One of the latest clinical studies found that intraoperative use of methadone could significantly reduce the need for post-tonsillectomy opioid use in children. Moreover, the study found that methadone was more effective than fentanyl in reducing the requirement for opioids.

In the US, more than half a million tonsillectomies are performed each year. Many of these patients require prolonged use of opioids for pain control in the post-operative phase. Moreover, there are no strict guidelines or consensus regarding opioid use in these patients. Hence, researchers carried out a study to understand how to reduce the use of opioids in these patients.

They were especially interested in exploring the role of methadone as an opioid-sparing therapy. Methadone is an opioid with an excellent safety profile. This drug is also used to manage opioid use disorder. However, It can also help reduce pain. What is good about methadone is its long half-life of 1 to 2 days. It means that a single dose of this drug can provide prolonged pain relief. Researchers also wanted to see how methadone works compared to short-duration opioids like fentanyl, which has a half-life of a few hours only.

In this new clinical study, researchers wanted to check the hypothesis that using methadone will not just provide good pain relief but it will also reduce the need for opioid use. They also wanted to check if methadone was superior to short-action opioids like fentanyl.

This study was done in children 3 to 17 years old undergoing tonsillectomy. They were either given methadone intravenously (0.1 mg/kg or 0.15 mg/kg) or short-acting opioid fentanyl. They compared the effectiveness of perioperative use of these opioids with control subjects. They also assessed how well these approaches worked for pain control.

In the study, researchers found that intraoperative use of methadone could reduce the need for oral morphine in the post-operative phase significantly. Further, they also found that a methadone dosage of 0.15 mg/kg was most effective for pain control and reducing the need for oral opioids in the post-operative phase. Methadone was much more effective compared to fentanyl in reducing the need for opioids after tonsillectomy.

Methadone was as good as fentanyl for pain control, and it was well-tolerated. It could reduce the need for opioids. Thus, a single dose of methadone used intraoperatively was better than multiple dosages of fentanyl.

There could be many reasons why methadone was superior. But, perhaps one of the most significant reasons for these findings is that methadone has an exceptionally long half-life. It means that even a single dose of methadone can provide prolonged pain relief, something not characteristic of fentanyl.

Of course, this was still an exploratory study. Nonetheless, this study found that methadone was significantly better than fentanyl, and it could reduce opioid use in the post-operative phase in a pediatric population.

In recent years, there has been increased interest in methadone’s role in pain management. It appears to be good for controlling various pain and is also among the safer opioids.

Tonsillectomy is among the most painful surgeries in children, and these findings provide hope for better pain control.

At present, methadone isn’t routinely used for pain control in pediatrics. It is uncommon to use methadone to control other kinds of pain. There is a need for more extensive trials to understand the role of this opioid in pain management.

Source:

Einhorn, L. M., Hoang, J., La, J. O., & Kharasch, E. D. (2024). Single-dose Intraoperative Methadone for Pain Management in Pediatric Tonsillectomy: A Randomized Double-blind Clinical Trial. Anesthesiology, 141(3), 463–474. https://doi.org/10.1097/ALN.0000000000005031

One of the most extensive retrospective studies found that co-prescription of stimulants and opioids may be fueling a twin epidemic of overdose. Those prescribed stimulants require opioids at higher dosages for pain control and vice-versa.

Although opioid prescription rates have declined in recent years in the US, but opioid overdose-related deaths are still very common. There are several reasons for that, including a poor understanding of the opioid epidemic.

Opioids are still one of the most effective painkillers, especially for those living with chronic pain. For many patients, nothing seems to work except opioids.

When trying to understand opioid use disorder (OUD) and opioid overdose-related deaths, it is vital to understand that most patients are taking multiple medications. It also means that certain drugs might increase opioid overdose risk. Now, one of the new and most extensive studies to date shows that those who are prescribed stimulants to manage ADHD along with opioids are at a much greater opioid overdose risk.

This new study was published in The Lancet Regional Health – Americas. It looked into health claims of 3 million US patients who were prescribed stimulants and opioids. They believed that prescribing these drugs together may increase the risk of a twin epidemic.

Both of these drugs act very differently on the brain and have an opposing action. However, in some instances, doctors need to prescribe these drugs together. Stimulants are mainly used to manage ADHD, which is a diagnosis for a lifetime, often requiring prolonged or continuous treatment with these drugs. However, many of those living with ADHD may also develop chronic pain and require opioids to manage their pain. But, since these drugs have quite an opposing action, those taking stimulants may require higher dosages of opioids for pain control and vice-versa. That is why prescribing them together may increase the risk of a twin epidemic.

In the study, researchers analyzed 96 million opioid prescriptions and a total of 2.9 million patients. So, researchers analyzed a massive dataset, making their study quite robust.

Of course, things are not that simple, as there are many different kinds of opioids, like codeine, hydrocodone, methadone, oxycodone, morphine, and others. So, researchers had to calculate or standardize things using morphine milligram equivalents (MME) of opioid use by those patients. Hence, they had to use lots of computation.

In the study, researchers found that 160,243 or 5.5% of those on opioids were also prescribed stimulants. They found that those who were prescribed stimulants needed higher dosages of opioids. Further, using stimulants along with opioids means that doctors often need to increase opioid dosage. Additionally, individuals prescribed these drugs together were also more likely to be living with other mental health issues like anxiety and depression along with ADHD.

Nonetheless, even when correcting for these confounding factors, researchers found that prescribing stimulants to those taking opioids resulted in opioid dose escalation. This means that if doctors prescribe stimulants to those taking opioids, they are required to increase opioid dosage for adequate pain control.

So, this study suggests that the use of stimulants may increase the risk of opioid overdose and vice versa. This study could identify one of the reasons behind this twin epidemic.

Co-prescription of these drugs not only increasesthe risk of drug overdose but also increases the risk of mental health issues and cardiovascular events.

Source:

Lee, S., Song, W., Bates, D. W., Urman, R. D., & Zhang, P. (2025). The recent trend of twin epidemic in the United States: A 10-year longitudinal cohort study of co-prescriptions of opioids and stimulants. The Lancet Regional Health – Americas, 44. https://doi.org/10.1016/j.lana.2025.101030

A new systemic review suggests that ketorolac might be quite effective for post-surgical pain control, like those in spine surgery patients. It may significantly reduce the need for opioids in these patients. However, researchers also noticed that most studies using ketorolac have small sample sizes and thus need more extensive studies.

Non-steroidal anti-inflammatory drugs (NSAIDs) have been around for long. They are the most extensively used painkillers globally. They help reduce not only pain but also inflammation and fever. Aspirin and Ibuprofen are examples of some of the commonly used NSAIDs that are even available without prescription in many nations.

There are tens of NSAIDs, and they differ in potency, duration of action, and safety profile. What makes these drugs great is that most of them have an excellent safety profile. That is why many drugs from this class are even sold without a prescription.

These drugs are quite good for mild to moderate pain. Some are better at reducing inflammation, while others are better at suppressing pain. So, there is a significant difference between various NSAIDs. Some of the NSAIDs are even good for severe pain or chronic pain. Thus, there is a need to fully understand the difference between various NSAIDs. Moreover, these drugs can sometimes replace opioids, or they reduce their requirement significantly – something well-known to doctors.

However, despite their proven safety record, it is unfortunate that there is insufficient research into their use in different clinical conditions. Though there are many small clinical studies, robust data/findings from large clinical trials are often missing. This is the reason why doctors are hesitant to use them for certain pain conditions.

Ketorolac is one such NSAID. It is known to be quite good for pain relief, especially for acute pains like postoperative pain. It may significantly reduce the requirement for opioids.

A systemic review was recently published to explore its efficacy in managing pain after spine surgery. Studies suggest that whether used alone or in combination with other painkillers, ketorolac may benefit significantly those undergoing lumbar spine surgery. Moreover, ketorolac may be used along with opioids or other painkillers.

In the new study, researchers could identify 13 studies on the topic. In these studies, ketorolac was used either alone or along with medications like bupivacaine, morphine, epinephrine,acetaminophen, and pregabalin.

Researchers found that ketorolac was significantly better than placebo for pain control within six to 12 hours and 12 to 24 hours after spinal surgery. Further, they found it was particularly good for suppressing pain within the first six hours. However, its ability to reduce pain was less pronounced after six hours. So, after six hours, its effects started declining.

Additionally, ketorolac use could significantly reduce postoperative morphine requirements. Which means it could reduce the need for opioids.

Not only that but due to pain reduction and probably due to its anti-inflammatory properties, it could also reduce hospital stay duration a bit.

However, issues like nausea, vomiting, and constipation were as common in the ketorolac group as in the control group. Further, researchers cautioned that in some individuals, ketorolac may cause severe side effects like acute kidney injury, gastric bleeding, and anaphylaxis, something that must be kept in mind when using it for pain management.

Although study authors noted that ketorolac appears to be good for post-surgical pain control, they also noted that most studies on the topic had small sample sizes. Thus, there is a need for larger clinical trials to define its role in pain management in such patients.

Source:

Guan, J., Feng, N., Yang, K., Abudouaini, H., & Liu, P. (2024). The efficacy and safety of ketorolac for postoperative pain management in lumbar spine surgery: A meta-analysis of randomized controlled trials. Systematic Reviews, 13(1), 275. https://doi.org/10.1186/s13643-024-02685-z

Summary: Some states in the US allow NPs to prescribe buprenorphine for OUD. A new study comparing outcomes from states where NPs are allowed to prescribe opioids to states where they are not shows that this did not result in an increase in high-risk prescriptions or a significant change in health outcomes.

Few states in the US have allowed nurse practitioners (NPs) to prescribe opioids to curb opioid epidemics. However, one of the latest studies shows that this did not result in better outcomes.

Not all, but few US states have allowed NPs to prescribe buprenorphine for managing opioid use disorder (OUD). The reason behind such a decision was to improve access to treatment. However, this did not result in better outcomes.

The findings of this new study were published in the JAMA Health Forum. This study compared the outcomes in states where NPs can prescribe opioids with states where they are not allowed to do so. In the study, experts did not find any statistically significant benefit.

While giving such rights to NPs may sound like a good idea, but not everyone agrees with this. Many believe that NPs are not just trained enough to handle complex OUD cases. Moreover, managing OUD is not just merely about prescribing buprenorphine. Managing OUD is quite challenging, requiring a deeper understanding of the topic.

On the other hand, supporters of these changes say that treatment access remains one of the most significant hurdles.

In this new study, researchers compared opioid prescription and outcomes by comparing the data from six states where NPs can prescribe opioids with 10 neighboring states where NPs are not allowed to prescribe opioids. This was a study done between January 2012 to December 2021. Researchers used insurance claims data from Blue Cross and Blue Shield Plans for the study. They analyzed the data of adults aged 18 to 64 years of age.

They found that in states that allowed NPs to prescribe, those did not have similar kind of demographic characteristics and opioid prescription patterns.

However, when researchers say that they did not see any change in opioid prescription to high-risk individuals, it also means that they did not find any issues with NPs prescribing these drugs. This did not increase any risk, and this did not result in overprescription or prescribing to wrongly selected patients.

Despite declining opioid prescriptions for chronic pain management, OUD remains one of the most significant problems. Prescription opioids might have played some role in this epidemic, but there are many other drivers of this epidemic. This explains why the problem continues to be relevant. Hence, many health experts have even challenged the need for reducing opioid prescriptions for chronic pain, as it might be causing more harm than good.

Thus, to manage OUD, it is essential to improve treatment access. There are a few ways of improving this access to OUD treatment, like allowing NPs to prescribe certain opioids or allowing the prescription of specific opioids through telemedicine platforms.

These new approaches to enhancing treatment access might not be making significant improvements, but studies also show that these regulatory changes are also not causing harm. Improve access to drugs like buprenorphine did not result in an increase in high-risk prescriptions.

Thus, it would be correct to say that although these new approaches might not significantly improve OUD treatment, they are not causing harm.

Source:

Cusimano, L. D., & Maestas, N. (2024). High-Risk Opioid Prescribing and Nurse Practitioner Independence. JAMA Health Forum, 5(12), e244544. https://doi.org/10.1001/jamahealthforum.2024.4544