I’ve been given opioids after surgery to take at home. What do I need to know?
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Opioids are commonly prescribed when you’re discharged from hospital after surgery to help manage pain at home.
These strong painkillers may have unwanted side effects or harms, such as constipation, drowsiness or the risk of dependence.
However, there are steps you can take to minimise those harms and use opioids more safely as you recover from surgery.
Which types of opioids are most common?
The most commonly prescribed opioids after surgery in Australia are oxycodone (brand names include Endone, OxyNorm) and tapentadol (Palexia).
In fact, about half of new oxycodone prescriptions in Australia occur after a recent hospital visit.
Most commonly, people will be given immediate-release opioids for their pain. These are quick-acting and are used to manage short-term pain.
Because they work quickly, their dose can be easily adjusted to manage current pain levels. Your doctor will provide instructions on how to adjust the dosage based on your pain levels.
Then there are slow-release opioids, which are specially formulated to slowly release the dose over about half to a full day. These may have “sustained-release”, “controlled-release” or “extended-release” on the box.
Slow-release formulations are primarily used for chronic or long-term pain. The slow-release form means the medicine does not have to be taken as often. However, it takes longer to have an effect compared with immediate-release, so it is not commonly used after surgery.
Controlling your pain after surgery is important. This allows you get up and start moving sooner, and recover faster. Moving around sooner after surgery prevents muscle wasting and harms associated with immobility, such as bed sores and blood clots.
Everyone’s pain levels and needs for pain medicines are different. Pain levels also decrease as your surgical wound heals, so you may need to take less of your medicine as you recover.
But there are also risks
As mentioned above, side effects of opioids include constipation and feeling drowsy or nauseous. The drowsiness can also make you more likely to fall over.
Opioids prescribed to manage pain at home after surgery are usually prescribed for short-term use.
But up to one in ten Australians still take them up to four months after surgery. One study found people didn’t know how to safely stop taking opioids.
Such long-term opioid use may lead to dependence and overdose. It can also reduce the medicine’s effectiveness. That’s because your body becomes used to the opioid and needs more of it to have the same effect.
Dependency and side effects are also more common with slow-release opioids than immediate-release opioids. This is because people are usually on slow-release opioids for longer.
Then there are concerns about “leftover” opioids. One study found 40% of participants were prescribed more than twice the amount they needed.
This results in unused opioids at home, which can be dangerous to the person and their family. Storing leftover opioids at home increases the risk of taking too much, sharing with others inappropriately, and using without doctor supervision.
How to mimimise the risks
Before using opioids, speak to your doctor or pharmacist about using over-the-counter pain medicines such as paracetamol or anti-inflammatories such as ibuprofen (for example, Nurofen, Brufen) or diclofenac (for example, Voltaren, Fenac).
These can be quite effective at controlling pain and will lessen your need for opioids. They can often be used instead of opioids, but in some cases a combination of both is needed.
Other techniques to manage pain include physiotherapy, exercise, heat packs or ice packs. Speak to your doctor or pharmacist to discuss which techniques would benefit you the most.
However, if you do need opioids, there are some ways to make sure you use them safely and effectively:
- ask for immediate-release rather than slow-release opioids to lower your risk of side effects
- do not drink alcohol or take sleeping tablets while on opioids. This can increase any drowsiness, and lead to reduced alertness and slower breathing
- as you may be at higher risk of falls, remove trip hazards from your home and make sure you can safely get up off the sofa or bed and to the bathroom or kitchen
- before starting opioids, have a plan in place with your doctor or pharmacist about how and when to stop taking them. Opioids after surgery are ideally taken at the lowest possible dose for the shortest length of time.
If you’re concerned about side effects
If you are concerned about side effects while taking opioids, speak to your pharmacist or doctor. Side effects include:
- constipation – your pharmacist will be able to give you lifestyle advice and recommend laxatives
- drowsiness – do not drive or operate heavy machinery. If you’re trying to stay awake during the day, but keep falling asleep, your dose may be too high and you should contact your doctor
- weakness and slowed breathing – this may be a sign of a more serious side effect such as respiratory depression which requires medical attention. Contact your doctor immediately.
If you’re having trouble stopping opioids
Talk to your doctor or pharmacist if you’re having trouble stopping opioids. They can give you alternatives to manage the pain and provide advice on gradually lowering your dose.
You may experience withdrawal effects, such as agitation, anxiety and insomnia, but your doctor and pharmacist can help you manage these.
How about leftover opioids?
After you have finished using opioids, take any leftovers to your local pharmacy to dispose of them safely, free of charge.
Do not share opioids with others and keep them away from others in the house who do not need them, as opioids can cause unintended harms if not used under the supervision of a medical professional. This could include accidental ingestion by children.
For more information, speak to your pharmacist or doctor. Choosing Wisely Australia also has free online information about managing pain and opioid medicines.
Katelyn Jauregui, PhD Candidate and Clinical Pharmacist, School of Pharmacy, Faculty of Medicine and Health, University of Sydney; Asad Patanwala, Professor, Sydney School of Pharmacy, University of Sydney; Jonathan Penm, Senior lecturer, School of Pharmacy, University of Sydney, and Shania Liu, Postdoctoral Research Fellow, Faculty of Medicine and Dentistry, University of Alberta
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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Overdosing on Chemo: A Common Gene Test Could Save Hundreds of Lives Each Year
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One January morning in 2021, Carol Rosen took a standard treatment for metastatic breast cancer. Three gruesome weeks later, she died in excruciating pain from the very drug meant to prolong her life.
Rosen, a 70-year-old retired schoolteacher, passed her final days in anguish, enduring severe diarrhea and nausea and terrible sores in her mouth that kept her from eating, drinking, and, eventually, speaking. Skin peeled off her body. Her kidneys and liver failed. “Your body burns from the inside out,” said Rosen’s daughter, Lindsay Murray, of Andover, Massachusetts.
Rosen was one of more than 275,000 cancer patients in the United States who are infused each year with fluorouracil, known as 5-FU, or, as in Rosen’s case, take a nearly identical drug in pill form called capecitabine. These common types of chemotherapy are no picnic for anyone, but for patients who are deficient in an enzyme that metabolizes the drugs, they can be torturous or deadly.
Those patients essentially overdose because the drugs stay in the body for hours rather than being quickly metabolized and excreted. The drugs kill an estimated 1 in 1,000 patients who take them — hundreds each year — and severely sicken or hospitalize 1 in 50. Doctors can test for the deficiency and get results within a week — and then either switch drugs or lower the dosage if patients have a genetic variant that carries risk.
Yet a recent survey found that only 3% of U.S. oncologists routinely order the tests before dosing patients with 5-FU or capecitabine. That’s because the most widely followed U.S. cancer treatment guidelines — issued by the National Comprehensive Cancer Network — don’t recommend preemptive testing.
The FDA added new warnings about the lethal risks of 5-FU to the drug’s label on March 21 following queries from KFF Health News about its policy. However, it did not require doctors to administer the test before prescribing the chemotherapy.
The agency, whose plan to expand its oversight of laboratory testing was the subject of a House hearing, also March 21, has said it could not endorse the 5-FU toxicity tests because it’s never reviewed them.
But the FDA at present does not review most diagnostic tests, said Daniel Hertz, an associate professor at the University of Michigan College of Pharmacy. For years, with other doctors and pharmacists, he has petitioned the FDA to put a black box warning on the drug’s label urging prescribers to test for the deficiency.
“FDA has responsibility to assure that drugs are used safely and effectively,” he said. The failure to warn, he said, “is an abdication of their responsibility.”
The update is “a small step in the right direction, but not the sea change we need,” he said.
Europe Ahead on Safety
British and European Union drug authorities have recommended the testing since 2020. A small but growing number of U.S. hospital systems, professional groups, and health advocates, including the American Cancer Society, also endorse routine testing. Most U.S. insurers, private and public, will cover the tests, which Medicare reimburses for $175, although tests may cost more depending on how many variants they screen for.
In its latest guidelines on colon cancer, the Cancer Network panel noted that not everyone with a risky gene variant gets sick from the drug, and that lower dosing for patients carrying such a variant could rob them of a cure or remission. Many doctors on the panel, including the University of Colorado oncologist Wells Messersmith, have said they have never witnessed a 5-FU death.
In European hospitals, the practice is to start patients with a half- or quarter-dose of 5-FU if tests show a patient is a poor metabolizer, then raise the dose if the patient responds well to the drug. Advocates for the approach say American oncology leaders are dragging their feet unnecessarily, and harming people in the process.
“I think it’s the intransigence of people sitting on these panels, the mindset of ‘We are oncologists, drugs are our tools, we don’t want to go looking for reasons not to use our tools,’” said Gabriel Brooks, an oncologist and researcher at the Dartmouth Cancer Center.
Oncologists are accustomed to chemotherapy’s toxicity and tend to have a “no pain, no gain” attitude, he said. 5-FU has been in use since the 1950s.
Yet “anybody who’s had a patient die like this will want to test everyone,” said Robert Diasio of the Mayo Clinic, who helped carry out major studies of the genetic deficiency in 1988.
Oncologists often deploy genetic tests to match tumors in cancer patients with the expensive drugs used to shrink them. But the same can’t always be said for gene tests aimed at improving safety, said Mark Fleury, policy director at the American Cancer Society’s Cancer Action Network.
When a test can show whether a new drug is appropriate, “there are a lot more forces aligned to ensure that testing is done,” he said. “The same stakeholders and forces are not involved” with a generic like 5-FU, first approved in 1962, and costing roughly $17 for a month’s treatment.
Oncology is not the only area in medicine in which scientific advances, many of them taxpayer-funded, lag in implementation. For instance, few cardiologists test patients before they go on Plavix, a brand name for the anti-blood-clotting agent clopidogrel, although it doesn’t prevent blood clots as it’s supposed to in a quarter of the 4 million Americans prescribed it each year. In 2021, the state of Hawaii won an $834 million judgment from drugmakers it accused of falsely advertising the drug as safe and effective for Native Hawaiians, more than half of whom lack the main enzyme to process clopidogrel.
The fluoropyrimidine enzyme deficiency numbers are smaller — and people with the deficiency aren’t at severe risk if they use topical cream forms of the drug for skin cancers. Yet even a single miserable, medically caused death was meaningful to the Dana-Farber Cancer Institute, where Carol Rosen was among more than 1,000 patients treated with fluoropyrimidine in 2021.
Her daughter was grief-stricken and furious after Rosen’s death. “I wanted to sue the hospital. I wanted to sue the oncologist,” Murray said. “But I realized that wasn’t what my mom would want.”
Instead, she wrote Dana-Farber’s chief quality officer, Joe Jacobson, urging routine testing. He responded the same day, and the hospital quickly adopted a testing system that now covers more than 90% of prospective fluoropyrimidine patients. About 50 patients with risky variants were detected in the first 10 months, Jacobson said.
Dana-Farber uses a Mayo Clinic test that searches for eight potentially dangerous variants of the relevant gene. Veterans Affairs hospitals use a 11-variant test, while most others check for only four variants.
Different Tests May Be Needed for Different Ancestries
The more variants a test screens for, the better the chance of finding rarer gene forms in ethnically diverse populations. For example, different variants are responsible for the worst deficiencies in people of African and European ancestry, respectively. There are tests that scan for hundreds of variants that might slow metabolism of the drug, but they take longer and cost more.
These are bitter facts for Scott Kapoor, a Toronto-area emergency room physician whose brother, Anil Kapoor, died in February 2023 of 5-FU poisoning.
Anil Kapoor was a well-known urologist and surgeon, an outgoing speaker, researcher, clinician, and irreverent friend whose funeral drew hundreds. His death at age 58, only weeks after he was diagnosed with stage 4 colon cancer, stunned and infuriated his family.
In Ontario, where Kapoor was treated, the health system had just begun testing for four gene variants discovered in studies of mostly European populations. Anil Kapoor and his siblings, the Canadian-born children of Indian immigrants, carry a gene form that’s apparently associated with South Asian ancestry.
Scott Kapoor supports broader testing for the defect — only about half of Toronto’s inhabitants are of European descent — and argues that an antidote to fluoropyrimidine poisoning, approved by the FDA in 2015, should be on hand. However, it works only for a few days after ingestion of the drug and definitive symptoms often take longer to emerge.
Most importantly, he said, patients must be aware of the risk. “You tell them, ‘I am going to give you a drug with a 1 in 1,000 chance of killing you. You can take this test. Most patients would be, ‘I want to get that test and I’ll pay for it,’ or they’d just say, ‘Cut the dose in half.’”
Alan Venook, the University of California-San Francisco oncologist who co-chairs the panel that sets guidelines for colorectal cancers at the National Comprehensive Cancer Network, has led resistance to mandatory testing because the answers provided by the test, in his view, are often murky and could lead to undertreatment.
“If one patient is not cured, then you giveth and you taketh away,” he said. “Maybe you took it away by not giving adequate treatment.”
Instead of testing and potentially cutting a first dose of curative therapy, “I err on the latter, acknowledging they will get sick,” he said. About 25 years ago, one of his patients died of 5-FU toxicity and “I regret that dearly,” he said. “But unhelpful information may lead us in the wrong direction.”
In September, seven months after his brother’s death, Kapoor was boarding a cruise ship on the Tyrrhenian Sea near Rome when he happened to meet a woman whose husband, Atlanta municipal judge Gary Markwell, had died the year before after taking a single 5-FU dose at age 77.
“I was like … that’s exactly what happened to my brother.”
Murray senses momentum toward mandatory testing. In 2022, the Oregon Health & Science University paid $1 million to settle a suit after an overdose death.
“What’s going to break that barrier is the lawsuits, and the big institutions like Dana-Farber who are implementing programs and seeing them succeed,” she said. “I think providers are going to feel kind of bullied into a corner. They’re going to continue to hear from families and they are going to have to do something about it.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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The Fiber Fueled Cookbook – by Dr. Will Bulsiewicz
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We’ve previously reviewed Dr. Bulsiewicz’s book “Fiber Fuelled” (which is great), but this one is more than just a cookbook with the previous book in mind. Indeed, this is even a great stand-alone book by itself, since it explains the core principles well enough already, and then adds to it.
It’s also about a lot more than just “please eat more fiber”, though. It looks at FODMAPs, purine, histamine intolerance, celiac disease, altered gallbladder function, acid reflux, and more.
He offers a five-part strategy:
Genesis (what is the etiology of your problem)
- Restrict (cut things out to address that first)
- Observe (keep a food/symptom diary)
- Work things back in (re-add potential triggers one by one, see how it goes)
- Train your gut (your microbiome does not exist in a vacuum, and communication is two-way)
- Holistic healing (beyond the gut itself, looking at other relevant factors and aiming for synergistic support)
As for the recipes themselves, there are more than a hundred of them and they are good, so no more “how can I possibly cook [favorite dish] without [removed ingredient]?”
Bottom line: if you’d like better gut health, this book is a top-tier option for fixing existing complaints, and enjoying plain-sailing henceforth.
Click here to check out The Fiber Fueled Cookbook; your gut will thank you later!
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The Recipe For Empowered Leadership – by Doug Meyer-Cuno
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This is not a “here’s how to become a leader, you young would-be Machiavelli”; it’s more a “so you’re in a leadership role; now what?” book. The book’s subtitle describes well its contents: “25 Ingredients For Creating Value & Empowering Others”
The book is written with the voice of experience, but without the ego-driven padding that accompanies many such books. Especially: any anecdotal illustrations are short and to-the-point, no chapter-long diversions here.
Which we love!
Equally helpful is where the author does spend a little more time and energy: on the “down to brass tacks” of how exactly to do various things.
In short: if instead of a lofty-minded book of vague idealized notions selling a pipedream, you’d rather have a manual of how to actually be a good leader when it comes down to it, this is the book for you.
Pick Up The Recipe For Empowered Leadership On Amazon Today!
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Osteoporosis & Exercises: Which To Do (And Which To Avoid)
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It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝Any idea about the latest research on the most effective exercises for osteoporosis?❞
While there isn’t much new of late in this regard, there is plenty of research!
First, what you might want to avoid:
- Sit-ups, and other exercises with a lot of repeated spinal flexion
- Running, and other high-impact exercises
- Skiing, horse-riding, and other activities with a high risk of falling
- Golf and tennis (both disproportionately likely to result in injuries to wrists, elbows, and knees)
Next, what you might want to bear in mind:
While in principle resistance training is good for building strong bones, good form becomes all the more important if you have osteoporosis, so consider working with a trainer if you’re not 100% certain you know what you’re doing:
Some of the best exercises for osteoporosis are isometric exercises:
5 Isometric Exercises for Osteoporosis (with textual explanations and illustrative GIFs)
You might also like this bone-strengthening exercise routine from corrective exercise specialist Kendra Fitzgerald:
Enjoy!
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Natto vs Tofu – Which is Healthier?
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Our Verdict
When comparing nattō to tofu, we picked the nattō.
Why?
In other words, in the comparison of fermented soy to fermented soy, we picked the fermented soy. But the relevant difference here is that nattō is fermented whole soybeans, while tofu is fermented soy milk of which the coagulated curds are then compressed into a block—meaning that the nattō is the one that has “more food per food”.
Looking at the macros, it’s therefore no surprise that nattō has a lot more fiber to go with its higher carb count; it also has slightly more protein. You may be wondering what tofu has more of, and the answer is: water.
In terms of vitamins, nattō has more of vitamins B2, B4, B6, C, E, K, and choline, while tofu has more of vitamins A, B3, and B9. So, a 7:3 win for nattō, even before considering that that vitamin C content of nattō is 65x more than what tofu has.
When it comes to minerals, nattō has more copper, iron, magnesium, manganese, potassium, and zinc, while tofu has more calcium, phosphorus, and selenium. So, a 6:3 win for nattō, and yes, the margins of difference are comparable (being 2–3x more for most of these minerals).
In short, both of these foods are great, but nattō is better.
Want to learn more?
You might like to read:
21% Stronger Bones in a Year at 62? Yes, It’s Possible (No Calcium Supplements Needed!)
Take care!
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How to Use Topical Estrogen Cream For Aging Skin
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Dr. Sam Ellis, dermatologist, explains:
Tackling the cause
Estrogen is important for very many aspects of health beyond the sexual aspects. When it comes to skin, a drop in estrogen (usually because of menopause) leads to changes like collagen loss, dryness, reduced elasticity, and slower wound healing. Applying estrogen creams to the skin can reverse these changes.
If your estrogen levels are already within normal pre-menopausal female ranges, by the way, there isn’t so much science to indicate its benefit when used topically. If you are already on systemic HRT (i.e., you take estrogen already to raise your blood estrogen levels and affect your body in its entirety), you may or may not gain extra benefits from the topical cream, depending on factors such as your estrogen dose, your route of administration, your cardiovascular health, and other factors.
For those with lower estrogen and not currently on HRT, you may be wondering: can topical estrogen cream affect systemic estrogen levels? And the answer is that it mostly depends on the dose. In other words: it’s definitely possible, but for most people it’s unlikely.
As ever, if thinking of taking up any hormonal treatment, do consult an endocrinologist and/or gynecologist, and if you have an increased breast cancer risk (for example genetically or prior history), then an oncologist too, just to be safe.
That sounds like a lot of scary things, but mostly it’s just to be on the safe side. The dose of estrogen is very low in topical creams, and even then, only a tiny amount is used per day.
For more on all of this, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
- “Why Does It Hurt When I Have Sex?” (And What To Do About It) ← because topical estrogen is not just for your face! Yes, you can use it down there too and it’s commonly prescribed for exactly this use.
- Hormones & Health, Beyond The Obvious
- The Hormone Therapy That Reduces Breast Cancer Risk & More
Take care!
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