The reviewed studies show an increasing risk of serious adverse health outcomes-including misuse, overdose, and death-associated with increasing opioid analgesic dose. Further research is needed to characterize the relationship between opioid analgesic dose and the risk of addiction and abuse. This analysis could inform policy actions for regulators and clinical decision making for providers.

Patients who incur unintentional dural punctures with large-gauge needles are surprisingly likely to continue to suffer chronic headaches. Treatment with an epidural blood patch does not enhance the risk of chronic back pain. The pathophysiology underlying these symptoms and the best treatment for this syndrome are not known.

Topics: Anesthetic ComplicationsU nintentional dural puncture during epidural anesthesia occurs in 0.4% to 6% of patients and can lead to acute severe positional headache in B70% to 80% of these parturients. The headaches are often self-limited or are treated with an epidural blood patch (EBP) or conservative therapy. Because long-term sequelae have not been investigated, this case-control study was performed to determine the incidence of and risk factors for chronic headache and chronic back pain in women who had an unintentional dural puncture compared with matched controls.Patients who were included had a known dural puncture with a 17-G Tuohy needle. Of 65 index cases, 40 patients met inclusion criteria and were matched to a control patient who had the same type of neuraxial anesthesia and delivery but no dural puncture, delivered within 1 week of the index patient, and was closest in height, age, and weight. At 12 to 24 months after the dural puncture, the patients and matched controls were contacted by telephone. Two validated questionnaires were used to assess headache and back pain symptoms. The questionnaire for evaluating headaches was derived from the Chronic Pain Grade Questionnaire, created to measure chronic pain for severity, persistence, and disability. The questionnaire for chronic back pain was derived from the Low Back Pain Rating Scale, which separately rates pain, disability, and physical impairment with pain scales.The average time between delivery and administration of the questionnaires was 18 ± 5.6 months and was similar in study patients and controls. Thirty-three patients (83%) who had an unintentional dural puncture reported an acute postdural puncture headache (PDPH) during hospitalization. Among the index cases, those with a higher body mass index and body weight were more likely to develop acute PDPH compared with patients with a lower body mass index and body weight (P = 0.023 and P = 0.022 for the comparisons, respectively). No other significant associations were found between demographic variables and the incidence of acute headache. EBP was used to treat acute PDPH in 24 of the 33 patients. The average time to resolution of the acute headache was 2.8 ± 2.8 days. At 18 months after delivery, 11 of 40 parturients (28%) who had dural puncture had chronic

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