scholarly journals SAT-LB45 Chronic Opioid Use as a Cause of Severe Hypothyroidism: A Case Report

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Daniel Slack ◽  
Danielle Brooks ◽  
Alice C Levine
Keyword(s):  
Chronic Pain ◽  
Meta Analysis ◽  
Pain Syndrome ◽  
Posterior Lobe ◽  
Opioid Use ◽  
Free T4 ◽  
Normal Limits ◽  
Pituitary Thyroid Axis ◽  
Chronic Opioid Use ◽  
Opioid Users

Abstract Background: Hypogonadism and hypocortisolism are present in a sizeable proportion of chronic opioid users. (1) An association with hypothyroidism, however, has not been demonstrated. Clinical Case: A 56-year old woman with chronic pain syndrome on opioids presented from a nursing home with decreased level of consciousness and was found to be hypotensive requiring ICU admission. Several weeks prior to her presentation, she was hospitalized for progressive weakness and was found to have evidence of panhypopituitarism: low TSH (0.209 uIU/mL, nl 0.400 – 4.200), low free T4 (0.76 ng/dL, nl 0.80 – 1.50), low LH (<0.12 mIU/mL, nl 10.9 – 58.6), low FSH (1.7 mIU/mL, nl 16.7 – 113.6), and abnormal ACTH stim test (ACTH 6.4 pg/mL, nl 7.2 – 63; cortisol 0-min 3.8 mcg/dL, nl 6.7 – 22.6; 60-min 13.10). She was discharged on levothyroxine 25 mcg daily and prednisone 7.5 mg daily. On admission, her exam was notable for symmetric, non-pitting edema of the lower extremities to the knees with peau d’orange appearance. Initial tests revealed profound hypothyroidism with low TSH (0.381 uIU/mL), low free T4 (0.60 ng/dL), undetectable total T4 (<0.9 mcg/dL, nl 5 – 12.2), and undetectable free T3 (<1.00 pg/mL, nl 2.5 – 3.9). Thyroglobulin and TPO antibodies were within normal limits. Thyroxine binding globulin was low (6 mcg/mL, nl 13 -39). Additional biochemical studies re-demonstrated panhypopituitarism with low LH (<0.12 mIU/mL) and FSH (0.9 mIU/mL). Cortisol was elevated (73.2 mcg/dL) as she had received hydrocortisone. Despite fluid resuscitation and use of vasopressors, her hypotension persisted and she remained in critical condition. She was treated as a case of myxedema coma and started on full replacement dose thyroid hormone with 120 mcg IV levothyroxine daily and liothyronine 5 mcg every 8 hours. Over the next several days, the patient’s hemodynamics and mental status improved dramatically. A contrast-enhanced pituitary-protocoled MRI was notable for a moderately flattened sella (pituitary 3.5 mm in height) and absence of usual T1 bright signal in the posterior lobe. A work-up for causes of panhypopituitarism was mostly unremarkable: low IgG 4 (0.82, neg <1.50), indeterminate quant gold, negative HIV, low serum iron (35 mcg/dL, nl 50 – 200). Urine toxicology was positive only for opioids, reflective of the patient’s chronic pain regimen consisting of MS-Contin 60 mg twice daily and methadone 10 mg twice daily. Conclusion: This case demonstrates the potential for chronic opioid use to suppress the hypothalamic-pituitary-thyroid axis and highlights the importance of maintaining an index of suspicion for hypothyroidism in this population. Reference: (1) de Vries, F., Bruin, M., Lobatto, DJ., Dekkers, OM., Schoones, JW., van Furth, WR., Pereira, AM., Karavitaki, N., Biermasz, NR., Najafabadi, AHZ. Opioids and their endocrine effects: A systematic review and meta-analysis. JCEM. 2019. Doi: 10.1210/clinem/dgz022

scholarly journals Mindfulness-Oriented Recovery Enhancement remediates anhedonia in chronic opioid use by enhancing neurophysiological responses during savoring of natural rewards

2021 ◽  
pp. 1-10
Author(s):  
Eric L. Garland ◽  
Spencer T. Fix ◽  
Justin P. Hudak ◽  
Edward M. Bernat ◽  
Yoshio Nakamura ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Skin Conductance Level ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Natural Reward ◽  
Before And After ◽  
Natural Rewards ◽  
Chronic Opioid Use ◽  
Opioid Users

Abstract Background Neuropsychopharmacologic effects of long-term opioid therapy (LTOT) in the context of chronic pain may result in subjective anhedonia coupled with decreased attention to natural rewards. Yet, there are no known efficacious treatments for anhedonia and reward deficits associated with chronic opioid use. Mindfulness-Oriented Recovery Enhancement (MORE), a novel behavioral intervention combining training in mindfulness with savoring of natural rewards, may hold promise for treating anhedonia in LTOT. Methods Veterans receiving LTOT (N = 63) for chronic pain were randomized to 8 weeks of MORE or a supportive group (SG) psychotherapy control. Before and after the 8-week treatment groups, we assessed the effects of MORE on the late positive potential (LPP) of the electroencephalogram and skin conductance level (SCL) during viewing and up-regulating responses (i.e. savoring) to natural reward cues. We then examined whether these neurophysiological effects were associated with reductions in subjective anhedonia by 4-month follow-up. Results Patients treated with MORE demonstrated significantly increased LPP and SCL to natural reward cues and greater decreases in subjective anhedonia relative to those in the SG. The effect of MORE on reducing anhedonia was statistically mediated by increases in LPP response during savoring. Conclusions MORE enhances motivated attention to natural reward cues among chronic pain patients on LTOT, as evidenced by increased electrocortical and sympathetic nervous system responses. Given neurophysiological evidence of clinical target engagement, MORE may be an efficacious treatment for anhedonia among chronic opioid users, people with chronic pain, and those at risk for opioid use disorder.

scholarly journals Opioids and their endocrine effects: A systematic review and meta-analysis

2019 ◽  
Author(s):  
Friso de Vries ◽  
Mees Bruin ◽  
Daniel J Lobatto ◽  
Olaf M Dekkers ◽  
Jan W Schoones ◽  
...  
Keyword(s):  
Systematic Review ◽  
Dynamic Testing ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Opioid Use ◽  
Endocrine Effects ◽  
Data Synthesis ◽  
Insulin Tolerance ◽  
Chronic Opioid Use ◽  
Opioid Users

Abstract Context The increased use of opioids has resulted in an unprecedented opioid epidemic. Chronic opioid use causes hypogonadism, but its frequency, as well as the effects of opioids on other hypothalamo-pituitary-end organ hormone axes, remains unclear. Objective The aim of this systematic review and meta-analysis was to assess the effects of opioid use on pituitary function. Methods Eight electronic databases were searched for articles published up to May 8, 2018. Fixed- or random-effects meta-analysis was performed to estimate pooled proportions with 95% confidence intervals. This study is reported following the PRISMA- and MOOSE-guidelines. Data Synthesis 52 studies (22 low risk of bias) were included describing 18,428 subjects, consisting of patients with chronic pain (n=21 studies), or on maintenance treatment for opioid addiction (n=9) and healthy volunteers (n=4). The most frequently used opioid was methadone (n=13 studies), followed by morphine (n=12). Prevalence of hypogonadism was 63% (95% CI: 55-70%, 15 studies, 3,250 patients, 99.5% males). Prevalence of hypocortisolism relying on dynamic and non-dynamic testing was 15% (95% CI: 6-28%, 5 studies, 205 patients, 57.5% males) and including only studies using the insulin tolerance tests 24% (95% CI 16-33%, 2 studies, n=97 patients). In 5 out of 7 studies hyperprolactinemia was present. No clear effects on the somatotropic and hypothalamo-pituitary-thyroid axes were described. Conclusions Hypogonadism occurs in more than half of male opioid users, and hypocortisolism in approximately a fifth of all patients. Periodical evaluation of at least the gonadal and adrenal axes is therefore advisable.

scholarly journals Opioids and their endocrine effects: A systematic review and meta-analysis

2019 ◽  
Author(s):  
Friso de Vries ◽  
Mees Bruin ◽  
Daniel J Lobatto ◽  
Olaf M Dekkers ◽  
Jan W Schoones ◽  
...  
Keyword(s):  
Systematic Review ◽  
Dynamic Testing ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Opioid Use ◽  
Endocrine Effects ◽  
Data Synthesis ◽  
Insulin Tolerance ◽  
Chronic Opioid Use ◽  
Opioid Users

Abstract Context The increased use of opioids has resulted in an unprecedented opioid epidemic. Chronic opioid use causes hypogonadism, but its frequency, as well as the effects of opioids on other hypothalamo-pituitary-end organ hormone axes, remains unclear. Objective The aim of this systematic review and meta-analysis was to assess the effects of opioid use on pituitary function. Methods Eight electronic databases were searched for articles published up to May 8, 2018. Fixed- or random-effects meta-analysis was performed to estimate pooled proportions with 95% confidence intervals. This study is reported following the PRISMA- and MOOSE-guidelines. Data Synthesis 52 studies (22 low risk of bias) were included describing 18,428 subjects, consisting of patients with chronic pain (n=21 studies), or on maintenance treatment for opioid addiction (n=9) and healthy volunteers (n=4). The most frequently used opioid was methadone (n=13 studies), followed by morphine (n=12). Prevalence of hypogonadism was 63% (95% CI: 55-70%, 15 studies, 3,250 patients, 99.5% males). Prevalence of hypocortisolism relying on dynamic and non-dynamic testing was 15% (95% CI: 6-28%, 5 studies, 205 patients, 57.5% males) and including only studies using the insulin tolerance tests 24% (95% CI 16-33%, 2 studies, n=97 patients). In 5 out of 7 studies hyperprolactinemia was present. No clear effects on the somatotropic and hypothalamo-pituitary-thyroid axes were described. Conclusions Hypogonadism occurs in more than half of male opioid users, and hypocortisolism in approximately a fifth of all patients. Periodical evaluation of at least the gonadal and adrenal axes is therefore advisable.

scholarly journals Opioids and Their Endocrine Effects: A Systematic Review and Meta-analysis

2019 ◽  
Vol 105 (4) ◽  
pp. 1020-1029 ◽  
Author(s):  
Friso de Vries ◽  
Mees Bruin ◽  
Daniel J Lobatto ◽  
Olaf M Dekkers ◽  
Jan W Schoones ◽  
...  
Keyword(s):  
Systematic Review ◽  
Maintenance Treatment ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Opioid Use ◽  
Endocrine Effects ◽  
Data Synthesis ◽  
Insulin Tolerance ◽  
Chronic Opioid Use ◽  
Opioid Users

Abstract Context The increased use of opioids has resulted in an unprecedented opioid epidemic. Chronic opioid use causes hypogonadism, but its frequency, as well as the effects of opioids on other hypothalamo–pituitary–end organ hormone axes, remains unclear. Objective The aim of this systematic review and meta-analysis was to assess the effects of opioid use on pituitary function. Methods Eight electronic databases were searched for articles published up to May 8, 2018. Fixed or random effects meta-analysis was performed to estimate pooled proportions with 95% confidence intervals (CI). This study is reported following the PRISMA and MOOSE guidelines. Data synthesis 52 studies (22 low risk of bias) were included describing 18 428 subjects, consisting of patients with chronic pain (n = 21 studies) or on maintenance treatment for opioid addiction (n = 9) and healthy volunteers (n = 4). The most frequently used opioid was methadone (n = 13 studies), followed by morphine (n = 12). Prevalence of hypogonadism was 63% (95% CI: 55%–70%, 15 studies, 3250 patients, 99.5% males). Prevalence of hypocortisolism relying on dynamic and nondynamic testing was 15% (95% CI: 6%–28%, 5 studies, 205 patients, 57.5% males) and including only studies using the insulin tolerance tests 24% (95% CI 16%–33%, 2 studies, n = 97 patients). In 5 out of 7 studies, hyperprolactinemia was present. No clear effects on the somatotropic and hypothalamo–pituitary–thyroid axes were described. Conclusions Hypogonadism occurs in more than half of male opioid users, and hypocortisolism in approximately one-fifth of all patients. Periodical evaluation of at least the gonadal and adrenal axes is therefore advisable.

scholarly journals The impact of high-risk and chronic opioid use among commercially insured endometriosis patients on health care resource utilization and costs in the United States

2020 ◽  
Vol 16 ◽  
pp. 174550652096589
Author(s):  
Stephanie J Estes ◽  
Ahmed M Soliman ◽  
Marko Zivkovic ◽  
Divyan Chopra ◽  
Xuelian Zhu
Keyword(s):  
Health Care ◽  
High Risk ◽  
Resource Utilization ◽  
Health Care Resource ◽  
Low Risk ◽  
Opioid Use ◽  
Health Care Resource Utilization ◽  
Outpatient Visits ◽  
Chronic Opioid Use ◽  
Opioid Users

Objectives: Evaluate all-cause and endometriosis-related health care resource utilization and costs among newly diagnosed endometriosis patients with high-risk versus low-risk opioid use or patients with chronic versus non-chronic opioid use. Methods: A retrospective analysis of IBM MarketScan® Commercial Claims data from 2009 to 2018 was performed for females aged 18 to 49 with newly diagnosed endometriosis (International Classification of Diseases, Ninth Edition code: 617.xx; International Classification of Diseases, Tenth Edition code: N80.xx). Two sub-cohorts were identified: high-risk (⩾1 day with ⩾90 morphine milligram equivalents per day or ⩾1-day concomitant benzodiazepine use) or chronic opioid utilization (⩾90-day supply prescribed or ⩾10 opioid prescriptions). High-risk or chronic utilization was evaluated during the 12-month assessment period after the index date. Index date was the first opioid prescription within 12 months following endometriosis diagnosis. All outcomes were assessed over 12-month post-assessment period while adjusting for demographic and clinical characteristics. Results: Out of 61,019 patients identified, 18,239 had high-risk opioid use and 5001 chronic opioid use. Health care resource utilization drivers were outpatient visits and pharmacy fills, which were higher among high-risk versus low-risk patients (outpatient visits: 17.49 vs 15.51; pharmacy fills: 19.58 vs 16.88, p < 0.0001). Chronic opioid users had a higher number of outpatient visits (19.53 vs 15.00, p < 0.0001) and pharmacy fills (23.18 vs 16.43, p < 0.0001) compared to non-chronic opioid users. High-risk opioid users had significantly higher all-cause health care costs compared to low-risk opioid users (US$16,377 vs US$13,153; p < 0.0001). Chronic opioid users also had significantly higher all-cause health care costs compared to non-chronic opioid users (US$20,930 vs US$12,272; p < 0.0001). Similar patterns were observed among endometriosis-related HCRU, except pharmacy fills among high-risk and chronic sub-cohorts. Conclusion: This analysis demonstrates significantly higher all-cause and endometriosis-related health care resource utilization and total costs for high-risk opioid users compared to low-risk opioid users among newly diagnosed endometriosis patients over 1 year. Similar trends were observed for comparing chronic opioid users with non-chronic opioid users, except for endometriosis-related pharmacy fills and associated costs.

scholarly journals Prevalence of sleep-disordered breathing in opioid users with chronic pain: a systematic review and meta-analysis

2020 ◽  
Vol 16 (6) ◽  
pp. 961-969 ◽  
Author(s):  
Talha Mubashir ◽  
Mahesh Nagappa ◽  
Nilufar Esfahanian ◽  
Joseph Botros ◽  
Abdul A. Arif ◽  
...  
Keyword(s):  
Systematic Review ◽  
Chronic Pain ◽  
Sleep Disordered Breathing ◽  
Meta Analysis ◽  
Opioid Users ◽  
Disordered Breathing

Preoperative Chronic Opioid Use and Its Effects on Total Knee Arthroplasty Outcomes

2019 ◽  
Vol 33 (03) ◽  
pp. 306-313 ◽  
Author(s):  
Kelvin Kim ◽  
Kevin Chen ◽  
Afshin A. Anoushiravani ◽  
Mackenzie Roof ◽  
William J. Long ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Postoperative Period ◽  
Management Strategies ◽  
Opioid Use ◽  
Use Patterns ◽  
Usage Patterns ◽  
Total Knee ◽  
Chronic Opioid Use ◽  
Opioid Users

AbstractUnsafe opioid distribution remains a major concern among the total knee arthroplasty (TKA) population. Perioperative opioid use has been shown to be associated with poorer outcomes in patients undergoing TKA including longer length of stay (LOS) and discharges to extended care facilities. The current study aims to detail perioperative opioid use patterns and investigate the effects of preoperative chronic opioid use on perioperative quality outcomes in TKA patients. A retrospective analysis was performed on 338 consecutive TKAs conducted at our institution. Two cohorts were compared in this study—preoperative chronic opioid users and nonchronic opioid users. Opioid usage patterns and quality metrics were collected and analyzed over a 3-month preoperative and a 6-month postoperative period. Fifty-four (16.0%) preoperative chronic opioid users were identified out of the total 338 patients included in the study. Preoperative chronic opioid users experienced significantly longer LOS (2.9 vs 2.6 days; p = 0.026). Patients who remained persistent chronic users throughout the preoperative and postoperative stages demonstrated a significantly longer LOS (3.4 days vs 2.5 days; p = 0.017) compared with those who were no longer chronically using opioids by the 6 months postoperative period. By the 6 months postoperative time point, preoperative chronic users were consuming eight times the morphine-equivalents (mg/day) compared with nonchronic users (p < 0.001). Preoperative chronic opioid use was associated with substantially higher usage patterns throughout the postoperative stages. Such opioid use patterns were associated with longer LOS. Given that perioperative chronic opioid use has shown to negatively impact TKA outcomes, future studies refining current perioperative management strategies are warranted. This is a Level II, prognostic study.

scholarly journals Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service

2020 ◽  
Vol 45 (11) ◽  
pp. 847-852
Author(s):  
Michael J Buys ◽  
Kimberlee Bayless ◽  
Jennifer Romesser ◽  
Zachary Anderson ◽  
Shardool Patel ◽  
...  
Keyword(s):  
Salt Lake ◽  
Medical Center ◽  
Salt Lake City ◽  
Multivariable Logistic Regression Analysis ◽  
Opioid Use ◽  
Chronic Postsurgical Pain ◽  
Perioperative Pain Management ◽  
Lake City ◽  
Chronic Opioid Use ◽  
Opioid Users

BackgroundChronic postsurgical pain and opioid use is a problem among patients undergoing many types of surgical procedures. A multidisciplinary approach to perioperative pain management known as a transitional pain service (TPS) may lower these risks.MethodsThis retrospective cohort study was conducted at the Salt Lake City VA Medical Center to compare patients undergoing elective primary or revision total knee, hip, or shoulder replacement or rotator cuff repair in the year before (2017) and after (2018) implementation of a TPS. The primary outcome is the proportion of patients taking opioids 90 days after surgery. Secondary outcomes include new chronic opioid use (COU) after surgery as well as the proportion of previous chronic opioid users who stopped or decreased opioid use after surgery.ResultsAt 90 days after surgery, patients enrolled in TPS were significantly less likely to be taking opioids (13.4% TPS vs 27.3% pre-TPS; p=0.002). This relationship remained statistically significant in a multivariable logistic regression analysis, where the TPS group had 69% lower odds of postoperative COU compared with the preintervention group (OR: 0.31; 95% CI: 0.14 to 0.66; p=0.03). Opioid-naive patients enrolled in TPS were less likely to have new COU after surgery (0.7% TPS vs 8.4% pre-TPS; p=0.004). Further, patients enrolled in TPS with existing COU prior to surgery were more likely to reduce or completely stop opioid use after surgery (67.5% TPS vs 45.3% pre-TPS; p=0.037) as compared with pre-TPS.ConclusionsThese data suggest that a TPS is an effective strategy for preventing new COU and reducing overall opioid use following orthopedic joint procedures in a Veterans Affairs hospital.

A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors

Pain Medicine ◽  
2018 ◽  
Vol 20 (11) ◽  
pp. 2166-2178 ◽  
Author(s):  
Dalila R Veiga ◽  
Liliane Mendonça ◽  
Rute Sampaio ◽  
José M Castro-Lopes ◽  
Luís F Azevedo
Keyword(s):  
Chronic Pain ◽  
Clinical Outcomes ◽  
Opioid Therapy ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Chronic Noncancer Pain ◽  
Noncancer Pain ◽  
Opioid Users

Abstract Objectives Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes. Methods A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months. Results Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher pain interference scores. Conclusions This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.

scholarly journals Concomitant benzodiazepine and opioids decrease sleep apnoea risk in chronic pain patients

2020 ◽  
Vol 6 (3) ◽  
pp. 00093-2020
Author(s):  
Soodaba Mir ◽  
Jean Wong ◽  
Clodagh M. Ryan ◽  
Geoff Bellingham ◽  
Mandeep Singh ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Sleep Apnoea ◽  
Opioid Use ◽  
Arousal Index ◽  
Concurrent Use ◽  
Pain Clinics ◽  
Chronic Pain Patients ◽  
Negative Impacts ◽  
Opioid Users ◽  
Pain Patients

BackgroundThe concurrent use of sedating centrally acting drugs and opioids by chronic pain patients occurs routinely despite concerns of negative impacts on respiration during sleep. The effects of centrally acting drugs and opioids on sleep apnoea have not been well characterised. The objective of this study was to assess the effect of concomitant centrally acting drugs and opioids on the prevalence and severity of sleep apnoea in chronic pain patients.MethodsWe conducted a prospective cohort study at five chronic pain clinics. Each participant underwent an in-laboratory polysomnography and daily morphine milligram equivalents were calculated. Participants were grouped into centrally acting drugs and opioid users versus sole opioid users.ResultsOf the 332 consented participants, 204 underwent polysomnography and 120 (58.8%) had sleep apnoea (72% obstructive, 20% central, and 8% indeterminate sleep apnoea). Overall, 35% (71 of 204) were taking opioids alone, and 65% (133 of 204) were taking centrally acting drugs and opioids. There was a 69% decrease in the odds of having sleep apnoea (apnoea–hypopnoea index ≥5 events·h−1) in participants taking benzodiazepine/opioids versus sole opioid users (OR 0.31, 95% CI:0.12–0.80, p=0.015). Additionally, concomitant benzodiazepine/opioids versus sole opioid use was associated with a decrease in respiratory arousal index scores (p=0.03). Mean overnight SpO2 was approximately 1% lower in the concomitant benzodiazepine/opioids group versus sole opioid users (93.1±2.5 versus 94.4±2.1%, p=0.01).ConclusionIn chronic pain patients on opioids, administration of certain benzodiazepine sedatives induced a mild respiratory depression but paradoxically reduced sleep apnoea risk and severity by increasing the respiratory arousal threshold.

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