Continuous Perioperative Sublingual Buprenorphine

Buprenorphine, a semisynthetic thebaine derivative, is a unique opioid, as it has activity at multiple receptors, including mu (partial agonist), kappa (antagonist), OLR-1 (agonist), and delta (antagonist). Because buprenorphine's pharmacology is relatively complex, misconceptions about its actions are common. Most other opioids act solely or predominately as full mu receptor agonists. Common practice at many institutions calls for the cessation of regular buprenorphine use 48–72 hours prior to surgery. This practice is based on three foundational theories that have come from scant data about the properties of buprenorphine: (1) that buprenorphine is only a partial mu agonist and therefore is not a potent analgesic; (2) because buprenorphine has a ceiling effect on respiratory depression, it also has a ceiling effect on analgesia; and (3) that buprenorphine acts as a “blockade” to the analgesic effects of other opiates when coadministered due to its strong binding affinity. However, several recent studies have called this practice into question. At our institution, we continue buprenorphine perioperatively, whenever possible, in order to provide superior pain control, discourage potentially problematic use and the more dangerous side effects of full mu agonist opiates, and avoid putting recovery at risk for those with opiate dependency issues. We present a unique case comparing two different outcomes for the same surgical course performed at two different times on the same chronic pain patient. These differences may be attributable to the variable of buprenorphine being present for one perioperative course and not the other. Pain control was easier to achieve, and functional recovery was greater when buprenorphine was maintained throughout the perioperative period when compared with using a full mu agonist opioid for chronic pain preoperatively. This is an outcome that much of the literature heretofore suggests would be unlikely. We review some aspects of buprenorphine's unique pharmacology that may explain why remaining on buprenorphine perioperatively may be preferable, which contradicts many practice guidelines.     

Cost-Effectiveness of Apixaban Versus Other New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation

Background

Apixaban (5 mg BID), dabigatran (available as 150 mg and 110 mg BID in Europe), and rivaroxaban (20 mg once daily) are 3 novel oral anticoagulants (NOACs) currently approved for stroke prevention in patients with atrial fibrillation (AF).

Objective

The objective of this study was to evaluate the cost-effectiveness of apixaban against other NOACs from the perspective of the United Kingdom National Health Services.

Methods

A Markov model was developed to evaluate the pharmacoeconomic impact of apixaban versus other NOACs over a lifetime. Pair-wise indirect treatment comparisons were conducted against other NOACs by using ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation), RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy), and ROCKET-AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) trial results for the following end points: ischemic stroke, hemorrhagic stroke, intracranial hemorrhage, other major bleeds, clinically relevant nonmajor bleeds, myocardial infarction, and treatment discontinuations. Outcomes were life-years, quality-adjusted life years gained, direct health care costs, and incremental cost-effectiveness ratios.

Results

Apixaban was projected to increase life expectancy versus other NOACs, including dabigatran (both doses) and rivaroxaban. A small increase in therapeutic management costs was observed with apixaban due to projected gains in life expectancy and lower discontinuation rates anticipated on apixaban versus other NOACs through lifetime. The estimated incremental cost-effectiveness ratio was £9611, £4497, and £5305 per quality-adjusted life-year gained with apixaban compared with dabigatran 150 mg BID, dabigatran 110 mg BID, and rivaroxaban 20 mg once daily, respectively. Sensitivity analyses indicated that results were robust over a wide range of inputs.

Conclusions

Although our analysis was limited by the absence of head-to-head trials, based on the indirect comparison data available, our model projects that apixaban may be a cost-effective alternative to dabigatran 150 mg BID, dabigatran 110 mg BID, and rivaroxaban 20 mg once daily for stroke prevention in AF patients from the perspective of the United Kingdom National Health Services.     

Cognitive-Behavioral Therapy for Migraine Headaches: A Minimal-Therapist-Contact Approach Versus a Clinic-Based Approach

The efficacy of a clinic-based cognitive-behavioral program for the treatment of common migraine was compared to the same approach using a minimal-therapist-contact format by means of a randomized controlled trial. Forty-eight subjects between 18 and 50 years of age completed the program. Following four weeks of recording headache activity, subjects were randomly assigned to a waiting list control condition or to one of the two treatment conditions. Treatment was followed by four weeks of recording of headache activity immediately posttreatment and again six months later. Multivariate analysis of variance indicated that there was a significant reduction in headache frequency, duration and peak intensity following treatment for both treated groups. These reductions were maintained at six months follow-up. Treatment for the minimal-contact group was significantly more cost-effective than for the clinic group.     

Effect of Sleeve Gastrectomy on Buprenorphine Pharmacokinetics: A Planned Case Observation

PurposeBariatric surgery may affect the absorption and metabolism of drugs by various mechanisms. We present a planned case observation of a patient treated with sublingual buprenorphine in an opioid maintenance treatment program, and the observed changes in buprenorphine pharmacokinetics following gastric sleeve surgery.MethodsSerial blood samples during a dose interval of 24 hours were obtained approximately 1 year preoperatively as well as 1 week, 1 month and 12 months postoperatively and key pharmacokinetic variables were calculated.FindingsThe systemic exposure of buprenorphine (AUC) was relatively stable from the preoperative sampling to 1 week postoperatively (−6.3%), but declined markedly at 1 month (−43%) and 12 months (−42%) postoperatively. The maximum concentration of buprenorphine almost doubled at 1 week postoperatively before returning to baseline values 1 month and 12 months postoperatively.ImplicationsThis case observation indicates that after sleeve gastrectomy, the systemic exposure of sublingual buprenorphine can decrease. Clinicians should be aware of the possibility of loss of effect and emerging abstinence symptoms following sleeve gastrectomy. We recommend monitoring the patient closely for abstinence symptoms postoperatively and considering measuring serum concentrations of buprenorphine pre- and postoperatively.     

A Real-world Cost-effectiveness Analysis of Sevelamer Versus Calcium Acetate in Korean Dialysis Patients

Purpose

Sevelamer, a noncalcium phosphate binder, has been shown to attenuate the progression of vascular calcification and improve survival in patients with chronic kidney disease undergoing dialysis compared with calcium-based binders. Using real-world data from a cohort study and the Health Insurance Review and Assessment Service database, we conducted a cost-effectiveness analysis comparing sevelamer with calcium acetate in dialysis patients from the perspective of the National Health Insurance Service in South Korea.

A Cost-Effectiveness Analysis of Parecoxib in the Management of Postoperative Pain in the Greek Health Care Setting

Background

Postoperative pain management represents a significant factor of morbidity and reduced quality of life for patients, as well as a situation that substantially increases perioperative costs. Available analgesia treatments improve patient outcomes and reduce resource use associated with pain management, although with varying costs and adverse effects.

Objectives

The aim of this analysis was to assess the costs and patient outcomes of parecoxib used in combination with opioids versus use of opioids alone (monotherapy) in the postoperative treatment of surgical patients in Greece.

Methods

A model comparing parecoxib plus opioid treatment versus opioids alone was developed that simulated the first 3 days postsurgery. Clinical efficacy was based on a Phase III, randomized, double-blind, clinical trial that also provided the frequencies of the occurrence of clinically meaningful events (CMEs) related to opioid use for both treatment arms. Resource use associated with each CME was elicited via strictly structured questionnaire-based interviews conducted by a panel of experts (surgeons and anesthesiologists), and costs were determined from the perspective of Social Insurance in Greece (2012 euros). Treatment effectiveness was calculated in summed pain intensity scores. A series of 1-way sensitivity analyses were conducted to check the robustness of the outcomes.

Results

Patients treated with parecoxib plus opioids had lower summed pain intensity scores (59.20 vs 80.80) and fewer CMEs (0.62 vs 1.04 per patient) compared with opioids alone for a 3-day period. This outcome led to a full offset of the excess cost of the addition of parecoxib and led to potential savings of €858 per patient compared with opioid use alone. Savings were mainly attributable to decreased CMEs due to reduced intensive care unit and general ward bed-days as well as to reduced physician and nurse time. Results were sensitive with regard to probabilities of occurrence or co-occurrence of CMEs (≥2 CMEs occurring simultaneously), although only to a small extent. Medication costs had a minimal impact on the results of the sensitivity analysis.

Conclusions

Parecoxib may be a useful addition to opioid treatment by improving postoperative analgesic management, reducing opioid-related adverse events, and lowering per-patient treatment costs.     

Cost-Effectiveness Analysis in the Nursing Literature, 1992–1996

Purpose: To review the recommendations by the U.S. Panel on Cost-Effectiveness in Health and Medicine (panel) for use in future nursing research. The review (a) provides a critique of the nursing cost-effectiveness and cost utility literature from the perspective of the recommendations set forth by the panel and other recognized authorities in cost-effectiveness analysis (CEA), (b) constructs an interdisciplinary framework to show the steps in the conduct of CEA, (c) makes the fechniques and major findings of nursing CEA studies available and understandable, and (d) offers guidelines for the incorporation of CEA into the evaluation of future nursing intervention and research.
Data Sources: Seven nursing studies published between 1992 and 1996 that compared two or more interventions for costs and outcomes.
Organizing Framework: For each study, the (a) perspective, fb) net costs, (c) net effect, (d) analysis of costs and effects, and (e) decision outcomes were analyzed.
Findings: If the panel's recommendations reflect the problems in the health care CEA literature in general, then on balance, the nursing CEA 1992–1996 studies are no more or less flawed than CEA studies in the health or medical care fields.
Conclusions: Methodologic guidelines and interdisciplinary strategies are needed to advance the progress of nursing cost-effectiveness research.     

3种方案治疗小儿支气管肺炎合并心肌损害的成本-效果分析

目的 比较分析1,6-二磷酸果糖注射液联合肌苷、1,6-二磷酸果糖注射液及磷酸肌酸3种方案治疗小儿支气管肺炎合并心肌损害的成本-效果。方法 将120例支气管肺炎合并心肌损害的患儿按随机数字表法分为果糖联合组、果糖组和磷酸肌酸组3组,每组40例。3组患儿均在接受相同基础治疗的基础上,果糖联合组给予1,6-二磷酸果糖（200 mg·kg^-1·d^-1）、肌苷注射液（0.2 g·d^-1）静脉滴注;果糖组给予1,6-二磷酸果糖注射液（200 mg·kg^-1·d^-1）、磷酸肌酸组给予磷酸肌酸注射液（0.5 g·d^-1）静脉滴注。3组均治疗7 d为1个疗程。观察3组患儿的治愈率,运用药物经济学原理对3种治疗方案进行成本-效果分析。结果 果糖联合组、果糖组及磷酸肌酸组的治愈率分别为87.5%、75.0%及92.5%;主药治疗成本分别为187.6元、186.2元、518.7元;主药成本效果比分别为2.14、2.48、5.61。结论 1,6-二磷酸果糖联合肌苷为治疗小儿支气管肺炎合并心肌损害的经济有效的治疗方案。     

A Buprenorphine Program Evaluation Before and During the COVID-19 Pandemic

This project evaluated the service delivery (ie, attendance rate) of a buprenorphine management treatment program and compared patient recovery-related information between service methods. This was a medical record review and cross-sectional comparison of pre–COVID-19 vs post onset of COVID-19 data. In the sample of 28 adults, mean attendance rates did not differ significantly before (99.46%) vs during the pandemic (96.13%; t = 1.92, P = .07). Patient participation in therapy before and during the pandemic did differ significantly (χ² = 1.98, P = .03). The use of telemental health services within a BMT program may be a viable option when normal in-person services are disrupted.     

A Cost-Utility Analysis of Pregabalin Versus Duloxetine for the Treatment of Painful Diabetic Neuropathy

ABSTRACT

The objective of the current study was to determine the cost-utility of pregabalin versus duloxetine for treating painful diabetic neuropathy (PDN) using a decision tree analysis. Literature searches identified clinical trials and real-world studies reporting the efficacy, tolerability, safety, adherence, opioid usage, health care utilization, and costs of pregabalin and duloxetine. The proportions of patients reported in the included studies were used to determine probabilities in the decision tree model. The base-case model included the Food and Drug Administration (FDA)-approved doses of pregabalin (300 mg/day) and duloxetine (60 mg/day), whereas “real-world” sensitivity analyses explored the effects over a range of doses (pregabalin 75–600 mg/day, duloxetine 20–120 mg/day). A 6-month time horizon and a US third-party payer perspective were chosen for the study. Outcomes from the model were expressed as cost per quality-adjusted life-year (QALY). In the base-case model, duloxetine cost less and was more effective than pregabalin (incremental cost ?$187, incremental effectiveness 0.011 QALYs). Results from two real-world sensitivity analyses indicated that duloxetine cost $16,300 and $20,667 more per additional QALY than pregabalin. Using a decision tree model that incorporated both clinical trial and real-world data, duloxetine was a more cost-effective option than pregabalin in the treatment of PDN from the perspective of third-party payers.     

Methadone, another cause of opioid-associated hearing loss: a case report

Background

Methadone has been used for many years in the clinical setting and has many well-described side effects. In recent years, the use of methadone and other opioids have been increasing throughout the United States (US), and presentations to US Emergency Departments (EDs) due to opioid use and abuse are increasing as well.

Objectives

As methadone and opioid use increases, ED physicians should be aware of infrequently seen side effects and toxicities associated with the use of these drugs.

Case Report

We report the case of a previously healthy 20-year-old man who presented with acute onset of bilateral hearing loss secondary to an unintentional methadone overdose. At follow-up, the patient’s hearing had returned to normal, with the only intervention being abstinence from methadone.

Conclusion

Although bilateral hearing loss is a rare toxic finding of opioid ingestion, given the prevalence of opioid use, this etiology should be considered in any patient presenting with this chief complaint.     

美沙酮维持治疗患者脱失情况的调查及对策

目的探讨美沙酮维持治疗患者门诊的脱失情况及干预对策。方法通过美沙酮药物维持治疗管理系统及门诊病历档案,对177例脱失人员采用上门随访、电话回访及社区调查等方式,对其脱失治疗的主要原因进行描述性分析。结果主动退出、自认为戒断、外出工作等是患者脱失的主要原因。结论选择合适的治疗剂量、开展健康教育、加强心理干预和多层面的沟通协调,是降低美沙酮药物维持治疗脱失率的有效方法。     

Radiofrequency Catheter Ablation Versus Cryoballoon Ablation in the Treatment of Paroxysmal Atrial Fibrillation: A Cost-effectiveness Analysis in China

Purpose

The aim of this study was to evaluate the cost-effectiveness of radiofrequency catheter ablation (RFCA) compared with cryoballoon (CB) ablation in the treatment of patients with paroxysmal atrial fibrillation (PAF) from the payer's perspective in China.

Clopidogrel Versus Aspirin for the Treatment of Acute Coronary Syndrome After a 12-Month Dual Antiplatelet Therapy: A Cost-effectiveness Analysis From China Payer's Perspective

Purpose

Monotherapy with either aspirin or clopidogrel is recommended for long-term use after discontinuation of dual-antiplatelet therapy (DAPT) for acute coronary syndrome (ACS) management after percutaneous coronary intervention (PCI). The present study is to evaluate the cost-effectiveness of clopidogrel versus aspirin after 12-month DAPT for patients with ACS who underwent PCI in China.

Cost-Effectiveness and Cost-Utility of Internet-Delivered Exposure Therapy for Fibromyalgia: Results From a Randomized,Controlled Trial

Fibromyalgia (FM) is a prevalent and debilitating chronic pain disorder associated with a substantial economic burden. Although there are several studies investigating the effectiveness of psychological treatments such as cognitive-behavioral therapy for FM, studies on cost-effectiveness are scarce. The aim of the present study was to investigate the cost-effectiveness of Internet-delivered exposure therapy (iExp) for FM. We used health economic data from a recently conducted randomized, controlled trial, where 140 participants were randomized to either iExp or a waitlist control (WLC) condition. Economic data were collected at pre-treatment, post-treatment, and at the 1-year follow-up. Treatment effectiveness in relation to costs were analyzed using both a societal perspective (including all direct and indirect costs) and a health care unit perspective (including only the direct treatment costs). Bootstrapped net benefit regression analyses were also conducted, comparing the difference in costs and effects between iExp and WLC, within different willingness-to-pay scenarios. Results showed that the incremental cost-effectiveness ratio was –$15,295, indicating that iExp was highly cost-effective as each successfully treated case (treatment responder) was associated with a substantial net reduction in costs. The robustness of the results was tested in 2 different sensitivity analyses, where iExp remained cost-effective, even in a willingness-to-pay-scenario of $0. We conclude that iExp is a cost-effective treatment that generates large societal cost savings.

Effects of Home-Based Versus Clinic-Based Rehabilitation Combining Mirror Therapy and Task-Specific Training for Patients With Stroke: A Randomized Crossover Trial

Objective

We investigated the treatment effects of a home-based rehabilitation program compared with clinic-based rehabilitation in patients with stroke.