Background: Opioid use, abuse, and adverse consequences, including death, have escalated at an alarming rate since the 1990s. In an attempt to control opioid abuse, numerous regulations and guidelines for responsible opioid prescribing have been developed by various organizations. However, the US opioid epidemic is continuing and drug dose deaths tripled during 1999 to 2015. Recent data show a continuing increase in deaths due to natural and semisynthetic opioids, a decline in methadone deaths, and an explosive increase in the rates of deaths involving other opioids, specifically heroin and illicit synthetic fentanyl. Contrary to scientific evidence of efficacy and negative recommendations, a significant proportion of physicians and patients (92%) believe that opioids reduce pain and a smaller proportion (57%) report better quality of life. In preparation of the current guidelines, we have focused on the means to reduce the abuse and diversion of opioids without jeopardizing access for those patients suffering from non-cancer pain who have an appropriate medical indication for opioid use. Objectives: To provide guidance for the prescription of opioids for the management of chronic non-cancer pain, to develop a consistent philosophy among the many diverse groups with an interest in opioid use as to how appropriately prescribe opioids, to improve the treatment of chronic non-cancer pain and to reduce the likelihood of drug abuse and diversion. These guidelines are intended to provide a systematic and standardized approach to this complex and difficult arena of practice, while recognizing that every clinical situation is unique. Methods: The methodology utilized included the development of objectives and key questions. The methodology also utilized trustworthy standards, appropriate disclosures of conflicts of interest, as well as a panel of experts from various specialties and groups. The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed, with a best evidence synthesis of the available literature, and utilized grading for recommendation as described by the Agency for Healthcare Research and Quality (AHRQ).

Opioids have been and continue to be used for the treatment of chronic pain. Evidence supports the notion that opioids can be safely administered in patients with chronic pain without the development of addiction or chemical dependency. However, over the past several years, concerns have arisen with respect to administration of opioids for the treatment of chronic pain, particularly non-cancer pain. Many of these involve legal issues with respect to diversion and prescription opioid abuse. Amongst these, opioid induced hyperalgesia (OIH) is becoming more prevalent as the population receiving opioids for chronic pain increases. OIH is a recognized complication of opioid therapy. It is a pro-nocioceptive process which is related to, but different from, tolerance. This focused review will elaborate on the neurobiological mechanisms of OIH as well as summarize the pre-clinical and clinical studies supporting the existence of OIH. In particular, the role of the excitatory neurotransmitter, Nmethyl-D-aspartate appears to play a central, but not the only, role in OIH. Other mechanisms of OIH include the role of spinal dynorphins and descending facilitation from the rostral ventromedial medulla. The links between pain, tolerance, and OIH will be discussed with respect to their common neurobiology. Practical considerations for diagnosis and treatment for OIH will be discussed. It is crucial for the pain specialist to differentiate amongst clinically worsening pain, tolerance, and OIH since the treatment of these conditions differ. Tolerance is a necessary condition for OIH but the converse is not necessarily true. Office-based detoxification, reduction of opioid dose, opioid rotation, and the use of specific NMDA receptor antagonists are all viable treatment options for OIH. The role of sublingual buprenorphine appears to be an attractive, simple option for the treatment of OIH and is particularly advantageous for a busy interventional pain practice. Key words: Opioid hyperalgesia, hyperalgesia, tolerance, NMDA receptor antagonists, NMDA receptor induced hyperalgesia, spinal dynorphin induced hyperalgesia, descending facilitation and hyperalgesia, buprenorphine and hyperalgesia, opioid detoxification, officebased detoxification, complications of opioid therapy

Background: Use of opioids for chronic non-cancer pain (CNCP) has increased in recent years because this pain had been undertreated. There was also a simultaneous increase in misuse and abuse of opioids. Deaths due to such abuse and misuse also have risen as seen in the many reports published every day in local papers as well as in the medical literature. So, it is imperative that patients who are prescribed these medications be monitored for adherence so misuse and abuse can be curtailed and opioids are available to those who genuinely need them for chronic pain control. There are various screening tools available to monitor such adherence, and there is an abundance of literature about it in addiction and psychiatric medicine. There is, though, a paucity of such literature as applied to pain medicine. Objectives: Our objectives for this review were twofold. We wanted to identify which screening tools are available to monitor opioid adherence and we wanted to see if there were prospective comparative studies of these tools to identify a single best tool that can be applied to all chronic non-cancer pain patients managed with opioids. Study Design: We did a review of the current literature about monitoring of opioid adherence. We also looked at their use, validity, and comparative studies. Methods: We performed a literature search using PubMed, EMBASE, and the Cochrane library. The search was conducted using the terms opioids, non-cancer pain, monitoring, and adherence. The databases from 1996 to November 2010 were reviewed. The search included prospective and retrospective studies, review articles, and FDA records. Bibliographies and cross references were reviewed when deemed appropriate. Conclusion: We found 52 publications, of which 22 met the criteria to be included in this manuscript. We found only one study that was prospective, and compared the various screening tools that are available to monitor opioid adherence. In the majority of the studies the number treated was small. There was not a single screening tool that can be applied universally to all patients who are on opioid therapy for chronic non-cancer pain. Key words: Opioids, chronic pain, chronic non-cancer pain, opioid adherence, monitoring of opioid adherence, controlled substances, prescription monitoring programs, screening tools

Purpose: Computed tomography (CT)-guided percutaneous core biopsy of intrathoracic lesions is a well-established, minimally invasive procedure. However, clinically significant resultant pneumthoraces do occur. We investigated whether the use of a desiccated polyethylene glycol hydrogel lung plug prevents clinically significant pneumothoraces requiring chest tube placement and admission. Materials: A HIPPA compliant IRB approved retrospective study was performed. From 6/2013 to 5/2014, 168 consecutive patients were identified to have undergone CT-guided percutaneous core lung biopsy. 82 patients were treated with the plug device after biopsy, and the other 85 patients received standard post lung biopsy care. Chi square statistical analysis was performed. Additional stratification was evaluated, including lesion size, pleural to lesion distance, skin to lesion distance, presence of emphysema, and number of needle passes utilizing two-tailed t-test statistical analysis. Results: The pneumothorax rate for the standard post lung biopsy care was 39/85 (45.9%), compared to 30/82 (36.6%) for the sealant group, p¼0.091. 19/85 (22.4%) patients had clinically significant pneumothoraces with standard post biopsy care requiring chest tube placement and subsequent admission, and 9/82 (11%) patients developed clinically significant pneumothoraces with the plug device, p¼0.01. No significant differences were found in the rate of pneumothorax between the two groups isolating for lesion size (p¼0.14), pleura to lesion distance (p¼0.024), skin to lesion distance (p¼0.64), and number of needle passes (p¼0.08). 14/30 (47%) patients with emphysema developed pneumothorax after biopsy with the device compared to 13/23 (56.5%) without it, p¼0.05. 7/30 (23%) patients with emphysema who received the plug device after lung biopsy required chest tube placement and admission, compared to 11/23 (47.8%) without it, p¼0.0006. Conclusions: Patients who received the plug after CT-guided lung biopsy developed less clinically significant pneumothoraces requiring chest tube placement and admission accounting for lesion size, position, and emphysema, resulting in significant cost savings.

The prescription drug epidemic continues to plague the USA. In 2013, there were 16,235 opioid-related deaths in the USA. 83 % of these were considered unintentional. Although this represents a slight reduction from 2011 (17,000), the mortality rates continue to affect thousands of people, from relatives of patients to healthcare workers. Opioid-related deaths have a significant impact on the healthcare systemThere are a variety of strategies have been advocated to minimize risks of opioid-related deaths. Risk mitigation strategies that have been shown to minimize morbidity and to prevent deaths have included a detailed comprehensive evaluation, directed questionnaires, drug testing, and the accessing of prescription drug monitoring plans. However, not until recently has there been an effort to actually treat witnessed opioid overdose with pharmacologic agents known to reverse the respiratory depressant effects of opioids.Providing a reversal agent to an individual who has overdosed on opioids is time sensitive. Once one has overdosed and developed respiratory depression, it is necessary to either reverse the opioid or provide artificial ventilation to the patient in order to avoid irreversible brain injury. If a patient cannot be immediately ventilated, the only other option is to reverse the respiratory depressant effect of opioids with a pharmacologic reversal agent.It seems self-evident that providing an opioid reversal agent to patients and friends or family members, that can be safely administered, will improve the speed of the treatment and thus may improve the survival rate following a respiratory