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Analgesics during Pregnancy
Published in “Bert” Bertis Britt Little, Drugs and Pregnancy, 2022
A synthetic narcotic, hydrocodone, is used to treat moderate pain but is infrequently used during labor and delivery. Hydrocodone is a component of cough suppressant formulations. Congenital anomalies were slightly increased in frequency (7.2 percent) compared to the background rate in the general population (5 percent) in an unpublished study of 332 infants born to women who used this drug during the first trimester (Rosa, unpublished data, Briggs et al., 2017). Congenital anomalies in a clinical case series of 40 infants whose mothers used hydrocodone during the first trimester were heterogeneous, and did not seem to comprise a constellation or pattern, as would be expected in a syndrome. (Schick et al., 1996). Analysis of the association of birth defects with hydrocodone use in the first trimester in the National Birth Defects Prevention Study found several associations. Spina bifida, five types of heart defects (atrioventricular septal defect, tetralogy of Fallot, left ventricular outflow tract obstruction defect, hypoplastic left heart syndrome, pulmonary valve stenosis, ventricular septal defect plus atrial septal defect) and cleft palate were significantly increased in frequency among infants whose mothers used hydrocodone during pregnancy (Broussard et al., 2011). Birth defects were increased in frequency in the offspring of hamsters injected with extremely large doses of this agent (Geber and Schramm, 1975).
Substance Use Disorders
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
The United States is amidst an opioid epidemic. Between 1999 and 2014 the prevalence of OUD quadrupled reaching 6.5/1000 delivery hospitalizations. While no state has been exempt from the rise in OUD the prevalence varies from 0.7 to 48.6/1000 [56]. Other estimates indicate that 5.6–12/1000 pregnant patients reported misuse of prescription opioid analgesics [12, 57]. Heroin use more than doubled from 2004– 2005 through 2012–2013, along with the rise in prescription opioid misuse, but has since returned to baseline levels (5/10,000 in 2016–2017) [58]. Oxycodone and hydrocodone are the most commonly abused prescription opioid analgesics. Among pregnant patients misusing opioids, 46% reported receiving those opioids from their own doctor [59]. In 2012, of 21553 pregnant substance use treatment admissions, 23% reported heroin use and 28% reported non-heroin opioid misuse [60]. In tandem with the rise in OUD, Neonatal Opioid Withdrawal Syndrome (NOWS) increased five-fold from 2004 to 2014 (14.4/1000 births in a Medicaid population; 5/1000 births overall) [6, 61]. Presently, maintenance medications for OUD (e.g., buprenorphine) account for the majority of NOWS. Opioid misuse decreases during pregnancy reaching the lowest rate in the third trimester.
Pharmacology of Opioids
Published in Pamela E. Macintyre, Stephan A. Schug, Acute Pain Management, 2021
Pamela E. Macintyre, Stephan A. Schug
Hydrocodone is available for oral administration in the United States, usually in combination formulations with nonopioid analgesics such as paracetamol or aspirin, which limits the amount of the opioid that can be given. Its analgesic effect depends on metabolism by CYP2D6 to hydromorphone, and ultrarapid metabolizers will have much higher hydromorphone blood concentrations (Owusu Obeng et al, 2017).
Safety implications of concomitant administration of antidepressants and opioid analgesics in surgical patients
Published in Expert Opinion on Drug Safety, 2023
Rosa Rodriguez-Monguio, Zhixin Lun, Drew T Dickinson, Connie Do, Bailey Hyland, Eline Kocharyan, Leanne Liu, Michael A Steinman
Our findings on the decreased analgesic effect of opioids in patients concomitantly taking inhibiting antidepressants contribute to a growing body of evidence that supports the consideration of pharmacokinetic drug-drug-interactions, such as CYP2D6 inhibition, when addressing pain management. A recent study found that patients undergoing total knee replacement or total hip surgery taking CYP2D6 inhibitors used a higher total dose of hydrocodone during hospitalization and after discharge [18]. Other retrospective studies found that paroxetine inhibited the bioconversion of tramadol [19] and hydrocodone [20,21] to active metabolites subsequently attenuating the agent’s analgesic properties. Lastly, a randomized controlled study, including a small sample of healthy volunteers, found that paroxetine diminished the oxycodone analgesic effect [22]. The 2022 updated Clinical Pharmacogenomics Implementation Consortium guidelines recommend against the use of codeine and tramadol in poor and ultrarapid metabolizers and acknowledge that there is insufficient evidence to make conclusive recommendations for hydrocodone and oxycodone [23].
Respiratory depression following medications for opioid use disorder (MOUD)-approved buprenorphine product oral exposures; National Poison Database System 2003–2019
Published in Clinical Toxicology, 2021
Michael A. Darracq, Stephen L. Thornton
Fox et al. described a 28.7% frequency of “severe respiratory depression” (defined by administration of naloxone or endotracheal intubation performed either pre-hospital or in-hospital) among adult patients presenting for acute buprenorphine overdose to two New York City emergency departments. In the same study, the frequency of severe respiratory depression following hydrocodone (9/31, 29%), oxycodone (40/124, 32.3%), and tramadol (3/12, 25%) were also reported [24]. Applying the same definition of respiratory depression to the current study of NPDS data as that applied by Fox et al. results in a frequency of severe respiratory depression for adult oral buprenorphine exposures of 25.5% (3845/15,121) and 25.9% (3131/12,069) for pediatric oral buprenorphine exposures overall. Very similar rates of respiratory depression defined by administration of naloxone or endotracheal intubation were observed in both the Fox study and the current NPDS dataset.
Hidradenitis suppurativa for the nondermatology clinician
Published in Baylor University Medical Center Proceedings, 2020
Kavina Patel, Lucy Liu, Benjamin Ahn, Annika S. Silfvast-Kaiser, So Yeon Paek
Pain can be severely debilitating for HS patients and can lead to more distress than the presence of lesions alone. As such, management of both acute and chronic pain is important. No formal evidence exists regarding pain management in HS. Management of pain relies on general pain management guidelines as well as patient and provider preference. Topical analgesics, nonsteroidal anti-inflammatory drugs, or opioids are often used to alleviate pain and inflammation in HS. Some guidelines recommend nonsteroidal anti-inflammatory drugs for acute pain management. Contraindications to nonsteroidal anti-inflammatory drug use include liver or renal impairment, gastrointestinal bleeding, peptic ulcers, inflammatory bowel disease, and heart failure. Opioids are used for refractory pain management and are contraindicated in patients with liver, renal, and pulmonary impairment. Codeine and hydrocodone should be used only for acute pain management and for a limited amount of time and dosage.4 Consulting a pain management specialist may also be beneficial. The key to treating HS-related pain and discomfort is to control underlying inflammation by decreasing the amount and severity of flares. Most importantly, providers and patients must acknowledge that treatment of the inflammatory disease state is key to controlling underlying pain.39 The use of opiates is mentioned as a possible adjunctive treatment for severe cases of HS in very few guidelines.