The fact that opioids constrict the pupil is known to healthcare workers and the lay public. In this chapter, the mechanism of this effect is discussed and how an understanding of this mechanism can be useful to the clinician. There are many parameters that can be measured from the pupil with portable pupillometers. The measure that most closely predicts the onset of severe respiratory depression is pupillary unrest in ambient light (PUAL). This measure is compared to pupil size and pupillary constriction amplitude as a measure of toxic levels of opioids.

Trained in addictions in Edinburgh, perhaps an easier specialty given personal experience. Then obtained a consultant post in the Scottish Borders, and a year later one in Edinburgh.

Managing oral pain is a daily task for dental practitioners. Understanding the type of pain, accurately diagnosing the cause and being able to choose the most appropriate drug regimen (if required) is a fundamental skill for all dentists. This chapter describes the medicines commonly used for pain management in dentistry, their mechanism of action, appropriate doses, adverse effects, common drug interactions and their place in therapy.

A class of analgesics structurally similar to the natural alkaloids derived from the resin of the opium poppy. Natural alkaloids are known as opiates and they include morphine and other similarly structured drugs, such as codeine, hydrocodone, and oxycodone. Synthetic derivates include hydromorphone, fentanyl, and heroin, among others (3). Three opiate receptors – µ, ?, and d – were found predominantly in the CNS. Most analgesic effect of opioids is mediated by the µ receptor. Decrease presynaptic calcium influx and increase postsynaptic potassium efflux, leading to inhibition of neuronal firing and neurotransmitter release.

Sickle cell crisis is a term used to capture myriad acute manifestations of sickle cell disease (SCD). Underlying pathophysiology is due to polymerization of HbS, sickling of erythrocytes, and microvascular occlusion and injury. Sickle cell disease and related pain is common in the US, especially among black Americans. Routine newborn screening picks up the majority of cases and helps guide prevention and treatment of acute pain crises early on. The mainstay of treating vaso-occlusive crises is analgesia and is often achieved with NSAIDs, opioids, or combination therapy.

Pain is quite common in patients with cancer, especially those with metastaticdisease. Oncologic pain implications: decreased quality of life, can be an indicator of the progression of a tumor, and psychosocial effects such as anxiety and depression. Cancer pain is divided into acute form and chronic form. Advances have been made in both oncology and pain management. The application of pain management into clinical oncology is still a work in progress. Pain management that is sufficient and consistent is difficult in cancer patients. Cancer pain affects a large portion of those with cancerous disease processes. Metastatic disease tends to be associated with more pain. Pain can come from the cancer itself or from the treatment. More work is needed to standardize the evaluation and treatment of cancer pain. Further work is needed to take into account each individual’s unique circumstance.

Chapter 8 contains an in-depth case study of the opioid mass tort litigation in federal and state courts. It describes the inception and development of the opioid drug crisis and how the opioid crisis affected state and local municipalities, in requiring additional expenditures of money to provide medical, policing, and various social services to communities affected by the crisis. The chapter describes the initiation of opiod litigation, the hundreds of lawsuit, consolidation and transfer of all the opioid litigation into a federal MDL under Judge Dan Polsters supervision in the Northern District of Ohio. The chapter chronicles the management and litigation in the federal MDL proceedings and Judge Polsters approval of a public nuisance claim which actually went to trial. The chapter narrates the resulting, cascading opioid settlements with opioid manufacturers, distributors, and pharmacies concurrent with and after the MDL bellwether public nuisance trial. The chapter further chronicles the fate of opioid public nuisance in state courts, with a notable rejection of a public nuisance claim by the Oklahoma Supreme Court. The chapter ends by documenting the many state court opioid settlements during 2021-2022.

Methadone, a medication used to treat opioid use disorder (OUD), has resulted in decreased opioid overdose deaths, while increasing treatment retention and lowering the rates of infectious diseases associated with intravenous substance use. Access to methadone is limited in the United States due to federal laws and regulatory policies that are rooted in racist “criminal justice approaches” to substance use. Unlike other controlled prescription medications, methadone is subject to restrictions on the number of doses a person can receive at any given time, known as “take-home doses” (THDs). Federal regulations mandate that patients receiving methadone must travel to government-certified clinics known as opioid treatment programs (OTPs) almost daily to receive medication for at least the first 90 days of treatment. Due to the need to practice social distancing during COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) – the regulatory agency which sets the accreditation standards for OTPs – released a federal waiver in March 2020 granting significant exemptions to THD regulations. Thousands of patients have now received increased THDs, a historic and impactful shift in care for people with OUD. This chapter begins with an overview of the regulation of methadone for OUD before COVID-19. Next, it reviews the evidence for regulatory reform alongside our analysis of qualitative data we collected during COVID-19 that reflects patients’ experiences with increased access to THDs. Based on the findings of our qualitative study and the empirical literature, we conclude the chapter with recommendations for modifications of THD regulations.

Patients with various ailments present to hospital with pain. This chapter defines pain and explores the assessment and the fundamental pathophysiology behind this common symptom. Pain can be managed using various pharmacological and non-pharmacological methods including interventional techniques. This chapter also explains the principles of management of acute pain in chronic pain patients on long term opioids and the problem of chronic post-surgical pain.