether that's anxiety or dysphoria or annoyance or any of the above, they just take a little bit of kratom and feel better, which is probably true,' Levounis said. 'But at what cost?' What are Kratom and 7-OH? 'Kratom' refers to both Mitragyna speciosa, a tree native to Southeast Asia, and to products derived from its leaves that are marketed as herbal supplements. Kratom products are commonly found at gas-station counters, vape and head shops, cannabidiol dispensaries, online vendors, and occasionally in 'wellness' aisles in mainstream pharmacies. Traditional kratom products made from the dried leaves of M speciosa naturally contain dozens of bioactive alkaloids. The most well-studied compounds in kratom are mitragynine and 7-OH. Mitragynine is the predominant alkaloid, making up about 60%-65% of dried leaves, while 7-OH is present only in trace amounts (often < 0.05% of the leaf). Both molecules are psychoactive and are partial agonists at the µ-opioid receptor, with a binding strength the US Food and Drug Administration (FDA) has said is similar to scheduled opioid drugs. At low doses, mitragynine's mixed receptor profile (adrenergic, serotonergic, dopaminergic) yields mild stimulant and mood-boosting effects. By contrast, concentrated 7-OH preparations are 30-40 times more potent at opioid receptors and produce rapid-onset analgesia, euphoria, respiratory depression, and classic opioid-type withdrawal. As previously reported by Medscape Medical News , research has shown that 7-OH (formerly known as (7-HMG) has high abuse potential and may also increase the intake of other opiates. Why the Alarm? Current estimates of kratom use vary widely, with federal data reporting just under 2 million users in 2022 and a national kratom advocacy group putting the number significantly higher, at 11-16 million. The US retail sales were estimated at roughly $2.2 billion in 2024. Since late 2023, there has been a surge in 'kratom' products marketed as '7-OH,' '7-Hydro,' or 'legal morphine.' And 7-OH is 'much more potent and there are some animal studies that have shown that 7-OH is much more addictive than the good old parent molecule and can very well get you in trouble,' Levounis said. Even the American Kratom Association recently issued a consumer alert on synthetically concentrated 7-OH products that are 'deceptively' labeled and marketed as 'kratom.' The association has warned that products with 7-OH levels that exceed 2% of the overall alkaloid content are no longer kratom. Recently, independent lab tests commissioned by regulators in Texas and Colorado have found some 7-OH pills exceeding 40% purity and mislabeled as 'kratom extract.' The FDA issued an alert last year, warning consumers not to ingest optimized plant mediated solutions black liquid kratom, noting that the product, which contains 7-OH, has been linked to one death and numerous adverse health effects including seizures and liver toxicity. The FDA reported cases of kratom-related substance use disorder (SUD), in which patients use kratom for longer and in larger amounts than intended, experience kratom cravings and withdrawal symptoms, and continue use despite adverse consequences (either physically or in their personal life). Cases of neonatal abstinence syndrome, in which newborns experience such as jitteriness, irritability, muscle stiffness, and other withdrawal signs following prolonged prenatal exposure to kratom, have also been reported. Are Kratom and 7-OH Regulated? Although widely available, kratom and its ingredients have not been approved by the FDA. 'There are no FDA approved kratom drug products or over the counter drugs containing kratom, or its ingredients — mitragynine, or 7-OH-mitragynine — that are legally on the market in the US. FDA continues to warn consumers not to use kratom because of the risk of serious adverse events, including liver toxicity, seizures, and substance use disorder.' In 2016, the US Drug Enforcement Agency (DEA) declared its intent to classify kratom as Schedule I, which would have criminalized possession and distribution of the substance. However, the agency withdrew the notice after push back from the public and members of Congress. As a result, on the federal level, kratom products are not specifically regulated, nor are kratom or 7-OH listed as controlled substances, reported the Legislative Analysis and Public Policy Association. However, kratom remains on the DEA's 'Drugs of Concern' list. At the state level, there is a patchwork of regulations on kratom. Six states – Alabama, Arkansas, Indiana, Rhode Island, Vermont, Wisconsin – currently ban the substance outright and nine states have imposed specific regulations or restrictions on sale and distribution of kratom products. Kratom is legal without specific statewide regulations in 35 states, although certain local jurisdictions within these states may have their own restrictions or bans. Earlier this year, Colorado lawmakers advanced a bill to require companies that process the plant M speciosa to register with the state and follow labeling and product rules designed to limit potency. And the governor of Georgia recently signed a law adding regulations for production and sale of kratom. Is My Patient Using Kratom? Kratom use is 'something that all clinicians should ask patients about as they can buy it at convenience stores or online and its use is going up so we need to ask about it,' Roger S. McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, Toronto, Ontario, Canada, told Medscape Medical News . The key is knowing which kratom product a patient is using, said researcher Kirsten Smith, PhD, MSW, assistant professor of psychiatry and behavioral sciences, Johns Hopkins Medicine, Baltimore. 'R ule number one — ask patients exactly what they are using and record the brand name because there are so many different products out there,' she told Medscape Medical News . 'Right now you can fairly easily test for mitragynine and usually when people say that they tested for kratom, what they're really saying is that they tested for mitragynine because if someone is using it regularly, it can stay in their blood for like 12 days after their last use,' Smith said. Testing for 7-OH right now is much harder. 'You would have to send it off to a specialty lab, and it's going to be more qualitative than quantitative because 7-OH is just not stable in the blood for that long,' Smith said. Even in the absence of testing, many patients will readily admit to using kratom — much more so than cocaine, methamphetamine, or heroin — because the culture has moved to the point where it is considered to be just a supplement, Levounis said. 'The bad news is that they will also feel that there is nothing wrong with using kratom,' he said. 'It appears from a clinical perspective that the number one reason why people use kratom is to self-medicate kratom withdrawal. It's something that we have seen with benzodiazepines and cannabis where people use these substances to self-medicate the benzodiazepine or cannabis withdrawal,' he added. 'All of these substances that make you feel better are misinterpreted by the patients as doing something good for them. Meanwhile all that it is doing is bringing them back momentarily to baseline in order to satisfy the withdrawal symptoms,' Levounis said. How Do I Treat Kratom Misuse? Currently, there are no specific medications available to treat kratom misuse. While the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision does not specifically list kratom use disorder, experts noted that the 'substance use disorder — not elsewhere classified (SUD-NEC)' is a catch-all category for SUDs that don't fit neatly into the specific categories for specific substances like alcohol and cannabis. 'It's important to note that lower doses of kratom work as a stimulant and higher doses as an opioid. If you are pretty convinced that what you see is a stimulant aspect of kratom use, it's perfectly okay to give a patient a diagnosis of stimulant use disorder and then explain in your note that this is primarily kratom,' Levounis said. 'If you are convinced that the way that this particular patient uses kratom is as an opioid, because of a higher dose, then it's okay to give the patient the opioid use disorder diagnosis and in your note address the fact that this opioid is kratom,' he noted. The most frequent approach for treating kratom-related physical dependence is medication for OUD, specifically buprenorphine or buprenorphine-naloxone, Smith said, adding that treatment should be individualized. Treatment may also include psychotherapy and counseling, Levounis noted, adding 'it's important to treat any co-occurring psychiatric or other medical conditions, such as a legitimate pain disorder or opioid use disorder or anxiety or depression.' One reason for the lack of kratom-specific treatments is the lack of published case reports on kratom and 7-OH, Smith said.
