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Vest BM, Hoopsick RA, Homish DL, Homish GG. Lower levels of bodily pain increase risk for non-medical use of prescription drugs among current US reserve soldiers. Addict Behav 2020; 108:106443. [PMID: 32315933 DOI: 10.1016/j.addbeh.2020.106443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/09/2020] [Accepted: 04/13/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Military populations have a higher prevalence of pain compared to their civilian counterparts and are also at increased risk for substance use. The link between clinically significant pain and substance use has been established, but it is unclear if lower levels of pain relate to risk. The goal of this inquiry was to determine if level of bodily pain was associated with increased risk of current substance use over time among a community sample of U.S. Army Reserve/National Guard (USAR/NG) soldiers. METHODS Data were drawn from an ongoing study of USAR/NG soldiers. We used generalized estimating equations to examine the longitudinal impact of baseline bodily pain level (modeled in standard deviations from the mean pain score) on current drug use (illicit and non-medical use of prescription drugs [NMUPD]) among soldiers (n = 387) over two-years. Final models controlled for baseline post-traumatic stress disorder (PTSD), anxiety, and depression symptomatology, history of deployment (yes/no), years of military service, and substance use norms. RESULTS Bodily pain was longitudinally associated with increased odds of current NMUPD (AOR: 1.49, p < .05), but not with the current use of illicit drugs (AOR: 1.18, p > .05), controlling for symptoms of PTSD, anxiety, depression, deployment, years of service, and substance use norms. CONCLUSIONS Overall, our findings indicate that bodily pain is longitudinally associated with NMUPD among male soldiers, but not with illicit drugs. Significantly, our results stem from a non-clinical sample of soldiers with overall lower levels of pain. This indicates that pain may be important, even at lower levels, and underscores the importance of early non-pharmacologic interventions for pain.
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Affiliation(s)
- Bonnie M Vest
- Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.
| | - Rachel A Hoopsick
- Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA; Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - D Lynn Homish
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Gregory G Homish
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA
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Wright P, Walsh Z, Margolese S, Sanchez T, Arlt S, Belle-Isle L, St Pierre M, Bell A, Daeninck P, Gagnon M, Lacasse G, MacCallum C, Mandarino E, Yale J, O'Hara J, Costiniuk C. Canadian clinical practice guidelines for the use of plant-based cannabis and cannabinoid-based products in the management of chronic non-cancer pain and co-occurring conditions: protocol for a systematic literature review. BMJ Open 2020; 10:e036114. [PMID: 32448797 PMCID: PMC7253000 DOI: 10.1136/bmjopen-2019-036114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Chronic pain and co-occurring disorders, such as sleep disorders, anxiety, depression, post-traumatic stress disorder and substance use disorders, are among the most common conditions for which cannabis and cannabinoid-based products derived from the cannabis plant (CBP) are used for therapeutic purposes. However, healthcare providers report that they lack sufficient information on the risks, benefits and appropriate use of cannabis and CBP derived from the cannabis plant for therapeutic purposes. METHODS AND ANALYSIS We will conduct a systematic review of studies investigating the use of cannabis and CBP derived from the cannabis plant for the treatment of chronic pain and co-occurring conditions. Randomised controlled trials, meta-analyses and observational studies will be prioritised. We will exclude reviews of cannabinoid mechanisms of actions, commentary articles and narrative reviews. The primary outcome of interest will be efficacy in relieving chronic pain. Secondary outcomes will be efficacy in ameliorating conditions such as sleep disorders, anxiety, depression, post-traumatic stress disorder and substance use disorders. We will search electronic bibliographic databases including Academic Search Complete, Cochrane Database of Systematic Reviews, Evidence based Medicine Reviewes, OVID Medline, PsychINFO, PubMed, CINAHL and Web of Science. Two reviewers will conduct screening and data collection independently. Study level of bias will be assessed using the Cochrane Risk of Bias Assessment Tool for randomised controlled trials and non-randomised studies. Narrative analysis will be utilised to interpret the data. ETHICS AND DISSEMINATION The results of this systematic review will inform guideline development for the use of cannabis and CBP derived from the cannabis plant in the management of chronic pain and co-occurring conditions. Areas requiring further study will also be highlighted. PROSPERO REGISTRATION NUMBER CRD42020135886.
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Affiliation(s)
| | - Zach Walsh
- Department of Psychology, University of British Columbia, Kelowna, British Columbia, Canada
| | - Shari Margolese
- Canadian HIV Trials Network Community Advisory Board, Vancouver, British Columbia, Canada
| | - Tatiana Sanchez
- Department of Psychology, University of British Columbia, Kelowna, British Columbia, Canada
| | - Stephanie Arlt
- Canadian Institute for Substance Use Research,University of Victoria, Victoria, British Columbia, Canada
| | | | - Michelle St Pierre
- Department of Psychology, University of British Columbia, Kelowna, British Columbia, Canada
| | - Alan Bell
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Daeninck
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marilou Gagnon
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | | | - Caroline MacCallum
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Enrico Mandarino
- Community Advisory, Canadian Institutes of Health Research Canadian HIV Trials Network, Vancouver, British Columbia, Canada
- MJardin Canada, Toronto, Ontario, Canada
| | - Janet Yale
- Arthritis Society of Canada, Toronto, Ontario, Canada
| | - James O'Hara
- Canadians for Fair Access to Medical Marijuana, Toronto, Ontario, Canada
| | - Cecilia Costiniuk
- Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
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Clinician Response to Aberrant Urine Drug Test Results of Patients Prescribed Opioid Therapy for Chronic Pain. Clin J Pain 2020; 35:1-6. [PMID: 30222612 DOI: 10.1097/ajp.0000000000000652] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Urine drug testing (UDT) is recommended for patients who are prescribed opioid medications, but little is known about the various strategies clinicians use to respond to aberrant UDT results. We sought to examine changes in opioid prescribing and implementation of other risk reduction activities following an aberrant UDT. METHODS In a national cohort of Veterans Affairs patients with new initiations of opioid therapy through 2013, we identified a random sample of 100 patients who had aberrant positive UDTs (results positive for nonprescribed/illicit substance), 100 who had aberrant negative UDTs (results negative for prescribed opioid), and 100 who had expected UDT results. We examined medical record data for opioid prescribing changes and risk reduction strategies in the 12 months following UDT. RESULTS Following an aberrant UDT, 17.5% of clinicians documented planning to discontinue or change the opioid dose and 52.5% initiated another strategy to reduce opioid-related risk. In multivariate analyses, variables associated with a planned change in opioid prescription status were having an aberrant positive UDT (odds ratio [OR], 30.77; 95% confidence interval [CI], 5.92-160.10) and higher prescription opioid dose (OR, 1.01; 95% CI, 1.01-1.02). The only variable associated with implementation of other risk reduction activities was having an aberrant positive UDT (OR, 0.29; 95% CI, 0.16-0.55). DISCUSSION The majority of clinicians enacted some type of opioid prescribing or other change to reduce risk following an aberrant UDT, and the action depended on whether the result was an aberrant positive or aberrant negative UDT. Experimental studies are needed to develop and test strategies for managing aberrant UDT results.
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Higgins C, Smith BH, Matthews K. Comparison of psychiatric comorbidity in treatment-seeking, opioid-dependent patients with versus without chronic pain. Addiction 2020; 115:249-258. [PMID: 31386238 DOI: 10.1111/add.14768] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 06/12/2019] [Accepted: 07/26/2019] [Indexed: 12/21/2022]
Abstract
AIM To compare psychiatric morbidity in treatment-seeking, opioid-dependent patients with versus without chronic pain. DESIGN A retrospective comparative cohort design was used involving record linkage from routinely collected, nationally held data sets. Data were managed within a Scottish Government-certified Safe Haven. SETTING AND PARTICIPANTS Participants comprised all patients of an NHS Substance Misuse Service in the East of Scotland (n = 467) who were in treatment during 2005 and had been in treatment for varying lengths of time. Their mean age at study inception was 35.0 years in the chronic pain group and 32.1 years; 68% of the chronic pain group and 74% of the no pain group were male. MEASUREMENTS The outcomes were (a) psychiatric comorbidity assessed at study inception using the 28-item General Health Questionnaire and the Clinical Outcomes in Routine Evaluation-Outcome Measure and (b) receipt of at least one prescription for a psychiatric condition during a 5-year period following study inception. The independent variable was chronic pain measured at study inception using the Brief Pain Inventory-Short Form. FINDINGS A total of 246 (52.7%) reported chronic pain and 221 (47.3%) did not. A higher proportion of patients with chronic pain had at least one psychiatric morbidity (62.4 versus 46.3%, P < 0.001). At the study inception, a higher proportion of patients with chronic pain were prescribed anxiolytics (49.0 versus 39.1%, P = 0.015) and antimanic drugs (9.9 compared with 4.9%, P = 0.015). CONCLUSIONS Patients of opioid treatment services in Scotland who report chronic pain may have a higher prevalence of psychiatric comorbidity than those who do not.
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Affiliation(s)
- Cassie Higgins
- Division of Neuroscience, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Blair H Smith
- Division of Population Health Sciences, University of Dundee, Way, Ninewells Hospital and Medical School, Dundee, UK
| | - Keith Matthews
- Division of Neuroscience, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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Nielsen S, Sproule B. The case for developing pharmacist workforce capacity in addiction medicine. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre Eastern Health Clinical School Monash University Melbourne Australia
| | - Beth Sproule
- Pharmacy Department Centre for Addiction and Mental Health Toronto Canada
- Leslie Dan Faculty of Pharmacy University of Toronto Toronto Canada
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Orhurhu V, Olusunmade M, Urits I, Viswanath O, Peck J, Orhurhu MS, Adekoya P, Hirji S, Sampson J, Simopoulos T, Jatinder G. Trends of Opioid Use Disorder Among Hospitalized Patients With Chronic Pain. Pain Pract 2019; 19:656-663. [PMID: 31077526 DOI: 10.1111/papr.12789] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/15/2019] [Accepted: 04/24/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients with chronic pain treated with opioids are at an increased risk for opioid misuse or opioid use disorder (OUD). Recent years have seen a stark increase in abuse, misuse, and diversion of prescription opioid medications. The aim of this study was to investigate trends in changing rates of opioid use disorder among patients with chronic pain. METHODS The National Inpatient Sample (NIS) database identified chronic pain admissions with OUD from 2011 to 2015. Patients were identified from the NIS database using International Classification of Diseases (9th and 10th revisions) diagnosis codes for chronic pain and OUD. Annual estimates and trends were determined for OUD, patient characteristics, OUD among subgroups of chronic pain conditions, and discharge diagnosis. RESULTS We identified 10.3 million patients with chronic pain. Of these, 680,631 patients were diagnosed with OUD. The number of patients with OUD increased from 109,222 in 2011 to 172,680 in 2015 (P < 0.001). Similarly, there were upward trends of OUD among females (53.2% to 54.5%; P = 0.09), patients 65 to 84 years of age (11.8% to 17%; P < 0.001), Medicare-insured patients (39.5% to 46.0%; P < 0.01), patients with low annual household incomes (27.8% to 33.3%; P < 0.001), and patients with cannabinoid use disorder (7.2% to 8.3%; P = 0.01). The prevalence of OUD increased from 2011 to 2015 in patients with chronic regional pain syndrome (5.53% to 7.46%; P = 0.01) and spondylosis (1.32% to 1.81%; P < 0.001). CONCLUSIONS These findings suggest that the prevalence of OUD increased substantially from 2011 to 2015. Disparities of OUD with increasing opioid use among vulnerable populations including women, those with Medicare insurance, tobacco use disorder, and low annual income should be explored further.
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Affiliation(s)
- Vwaire Orhurhu
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mayowa Olusunmade
- Department of Psychiatry, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Ivan Urits
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, U.S.A.,Creighton University School of Medicine, Omaha, Nebraska, U.S.A
| | - Jacquelin Peck
- Department of Anesthesiology, Mt. Sinai Medical Center of Florida, Miami Beach, Florida, U.S.A
| | - Mariam Salisu Orhurhu
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A
| | - Peju Adekoya
- Pain Division, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Sameer Hirji
- Departments of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - John Sampson
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A
| | - Thomas Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Gill Jatinder
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
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Dorscht L, Schön C, Geiss C, Gräßel E, Donath C. Access to Pain Management Programs: A Multifactorial Analysis of the Pathways of Care for Chronic Pain Patients in the University Clinic Erlangen. DAS GESUNDHEITSWESEN 2019; 82:e94-e107. [PMID: 31185498 DOI: 10.1055/a-0832-2173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Different treatment options are offered for patients suffering from chronic pain, which differ in intensity and costs: 1) monodisciplinary treatment, mostly in outpatient care and 2) interdisciplinary treatment with the option of participating in pain management programs as outpatients or inpatients. The present work investigates how patients at the University Clinic Erlangen receiving monodisciplinary treatment differ from those receiving interdisciplinary treatment (research question I) as well as how patients participating in a pain management program differ from those who do not (research question II). The aim is to generate insights into whether the differences between the patient groups under various treatment modalities reflect the officially defined criteria for the indication of chronic pain management programs. METHODS Routine data of 1,833 patients treated from January 2008 to March 2013 at the University Clinic Erlangen were analyzed. After univariate preanalyses and checks for multicollinearity, the remaining variables were used for the final multivariate model (multiple binary logistic regression) for research question I and II. RESULTS Research question I: Patients getting interdisciplinary treatment were more often employed, had higher affective experience of pain, more often regarded their pain as treatable, had more often participated in at least one pain-associated rehabilitation treatment in the past, were younger and rarely had application for retirement in consideration. Research question II: Patients who participated in a pain management program were more often female, more often employed, described their pain as mainly located at the upper part of the body, had more concomitant symptoms, were more often diagnosed with musculoskeletal pain and rarely had a retirement request pending. CONCLUSIONS It could be shown that patients in the analyzed pathways of care mainly differed in demographic variables, and regarding pain management programs, also in the type of pain. Differences between patients in different treatment paths reflecting the officially defined indication criteria for chronic pain management programs were detectable only to a minor extent. Clearer and operational practical guidance should help support the clinical decision to assign patients to different treatment options and close the gap between theory and practice.
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Affiliation(s)
- Lisa Dorscht
- Zentrum für Medizinische Versorgungsforschung, Psychiatrische Universitätsklinik Erlangen, Erlangen
| | - Christoph Schön
- Interdisziplinäres Schmerzzentrum, Universitätsklinikum Erlangen, Erlangen
| | - Christa Geiss
- Interdisziplinäres Schmerzzentrum, Universitätsklinikum Erlangen, Erlangen
| | - Elmar Gräßel
- Zentrum für Medizinische Versorgungsforschung, Psychiatrische Universitätsklinik Erlangen, Erlangen
| | - Carolin Donath
- Zentrum für Medizinische Versorgungsforschung, Psychiatrische Universitätsklinik Erlangen, Erlangen
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O'Loughlin I, Newton-John TRO. 'Dis-comfort eating': An investigation into the use of food as a coping strategy for the management of chronic pain. Appetite 2019; 140:288-297. [PMID: 31145944 DOI: 10.1016/j.appet.2019.05.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/18/2019] [Accepted: 05/21/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Chronic pain and obesity are major public health concerns. Animal and human models have demonstrated that eating high-sugar nutrient-dense foods confers analgesic effects. Moreover, recent research suggests that people with chronic pain may "comfort eat" to cope with their pain. Given the harmful impact of obesity on chronic pain, it is critical to determine whether pain elicits comfort eating amongst individuals with chronic pain to ensure that this potentially maladaptive pain coping strategy is not overlooked in chronic pain treatment. Therefore, this study aimed to: determine whether chronic pain intensity predicts pain-induced comfort eating and identify mediators of this relationship; to determine whether pain-induced comfort eating predicts elevated BMI; and to establish whether BMI predicts chronic pain interference. METHODS This study utilised a cross-sectional online survey design and a sample of 151 adults with chronic pain. RESULTS Over three-quarters of this chronic pain sample reported engaging in pain-induced comfort eating. Chronic pain intensity did not significantly predict pain-induced comfort eating. However, there was a significant indirect effect of chronic pain intensity on pain-induced comfort eating through stress-but not experiential avoidance or pain catastrophising. As predicted, pain-induced comfort eating significantly predicted increased BMI, and BMI in turn significantly predicted greater chronic pain interference. DISCUSSION This study indicates that pain-induced comfort eating is both common and harmful amongst individuals with chronic pain, across the entire BMI spectrum. Pain-induced comfort eating and stress have emerged as promising chronic pain treatment targets. The findings are discussed and interpreted in light of extant research and theory, as well as limitations of the current study. Future research directions and clinical implications are also considered.
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Affiliation(s)
- Imogen O'Loughlin
- Graduate School of Health, University of Technology Sydney, Australia
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De Aquino JP, Sofuoglu M, Stefanovics E, Rosenheck R. Adverse Consequences of Co-Occurring Opioid Use Disorder and Cannabis Use Disorder Compared to Opioid Use Disorder Only. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2019; 45:527-537. [PMID: 31112429 DOI: 10.1080/00952990.2019.1607363] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: While there is growing interest in the possibility that cannabis may be a partial substitute for opioids, studies have yet to examine whether individuals with co-occurring opioid and cannabis use disorders (OUD and CUD) have less risk of negative outcomes than those with OUD only. Objective: This study sought to compare the sociodemographic and clinical characteristics of patients diagnosed with co-occurring OUD and CUD to patients with OUD only, CUD only, and patients with any other drug use disorders. We hypothesized that co-occurring OUD and CUD would be associated with lower risk of inpatient admissions and emergency department (ED) visits, lower rates of homelessness, and fewer opioid prescriptions. Methods: Comparisons were based on bivariate analyses, logistic and linear multiple regression models of National Veterans Health Administration (VHA) data from Fiscal Year 2012. Results: Of the 234,181 (94% male) patients diagnosed with drug use disorders, 8.6% were diagnosed with co-occurring OUD and CUD; 33.3% with OUD only; 26.5% with CUD only; and 31.6% with other drug use disorders. Compared to the OUD only group (Mean = 4.8 (SD = 8.84)), the group with co-occurring OUD and CUD was associated with a lower number of opioid prescriptions (Mean = 3.79 (SD = 8.22)) (d = -0.16), but higher likelihood of inpatient psychiatric admission (RR = 1.95) and homelessness (RR = 1.52), and no significant difference in ED visits. Conclusions: These data highlight the need to further investigate whether the complex effects of cannabis use on patients with OUD are counterbalanced by potential benefits of reduced in opioid prescribing.
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Affiliation(s)
- Joao P De Aquino
- a Department of Psychiatry, Yale University School of Medicine , New Haven , CT , USA
| | - Mehmet Sofuoglu
- a Department of Psychiatry, Yale University School of Medicine , New Haven , CT , USA.,b U.S. Department of Veterans Affairs, New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System , West Haven , CT , USA
| | - Elina Stefanovics
- a Department of Psychiatry, Yale University School of Medicine , New Haven , CT , USA.,b U.S. Department of Veterans Affairs, New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System , West Haven , CT , USA
| | - Robert Rosenheck
- a Department of Psychiatry, Yale University School of Medicine , New Haven , CT , USA.,b U.S. Department of Veterans Affairs, New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System , West Haven , CT , USA
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Sources and Impact of Time Pressure on Opioid Management in the Safety-Net. J Am Board Fam Med 2019; 32:375-382. [PMID: 31068401 PMCID: PMC6988512 DOI: 10.3122/jabfm.2019.03.180306] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/20/2018] [Accepted: 01/06/2019] [Indexed: 11/08/2022] Open
Abstract
PURPOSE This study sought to understand clinicians' and patients' experience managing chronic noncancer pain (CNCP) and opioids in safety-net primary care settings. This article explores the time requirements of safer opioid prescribing for medically and socially complex patients in the context of safety-net primary care. METHODS We qualitatively interviewed 23 primary care clinicians and 46 of their patients with concurrent CNCP and substance use disorder (past or current). We also conducted observations of clinical interactions between the clinicians and patients. We transcribed, coded, and analyzed interview and clinical observation recordings using grounded theory methodology. RESULTS Clinicians reported not having enough time to assess patients' CNCP, functional status, and risks for opioid misuse. Inadequate assessment of CNCP contributed to tension and conflicts during visits. Clinicians described pain conversations consuming a substantial portion of primary care visits despite patients' other serious health concerns. System-level constraints (eg, changing insurance policies, limited access to specialty and integrative care) added to the perceived time burden of CNCP management. Clinicians described repeated visits with little progress in patients' pain or functional status due to these barriers. Patients acknowledged clinical time constraints and reported devoting significant time to following new opioid management protocols for CNCP. CONCLUSIONS Time pressure was identified as a major barrier to safer opioid prescribing. Efforts, including changes to reimbursement structures, are needed to relieve time stress on primary care clinicians treating medically and socially complex patients with CNCP in safety-net settings.
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Kneeland ET, Griffin ML, Taghian N, Weiss RD, McHugh RK. Associations between pain catastrophizing and clinical characteristics in adults with substance use disorders and co-occurring chronic pain. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2019; 45:488-494. [DOI: 10.1080/00952990.2019.1581793] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Elizabeth T. Kneeland
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Margaret L. Griffin
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Nadine Taghian
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA, USA
| | - Roger D. Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - R. Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Curry I, Malaktaris AL, Lyons R, Herbert MS, Norman SB. The Association Between Negative Trauma-Related Cognitions and Pain-Related Functional Status Among Veterans With Posttraumatic Stress Disorder and Alcohol Use Disorder. J Trauma Stress 2019; 32:317-322. [PMID: 30913347 PMCID: PMC6476639 DOI: 10.1002/jts.22394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/06/2018] [Accepted: 11/15/2018] [Indexed: 12/12/2022]
Abstract
Among veterans with posttraumatic stress disorder (PTSD), alcohol use disorders (AUDs) are highly prevalent. Furthermore, PTSD frequently co-occurs with chronic pain (CP), and CP is associated with an increased risk of AUD. Pain-related beliefs and appraisals are significantly associated with poorer pain-related functional status, yet few studies have examined negative trauma-related cognitions and their impact on pain-related functional disability in veterans with co-occurring PTSD and AUD. Accordingly, we examined the association between negative trauma-related cognitions and pain severity and pain disability in 137 veterans seeking treatment for PTSD and AUD. Using hierarchical multiple linear regression, we found that higher levels of negative trauma-related cognitions (e.g., "I am completely incompetent") were associated with a higher level of pain severity, after controlling for PTSD symptom severity and frequency of alcohol use, total R2 = .07, ΔR2 = .06. Additionally, as hypothesized, we found that higher levels of negative trauma-related cognitions were associated with higher levels of pain disability, after controlling for PTSD symptom severity, frequency of alcohol use, and pain severity, total R2 = .46, ΔR2 = .03. Given that negative trauma-related cognitions contributed to pain severity and pain disability, even when controlling for PTSD severity and frequency of alcohol use, future studies should explore the potential impact of interventions that address negative trauma-related cognitions (e.g., prolonged exposure or cognitive processing therapy) on pain severity and disability.
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Affiliation(s)
- Inga Curry
- VA San Diego Healthcare System, La Jolla, California, USA
- Department of Psychiatry, University of California, San Diego, San Diego, California, USA
| | - Anne L Malaktaris
- VA San Diego Healthcare System, La Jolla, California, USA
- Department of Psychiatry, University of California, San Diego, San Diego, California, USA
- Center of Excellence for Stress and Mental Health/VA San Diego Healthcare System, San Diego, California, USA
| | - Robert Lyons
- San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California, USA
| | - Matthew S Herbert
- VA San Diego Healthcare System, La Jolla, California, USA
- Department of Psychiatry, University of California, San Diego, San Diego, California, USA
- Center of Excellence for Stress and Mental Health/VA San Diego Healthcare System, San Diego, California, USA
| | - Sonya B Norman
- VA San Diego Healthcare System, La Jolla, California, USA
- Department of Psychiatry, University of California, San Diego, San Diego, California, USA
- Center of Excellence for Stress and Mental Health/VA San Diego Healthcare System, San Diego, California, USA
- San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California, USA
- National Center for PTSD, White River Junction, Vermont, USA
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63
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Lira MC, Tsui JI, Liebschutz JM, Colasanti J, Root C, Cheng DM, Walley AY, Sullivan M, Shanahan C, O’Connor K, Abrams C, Forman LS, Chaisson C, Bridden C, Podolsky MC, Outlaw K, Harris CE, Armstrong WS, del Rio C, Samet JH. Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study - a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV. HIV Res Clin Pract 2019; 20:48-63. [PMID: 31303143 PMCID: PMC6693587 DOI: 10.1080/15284336.2019.1627509] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/26/2019] [Accepted: 05/30/2019] [Indexed: 12/12/2022]
Abstract
Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, targeting effective analgesia in clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n = 41) were recruited from September 2015 to December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n = 187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: (1) a nurse care manager and electronic registry to assist with patient management; (2) opioid education and academic detailing; and (3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12 months. In parallel, PLWH receiving LTOT (n = 170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n = 117). Conclusions: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.
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Affiliation(s)
- Marlene C. Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Judith I. Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington and Harborview Medical Center
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan Colasanti
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Christin Root
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Alexander Y. Walley
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Meg Sullivan
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Christopher Shanahan
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Kristen O’Connor
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Catherine Abrams
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Leah S. Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | - Christine Chaisson
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | - Carly Bridden
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Melissa C. Podolsky
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Kishna Outlaw
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Catherine E. Harris
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Wendy S. Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Carlos del Rio
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
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64
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Parent S, Nolan S, Fairbairn N, Ye M, Wu A, Montaner J, Barrios R, Ti L. Correlates of opioid and benzodiazepine co-prescription among people living with HIV in British Columbia, Canada: A population-level cohort study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 67:52-57. [PMID: 30897373 DOI: 10.1016/j.drugpo.2019.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 01/09/2019] [Accepted: 01/17/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Co-prescribing benzodiazepines and opioids is relatively contraindicated due to the possible overdose risk. However, people living with HIV (PLWH) may have concurrent psychiatric and/or chronic pain diagnoses that may lead to the use of opioids and/or benzodiazepines for symptomatic treatment. Consequently, some PLWH may be at-risk for the health harms associated with the co-prescribing of these medications. Given this, the objectives of this study were to first examine the prevalence of opioids and benzodiazepines co-prescribing, and second, to characterize patient factors associated with the co-prescribing of opioids and benzodiazepines among PLWH in British Columbia (BC), Canada. METHODS Using data derived from a longitudinal BC cohort, we used bivariable and multivariable generalized estimating equation models to establish the prevalence of a benzodiazepine and opioid co-prescription and determine factors associated with this practice. RESULTS Between 1996 and 2015, 14 484 PLWH were included in the study and were followed for the entire study period. At baseline, 548 people (4%) were co-prescribed opioids and benzodiazepines, 6593 (46%) were prescribed opioids only, 2887 (20%) were prescribed benzodiazepines only, and 4456 (31%) were prescribed neither medication. A total of 3835 (27%) participants were prescribed both medications at least once during the study period. Factors positively associated with concurrent opioid and benzodiazepine prescribing included: depression/mood disorder [adjusted odds ratio (AOR) = 1.32; 95% confidence interval (CI) = 1.22-1.43] and anxiety disorder (AOR = 1.45; 95% CI = 1.27-1.66), whereas female sex (AOR = 0.76; 95% CI = 0.64-0.91) and substance use disorder (SUD) (AOR = 0.82; 95% CI = 0.74-0.90) were negatively associated with the outcome. CONCLUSION Our findings indicate that co-prescription of opioids and benzodiazepines was seen at some point during study follow-up in over a quarter of PLWH. Given the known risks associated with this prescribing practice, future research can focus on the outcomes of co-prescribing among this patient population and the development of strategies to reduce the co-prescribing of opioids and benzodiazepines.
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Affiliation(s)
- Stephanie Parent
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, 400-1045 HOwe Street, Vancouver, BC, V6Z 2A9
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, 400-1045 HOwe Street, Vancouver, BC, V6Z 2A9
| | - Monica Ye
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Anthony Wu
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Vancouver Coastal Health, 520 West 6(th)Avenue, Vancouver, BC V6Z 4H5, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, 400-1045 HOwe Street, Vancouver, BC, V6Z 2A9; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Rosen MI, Becker WC, Black AC, Martino S, Edens EL, Kerns RD. Brief Counseling for Veterans with Musculoskeletal Disorder, Risky Substance Use, and Service Connection Claims. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:528-542. [PMID: 29800338 PMCID: PMC6387983 DOI: 10.1093/pm/pny071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE High proportions of post-9/11 veterans have musculoskeletal disorders (MSDs), but engaging them in care early in their course of illness has been challenging. The service connection application is an ideal point of contact for referring veterans to early interventions for their conditions. DESIGN Among MSD claimants who reported risky substance use, we pilot-tested a counseling intervention targeting pain and risky substance use called Screening Brief Intervention and Referral to Treatment-Pain Module (SBIRT-PM). Veterans were randomly assigned in a 2:1:1 ratio to SBIRT-PM, Pain Module counseling only, or treatment as usual (TAU). METHODS Participants assigned to either counseling arm were offered a single meeting with a study therapist with two follow-up telephone calls as needed. Participants completed outcome assessments at four and 12 weeks after randomization. RESULTS Of 257 veterans evaluated, 101 reported risky substance use and were randomized. Counseling was attended by 75% of veterans offered it and was well received. VA pain-related services were used by 51% of participants in either of the pain-focused conditions but only by 27% in TAU (P < 0.04). Starting with average pain severity ratings of 5.1/10 at baseline, only minimal changes in mean pain severity were noted regardless of condition. Self-reported risky substance use was significantly lower over time in the SBIRT-PM condition relative to the two other conditions (P < 0.02). At week 12, proportions of veterans reporting risky substance use were 0.39, 0.69, and 0.71 for the SBIRT-PM, Pain Module counseling, and TAU conditions, respectively. CONCLUSIONS SBIRT-PM shows promise as a way to engage veterans in pain treatment and reduce substance use.
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Affiliation(s)
- Marc I Rosen
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - William C Becker
- VA Connecticut Healthcare System, West Haven, Connecticut
- Section of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anne C Black
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Steve Martino
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Ellen L Edens
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Robert D Kerns
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
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66
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Moment-to-moment changes in perceived social support and pain for men living with HIV: an experience sampling study. Pain 2019; 159:2503-2511. [PMID: 30074592 DOI: 10.1097/j.pain.0000000000001354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Research suggests that people living with HIV experience levels of pain disproportionate to the general population. Pain is a stressor that can negatively impact health-related quality of life. As the number of people aging with HIV increases, we must understand the dynamics of pain experiences among people living with HIV and how to effectively harness evidence-based treatments and supportive resources to enhance adaptive coping. We used an experience sampling method (also called Ecological Momentary Assessment) to assess moment-to-moment experiences of pain and social support 3 times a day for 7 days in a sample of 109 men living with HIV. Participants also responded to questionnaires assessing attachment-related insecurity and social support. In hierarchical linear modeling analyses controlling for age, race, sexual orientation, and socioeconomic status, we found that experiences of social support were associated with lower subsequent pain within-persons. On the other hand, experiences of pain were not associated with later experiences of social support. Men with higher levels of attachment-related avoidance reported more pain on average. Attachment-related avoidance also moderated the association between moment-to-moment experiences of felt social support on pain. Results suggest that within-persons, experiences of daily social support reduce experiences of pain. Between-persons, attachment style may influence how individuals make use of social support in coping with experiences of pain. These findings imply a need to assess social well-being at the clinic level and also support tailored biopsychosocial approaches to pain management in HIV care settings.
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67
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Campbell G, Stockings E, Nielsen S. Understanding the evidence for medical cannabis and cannabis-based medicines for the treatment of chronic non-cancer pain. Eur Arch Psychiatry Clin Neurosci 2019; 269:135-144. [PMID: 30635715 DOI: 10.1007/s00406-018-0960-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/21/2018] [Indexed: 12/18/2022]
Abstract
The use of medical cannabis and cannabis-based medicines has received increasing interest in recent years; with a corresponding surge in the number of studies and reviews conducted in the field. Despite this growth in evidence, the findings and conclusions of these studies have been inconsistent. In this paper, we outline the current evidence for medical cannabis and cannabis-based medicines in the treatment and management of chronic non-cancer pain. We discuss limitations of the current evidence, including limitations of randomised control trials in the field, limits on generalisability of previous findings and common issues such as problems with measurements of dose and type of cannabinoids. We discuss future directions for medicinal cannabinoid research, including addressing limitations in trial design; developing frameworks to monitor for use disorder and other unintended outcomes; and considering endpoints other than 30% or 50% reductions in pain severity.
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Affiliation(s)
- Gabrielle Campbell
- National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, UNSW Sydney, 22-32 King Street, Randwick, NSW, 2031, Australia.
| | - Emily Stockings
- National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, UNSW Sydney, 22-32 King Street, Randwick, NSW, 2031, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Level 2, 5 Arnold Street, Box Hill, VIC, 3128, Australia
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68
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Lakkakula BV, Sahoo R, Verma H, Lakkakula S. Pain Management Issues as Part of the Comprehensive Care of Patients with Sickle Cell Disease. Pain Manag Nurs 2018; 19:558-572. [DOI: 10.1016/j.pmn.2018.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 05/14/2018] [Accepted: 06/26/2018] [Indexed: 12/14/2022]
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69
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Balba NM, Elliott JE, Weymann KB, Opel RA, Duke JW, Oken BS, Morasco BJ, Heinricher MM, Lim MM. Increased Sleep Disturbances and Pain in Veterans With Comorbid Traumatic Brain Injury and Posttraumatic Stress Disorder. J Clin Sleep Med 2018; 14:1865-1878. [PMID: 30373686 DOI: 10.5664/jcsm.7482] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/23/2018] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Veterans are at an increased risk for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), both of which are associated with sleep disturbances and increased pain. Furthermore, sleep disturbances and pain are reciprocally related such that each can exacerbate the other. Although both TBI and PTSD are independently linked to sleep disturbances and pain, it remains unclear whether Veterans with comorbid TBI+PTSD show worse sleep disturbances and pain compared to those with only TBI or PTSD. We hypothesized that sleep and pain would be worse in Veterans with comorbid TBI+PTSD compared to Veterans with only TBI or PTSD. METHODS Veterans (n = 639) from the VA Portland Health Care System completed overnight polysomnography and self-report questionnaires. Primary outcome variables were self-reported sleep disturbances and current pain intensity. Participants were categorized into four trauma-exposure groups: (1) neither: without TBI or PTSD (n = 383); (2) TBI: only TBI (n = 67); (3) PTSD: only PTSD (n = 126); and (4) TBI+PTSD: TBI and PTSD (n = 63). RESULTS The PTSD and TBI+PTSD groups reported worse sleep compared to the TBI and neither groups. The TBI+PTSD group reported the greatest pain intensity compared to the other groups. CONCLUSIONS These data suggest sleep and pain are worst in Veterans with TBI and PTSD, and that sleep is similarly impaired in Veterans with PTSD despite not having as much pain. Thus, although this is a complex relationship, these data suggest PTSD may be driving sleep disturbances, and the added effect of TBI in the comorbid group may be driving pain in this population.
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Affiliation(s)
- Nadir M Balba
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon
| | - Jonathan E Elliott
- VA Portland Health Care System, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon
| | - Kris B Weymann
- VA Portland Health Care System, Portland, Oregon.,School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Ryan A Opel
- VA Portland Health Care System, Portland, Oregon
| | - Joseph W Duke
- Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona
| | - Barry S Oken
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health and Sciences University, Portland, Oregon
| | - Mary M Heinricher
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurological Surgery; Oregon Health and Science University, Portland, Oregon
| | - Miranda M Lim
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon.,Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, Oregon
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70
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McKernan LC, Finn MTM, Carr ER. Personality and Affect When the Central Nervous System is Sensitized: An Analysis of Central Sensitization Syndromes in a Substance Use Disorder Population. Psychodyn Psychiatry 2018; 45:385-409. [PMID: 28846511 DOI: 10.1521/pdps.2017.45.3.385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Functional somatic syndromes, or more recently termed central sensitivity syndromes (CSS), comprise a significant portion of the chronic pain population. Although it is evident that personality is intricately related to the pain experience, it has not been widely studied. This article examines the impact of CSS on the clinical presentation of individuals presenting to treatment for a substance use disorder (SUD), with an emphasis on personality and emotional functioning. We examined personality profiles of individuals presenting to treatment with SUD between three groups: those with a CSS (n = 30), non-CSS chronic pain (n = 79), and no pain (n = 232). Based on previous research and a psychodynamic conceptualization of CSS, we hypothesized that predictors of the presence of a CSS in this sample would be higher rates of overall anxiety, traumatic stress, perfectionistic traits, and a need for interpersonal closeness. Logistic regression analyses did not support our hypothesis. Exploratory analyses indicated which personality traits most strongly predicted the presence of CSS. We discuss these findings using descriptive psychopathology literature, with recommendations for future research.
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Affiliation(s)
- Lindsey C McKernan
- Assistant Clinical Professor, Vanderbilt University School of Medicine, Osher Center of Integrative Medicine
| | - Michael T M Finn
- Doctoral Candidate in Clinical Psychology, The University of Tennessee, Knoxville
| | - Erika R Carr
- Assistant Professor, Director of Inpatient Psychology, Yale University School of Medicine
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71
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Malon J, Shah P, Koh WY, Cattabriga G, Li E, Cao L. Characterizing the demographics of chronic pain patients in the state of Maine using the Maine all payer claims database. BMC Public Health 2018; 18:810. [PMID: 29954350 PMCID: PMC6022454 DOI: 10.1186/s12889-018-5673-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 06/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain is currently a significant health problem in the United States. A comprehensive strategy is needed to increase prevention of chronic pain and to improve care for chronic pain patients. However, development of a successful strategy relies, in part, on a better understanding of the demographics and socioeconomics of patients living with chronic pain conditions. The current study was designed to understand the burden of chronic pain in the state of Maine by identifying the prevalence of chronic pain and its relationship with selected demographic and socioeconomic factors in Maine. METHODS The Maine All Payer Claims Database (MEAPCD) (2006-2011) was used in the secondary data analysis to assess the demographic characteristics (such as age, sex, insurance type, and county of residence) of chronic pain patients in Maine. Chronic pain patients were identified based on the presence of pre-identified chronic pain-associated ICD-9 code(s) and opioid prescription information. Potential associations between the prevalence of chronic pain and a number of socioeconomic factors were determined by comparisons to Maine Census data. RESULTS More women in the state were identified as having chronic pain across all counties and all age groups (> 10 years old). Surprisingly, the majority of chronic pain patients were identified based on the diagnostic code criteria and not the opioid prescription criteria. A greater utilization of public health insurance was seen within the chronic pain patients. At the county level, although neither education level nor income were associated with the prevalence of chronic pain, these factors significantly correlated with the usage of public health insurance. CONCLUSIONS Further detailed characterization of the chronic pain patient population in the state of Maine, using multiple data sources, can help design population-targeted strategies to prevent and manage chronic pain.
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Affiliation(s)
- Jennifer Malon
- Center for Excellence in the Neurosciences, University of New England, 11 Hills Beach Rd., Biddeford, ME 04005 USA
| | - Parth Shah
- College of Osteopathic Medicine, University of New England, Biddeford, ME USA
| | - Woon Yuen Koh
- Department of Mathematical Sciences, University of New England, Biddeford, ME USA
| | | | - Edward Li
- College of Pharmacy, University of New England, Portland, ME USA
| | - Ling Cao
- Center for Excellence in the Neurosciences, University of New England, 11 Hills Beach Rd., Biddeford, ME 04005 USA
- College of Osteopathic Medicine, University of New England, Biddeford, ME USA
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72
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Vowles KE, Witkiewitz K, Pielech M, Edwards KA, McEntee ML, Bailey RW, Bolling L, Sullivan MD. Alcohol and Opioid Use in Chronic Pain: A Cross-Sectional Examination of Differences in Functioning Based on Misuse Status. THE JOURNAL OF PAIN 2018; 19:1181-1188. [PMID: 29758355 DOI: 10.1016/j.jpain.2018.04.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/16/2018] [Accepted: 04/29/2018] [Indexed: 12/11/2022]
Abstract
Opioid misuse is regularly associated with disrupted functioning in those with chronic pain. Less work has examined whether alcohol misuse may also interfere with functioning. This study examined frequency of opioid and alcohol misuse in 131 individuals (61.1% female) prescribed opioids for the treatment of chronic pain. Participants completed an anonymous survey online, consisting of measures of pain, functioning, and opioid and alcohol misuse. Cut scores were used to categorize individuals according to substance misuse status. Individuals were categorized as follows: 35.9% (n = 47) were not misusing either opioids or alcohol, 22.9% (n = 30) were misusing both opioids and alcohol, 38.2% (n = 50) were misusing opioids alone, and only 3.0% (n = 4) were misusing alcohol alone. A multivariate analysis of variance was performed to examine differences in pain and functioning between groups (after excluding individuals in the alcohol misuse group due to the small sample size). Group comparisons indicated that individuals who were not misusing either substance were less disabled and distressed in comparison to those who were misusing opioids alone or both opioids and alcohol. No differences were indicated between the latter 2 groups. Overall, the observed frequency of opioid misuse was somewhat higher in comparison to previous work (approximately 1 out of every 3 participants), and misuse of both alcohol and opioids was common (approximately 1 out of every 5 participants). While these data are preliminary, they do suggest that issues of substance misuse in those with chronic pain extends beyond opioids alone. PERSPECTIVE Opioid and alcohol misuse was examined in 131 individuals prescribed opioids for chronic pain. In total, 35.9% were not misusing either, 22.9% were misusing both, 38.2% were misusing opioids, and 3.1% were misusing alcohol. Individuals not misusing either were generally less disabled and distressed compared to those misusing opioids or both.
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Affiliation(s)
- Kevin E Vowles
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico.
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Melissa Pielech
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Karlyn A Edwards
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Mindy L McEntee
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Robert W Bailey
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Lena Bolling
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Mark D Sullivan
- University of Washington, Departments of Psychiatry and Behavioral Sciences, Seattle, Washington
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73
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Landsman-Blumberg PB, Katz N, Gajria K, Coutinho AD, Yeung PP, White R. Burden of Alcohol Abuse or Dependence Among Long-Term Opioid Users with Chronic Noncancer Pain. J Manag Care Spec Pharm 2018. [PMID: 28650247 PMCID: PMC10397637 DOI: 10.18553/jmcp.2017.23.7.718] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Substance abuse disorders among chronic noncancer pain (CNCP) patients add to the clinical challenges and economic burden of caring for such patients. Despite potential risks, some CNCP patients with a history of alcohol abuse or dependence (AAD) and pain that is refractory to nonopioid treatment options may still need opioids for pain management. However, there is a lack of data on adverse outcomes in long-term opioid users with CNCP and a history of substance abuse or AAD disorders. OBJECTIVE To compare adverse outcomes and all-cause health care costs among CNCP patients on long-term opioid treatment with and without a previous diagnosis of AAD. METHODS Using MarketScan claims databases (2006-2012), CNCP patients with ≥ 90 days of opioid supply after CNCP diagnosis and continuous enrollment 12 months before CNCP diagnosis (baseline period) and 12 months after opioid start (post-index period) were identified. AAD was defined by diagnosis codes at any time before opioid initiation. Outcomes included opioid overdose, accident, and injury episodes identified by ICD-9-CM diagnoses codes. T-tests and Mann-Whitney tests compared continuous measures, and chi-square and Fisher's exact tests compared categorical measures between those with and without AAD. Multivariable analyses for outcomes were conducted, adjusting for baseline differences between cohorts. RESULTS Of 21,203 CNCP patients with long-term opioid treatment, 750 (3.5%) had an AAD diagnosis before opioid initiation. AAD patients were significantly younger (48.4 [SD ± 11.4] years vs. 52.8 [SD ± 14.8] years), less likely to be enrolled in Medicare (17% commercial vs. 4% Medicare), and more likely to be male (67% vs. 48%; all P < 0.001). There were no differences in type or number of CNCP diagnoses or Charlson Comorbidity Index (CCI) scores. Patients with AAD had significantly higher rates of depression and anxiety diagnoses, antidepressant and benzodiazepine use, and drug abuse/dependence diagnoses in the baseline period. Twelvemonth post-index rates of opioid overdose (1.2% vs. 0.2%), accident (7.3% vs. 2.8%), and injury (46.1% vs. 36.8%) were greater in the AAD cohort (all P < 0.001). The differences were nonsignificant for accidents in multivariable analyses. While mean prescription costs were similar ($3,562 vs. $3,312; P = 0.212), AAD patients had significantly higher mean all-cause medical costs ($28,429 vs. $22,082; P < 0.001) and significantly higher all-cause total health care costs ($31,991 vs. $25,395; P < 0.001). The cost differences remained significant in multivariable analyses. CONCLUSIONS In the first year after long-term opioid initiation, CNCP patients with a previous AAD diagnosis had 5 times the rate of opioid overdose, 2.3 times the rate of accidents, 1.2 times the rate of injury, and higher all-cause health care costs compared with those not diagnosed with AAD. DISCLOSURES Funding for this research study and resultant publication was provided by Teva Global Health Economics and Outcomes Research, which fully reviewed the manuscript. Gajria and Yeung are employees of Teva Pharmaceuticals. White was an employee of Teva Pharmaceuticals at the time this research was conducted. Blumberg and Coutinho are employees of Xcenda, which received research funding from Teva Pharmaceuticals for the conduct of this study and for the preparation of this manuscript. Katz has received research funding and consulting fees from Teva Pharmaceuticals unrelated to this study. Study concept and design were contributed by Katz, White, and Blumberg, along with Coutinho and Yeung. Coutinho took the lead in data collection, assisted by the other authors. Data interpretation was performed by Blumberg, Katz, and Gajria, along with the other authors. The manuscript was written by Gajria, Yeung, Coutinho, and Blumberg, along with Katz and White, and revised by Gajria, Blumberg, Katz, and Coutinho, along with Yeung and White.
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Witkiewitz K, Vowles KE. Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review. Alcohol Clin Exp Res 2018; 42:478-488. [PMID: 29314075 PMCID: PMC5832605 DOI: 10.1111/acer.13594] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/29/2017] [Indexed: 12/20/2022]
Abstract
The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - Kevin E Vowles
- Department of Psychology, University of New Mexico, Albuquerque, NM
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Rieckmann T, Muench J, McBurnie MA, Leo MC, Crawford P, Ford D, Stubbs J, O'Cleirigh C, Mayer KH, Fiscella K, Wright N, Doe-Simkins M, Cuddeback M, Salisbury-Afshar E, Nelson C. Medication-assisted treatment for substance use disorders within a national community health center research network. Subst Abus 2018; 37:625-634. [PMID: 27218678 DOI: 10.1080/08897077.2016.1189477] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Affordable Care Act increases access to treatment services for people who suffer from substance use disorders (SUDs), including alcohol use disorders (AUDs) and opioid use disorders (OUDs). This increased access to treatment has broad implications for delivering health services and creates a dramatic need for transformation in clinical care, service lines, and collaborative care models. Medication-assisted treatments (MAT) are effective for helping SUD patients reach better outcomes. This article uses electronic health record (EHR) data to examine the prevalence of EHR-documented SUDs, patient characteristics, and patterns of MAT prescribing and screening for patients within the Community Health Applied Research Network (CHARN), a national network of 17 community health centers that facilitates patient-centered outcomes research among underserved populations. METHODS Hierarchical generalized linear models examined patient characteristics, SUD occurrence rates, MAT prescription, and human immunodeficiency virus (HIV) and hepatitis virus C screening for patients with AUDs or OUDs. Results: Among 572,582 CHARN adult patients, 16,947 (3.0%) had a documented AUD diagnosis and 6,080 (1.1%) an OUD diagnosis. Alcohol MAT prescriptions were documented for 547 AUD patients (3.2%) and opioid MAT for 1,764 OUD patients (29.0%). Among OUD patients, opioid MAT was significantly associated with HIV screening (odds ratio [OR] = 1.31, P < .001) in OUD patients, as was alcohol MAT among AUD patients (OR = 1.30, P = .013). CONCLUSIONS These findings suggest that effective opioid and alcohol MAT may be substantially underprescribed among safety-net patients identified as having OUDs or AUDs.
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Affiliation(s)
- Traci Rieckmann
- a School of Medicine, Oregon Health and Science University (OHSU) , Portland , Oregon , USA.,b School of Public Health, Oregon Health and Science University (OHSU) , Portland , Oregon , USA
| | - John Muench
- c Department of Family Medicine , Oregon Health and Science University Richmond Clinic , Portland , Oregon , USA
| | - Mary Ann McBurnie
- d Oregon Community Health Information Network (OCHIN) , Portland , Oregon , USA
| | - Michael C Leo
- e Community Health Applied Research Network (CHARN) Data Coordinating Center , Portland , Oregon , USA
| | - Phillip Crawford
- e Community Health Applied Research Network (CHARN) Data Coordinating Center , Portland , Oregon , USA
| | - Daren Ford
- b School of Public Health, Oregon Health and Science University (OHSU) , Portland , Oregon , USA
| | - Jennifer Stubbs
- b School of Public Health, Oregon Health and Science University (OHSU) , Portland , Oregon , USA
| | - Conall O'Cleirigh
- f Fenway Health, Harvard Medical School, and Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Kenneth H Mayer
- f Fenway Health, Harvard Medical School, and Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Kevin Fiscella
- g Departments of Family Medicine and Public Health Sciences , University of Rochester Medical Center , Rochester , New York , USA
| | - Nicole Wright
- h Association of Asian Pacific Community Health Organizations , Oakland , California , USA
| | - Maya Doe-Simkins
- i Alliance of Chicago Community Health Services , Chicago , Illinois , USA
| | - Matthew Cuddeback
- i Alliance of Chicago Community Health Services , Chicago , Illinois , USA
| | | | - Christine Nelson
- d Oregon Community Health Information Network (OCHIN) , Portland , Oregon , USA
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Nugent SM, Yarborough BJ, Smith NX, Dobscha SK, Deyo RA, Green CA, Morasco BJ. Patterns and correlates of medical cannabis use for pain among patients prescribed long-term opioid therapy. Gen Hosp Psychiatry 2018; 50:104-110. [PMID: 29153783 PMCID: PMC5788035 DOI: 10.1016/j.genhosppsych.2017.11.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/03/2017] [Accepted: 11/04/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Little is known about co-occurring long-term opioid therapy (LTOT) and medical cannabis use. We compared characteristics of patients prescribed LTOT who endorsed using medical cannabis for pain to patients who did not report cannabis use. METHOD Participants (n=371) prescribed LTOT completed self-report measures about pain, substance use, and mental health. RESULTS Eighteen percent of participants endorsed using medical cannabis for pain. No significant differences were detected on pain-related variables, depression, or anxiety between those who endorsed medical cannabis use and those who did not. Medical cannabis users had higher scores of risk for prescription opioid misuse (median=17.0 vs. 11.5, p<0.001), rates of hazardous alcohol use (25% vs. 16%, p<0.05), and rates of nicotine use (42% vs. 26%, p=0.01). Multivariable analyses indicated that medical cannabis use was significantly associated with risk of prescription opioid misuse (β=0.17, p=0.001), but not hazardous alcohol use (aOR=1.96, 95% CI=0.96-4.00, p=0.06) or nicotine use (aOR=1.61, 95% CI=0.90-2.88, p=0.11). CONCLUSION There are potential risks associated with co-occurring LTOT and medical cannabis for pain. Study findings highlight the need for further clinical evaluation in this population. Future research is needed to examine the longitudinal impact of medical cannabis use on pain-related and substance use outcomes.
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Affiliation(s)
- Shannon M. Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
| | | | - Ning X. Smith
- Kaiser Permanente Northwest Center for Health Research
| | - Steven K. Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
| | - Richard A. Deyo
- Kaiser Permanente Northwest Center for Health Research,Departments of Family Medicine, Internal Medicine, and the Oregon Institute for Occupational Health Sciences, Oregon Health & Science University,Public Health and Preventive Medicine, Oregon Health & Science University
| | - Carla A. Green
- Kaiser Permanente Northwest Center for Health Research,Public Health and Preventive Medicine, Oregon Health & Science University
| | - Benjamin J. Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
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Kofi LS, Sud A, Buchman DZ. Ethics at the Intersection of Chronic Pain and Substance Use. DEVELOPMENTS IN NEUROETHICS AND BIOETHICS 2018. [DOI: 10.1016/bs.dnb.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Soffin EM, Waldman SA, Stack RJ, Liguori GA. An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery. Anesth Analg 2017; 125:1704-1713. [DOI: 10.1213/ane.0000000000002433] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chronic pain and opioid misuse: a review of reviews. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2017; 12:36. [PMID: 28810899 PMCID: PMC5558770 DOI: 10.1186/s13011-017-0120-7] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 08/06/2017] [Indexed: 01/08/2023]
Abstract
Objective The crisis of prescription opioid (PO) related harms has focused attention toward identifying and treating high-risk populations. This review aims to synthesize systematic reviews on the epidemiology and clinical management of comorbid chronic pain and PO or other substance misuse. Methods A systematic database search was conducted to identify systematic reviews published between 2000 and 2016. Eligible studies were systematic reviews related to chronic non-cancer pain and PO or other substance misuse. Evidence from the included reviews was synthesized according to epidemiology and clinical management themes. Results Of 1908 identified articles, 18 systematic reviews were eligible for final inclusion. Two meta-analyses estimated the prevalence of chronic non-cancer pain in individuals using POs non-medically to be approximately 48% to 60%, which is substantially higher than the prevalence of chronic non-cancer pain in general population samples (11% to 19%). Five systematic reviews estimated the rates of PO or other opioid use in chronic pain populations with substantial variation in results (0.05% to 81%), likely due to widely varying definitions of dependence, substance use disorder, misuse, addiction, and abuse. Several clinical assessment and treatment approaches were identified, including: standardized assessment instruments; urine drug testing; medication counts; prescription drug monitoring programs; blood level monitoring; treatment agreements; opioid selection; dosing and dispensing strategies; and opioid agonist treatment. However, the reviews commonly noted serious limitations, inconsistencies, and imprecision of studies, and a lack of evidence on effectiveness or clinical utility for the majority of these strategies. Conclusion Overall, current systematic reviews have found a lack of high-quality evidence or consistent findings on the prevalence, risk factors, and optimal clinical assessment and treatment approaches related to concurrent chronic pain and substance misuse. Given the role of systematic reviews in guiding evidence-based medicine and health policy, there is an urgent need for high-quality primary research to guide future systematic reviews to address the escalating epidemic of harms related to chronic pain and substance misuse. Electronic supplementary material The online version of this article (doi:10.1186/s13011-017-0120-7) contains supplementary material, which is available to authorized users.
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80
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Paulus DJ, Viana AG, Ditre JW, Bakhshaie J, Garza M, Berger Cardoso J, Valdivieso J, Ochoa-Perez M, Lemaire C, Zvolensky MJ. Synergistic effects of pain and alcohol use in relation to depressive and anxiety symptoms among Latinos in primary care. Cogn Behav Ther 2017; 46:478-492. [DOI: 10.1080/16506073.2017.1336185] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Daniel J. Paulus
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Andres G. Viana
- Department of Psychology, University of Houston, Houston, TX, USA
- Texas Institute for Measurement, Evaluation, and Statistics, University of Houston, Houston, TX, USA
| | - Joseph W. Ditre
- Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Jafar Bakhshaie
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Monica Garza
- Legacy Community Health Services, Houston, TX, USA
| | | | | | | | - Chad Lemaire
- Legacy Community Health Services, Houston, TX, USA
| | - Michael J. Zvolensky
- Department of Psychology, University of Houston, Houston, TX, USA
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
We analyzed baseline data from an observational cohort of HIV-infected ART-naïve patients in St. Petersburg, Russia to explore whether pain was associated with HIV risk behaviors. The primary outcomes were (1) unprotected vaginal or anal sex in the past 90 days and (2) sharing of needles or equipment in the past month. Secondary outcomes included: use of alcohol prior to sex, current injection drug use, number of unprotected sex and sharing episodes, and days injected in the past month. The main independent variable was any past week pain. Multivariable regression models were fit for outcomes. After adjustment, the association with unprotected sex was of borderline significance (AOR = 2.06; 95 % CI 0.98-4.36, p = 0.058); there was no significant association between any past week pain and sharing of needles/equipment (AOR = 1.52; 95 % CI 0.65-3.59, p = 0.33). Participants with pain had higher odds of reporting alcohol use prior to sex (AOR = 2.42; 95 % CI 1.10-5.28, p = 0.03).
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Dahlman D, Kral AH, Wenger L, Hakansson A, Novak SP. Physical pain is common and associated with nonmedical prescription opioid use among people who inject drugs. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2017; 12:29. [PMID: 28558841 PMCID: PMC5450090 DOI: 10.1186/s13011-017-0112-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/19/2017] [Indexed: 11/20/2022]
Abstract
Background People who inject drugs (PWID) often have poor health and lack access to health care. The aim of this study was to examine whether PWID engage in self-treatment through nonmedical prescription opioid use (NMPOU). We describe the prevalence and features of self-reported physical pain and its association with NMPOU. Methods PWID (N = 702) in San Francisco, California (age 18+) were recruited to complete interviewer administered surveys between 2011 and 2013. Multivariate logistic regression analysis was conducted to examine the associations among self-reported pain dimensions (past 24-h average pain, pain interference with functional domains) and NMPOU, controlling for age, sex, psychiatric illness, opioid substitution treatment, homelessness, street heroin use and unmet healthcare needs. Results Almost half of the sample reported pain, based on self-reported measures in the 24 h before their interview. The most common pain locations were to their back and lower extremities. Past 24-h NMPOU was common (14.7%) and associated with past 24 h average pain intensity on a 10 point self-rating scale (adjusted odds ratio [AOR] = 2.15, 95% confidence interval [CI] 1.21–3.80), and past 24 h pain interference with general activity (AOR 1.82 [95% CI 1.04–3.21]), walking ability (AOR 2.52 [95% CI 1.37–4.63]), physical ability (AOR 2.01 [95% CI 1.16–3.45]), sleep (AOR 1.98 [95% CI 1.13–3.48]) and enjoyment of life (AOR 1.79 [95% CI 1.02–3.15]). Conclusion Both pain and NMPOU are common among PWID, and highly correlated in this study. These findings suggest that greater efforts are needed to direct preventive health and services toward this population.
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Affiliation(s)
- Disa Dahlman
- Department of Clinical Sciences Lund, Division of Psychiatry, Lund University, Lund, Sweden. .,Malmo Addiction Centre, Clinical Research Unit, Sodra Forstadsg. 35, plan 4, SE-205 02, Malmo, Sweden.
| | - Alex H Kral
- Behavioral and Urban Health Program, RTI International, San Francisco, USA
| | - Lynn Wenger
- Behavioral and Urban Health Program, RTI International, San Francisco, USA
| | - Anders Hakansson
- Department of Clinical Sciences Lund, Division of Psychiatry, Lund University, Lund, Sweden.,Malmo Addiction Centre, Clinical Research Unit, Sodra Forstadsg. 35, plan 4, SE-205 02, Malmo, Sweden
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Opioid pharmacovigilance: A clinical-social history of the changes in opioid prescribing for patients with co-occurring chronic non-cancer pain and substance use. Soc Sci Med 2017; 186:87-95. [PMID: 28599142 DOI: 10.1016/j.socscimed.2017.05.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 11/20/2022]
Abstract
There is growing concern among US-based clinicians, patients, policy makers, and in the media about the personal and community health risks associated with opioids. Perceptions about the efficacy and appropriateness of opioids for the management of chronic non-cancer pain (CNCP) have dramatically transformed in recent decades. Yet, there is very little social scientific research identifying the factors that have informed this transformation from the perspectives of prescribing clinicians. As part of an on-going ethnographic study of CNCP management among clinicians and their patients with co-occurring substance use, we interviewed 23 primary care clinicians who practice in safety-net clinical settings. In this paper, we describe the clinical and social influences informing three historic periods: (1) the escalation of opioid prescriptions for CNCP; (2) an interim period in which the efficacy of and risks associated with opioids were re-assessed; and (3) the current period of "opioid pharmacovigilance," characterized by the increased surveillance of opioid prescriptions. Clinicians reported that interpretations of the evidence-base in favor of and opposing opioid prescribing for CNCP evolved within a larger clinical-social context. Historically, pharmaceutical marketing efforts and clinicians' concerns about racialized healthcare disparities in pain treatment influenced opioid prescription decision-making. Clinicians emphasized how patients' medical complexity (e.g. multiple chronic health conditions) and structural vulnerability (e.g. poverty, community violence) impacted access to opioids within resource-limited healthcare settings. This clinical-social history of opioid prescribing practices helps to elucidate the ongoing challenges of CNCP treatment in the US healthcare safety net and lends needed specificity to the broader, nationwide conversation about opioids.
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Chang JS, Kushel M, Miaskowski C, Ceasar R, Zamora K, Hurstak E, Knight KR. Provider Experiences With the Identification, Management, and Treatment of Co-occurring Chronic Noncancer Pain and Substance Use in the Safety Net. Subst Use Misuse 2017; 52:251-255. [PMID: 27754719 PMCID: PMC5345572 DOI: 10.1080/10826084.2016.1223138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the United States and internationally, providers have adopted guidelines on the management of prescription opioids for chronic noncancer pain (CNCP). For "high-risk" patients with co-occurring CNCP and a history of substance use, guidelines advise that providers monitor patients using urine toxicology screening tests, develop opioid management plans, and refer patients to substance use treatment. OBJECTIVE We report primary care provider experiences in the safety net interpreting and implementing prescription opioid guideline recommendations for patients with CNCP and substance use. METHODS We interviewed primary care providers who work in safety net settings (N = 23) on their experiences managing CNCP and substance use. We analyzed interviews using a content analysis method. RESULTS Providers found management plans and urine toxicology screening tests useful for informing patients about clinic expectations of opioid therapy and substance use. However, they described that guideline-based clinic policies had unintended consequences, such as raising barriers to open, honest dialogue about substance use and treatment. While substance use treatment was recommended for "high-risk" patients, providers described lack of integration with and availability of substance use treatment programs. CONCLUSIONS Our findings indicate that clinicians in the safety net found guideline-based clinic policies helpful. However, effective implementation was challenged by barriers to open dialogue about substance use and limited linkages with treatment programs. Further research is needed to examine how the context of safety net settings shapes the management and treatment of co-occurring CNCP and substance use.
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Affiliation(s)
- Jamie Suki Chang
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
| | - Margot Kushel
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christine Miaskowski
- Physiologic Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Rachel Ceasar
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kara Zamora
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Emily Hurstak
- University of California, San Francisco, San Francisco, California, USA
| | - Kelly R. Knight
- Department of Anthropology, History & Social Medicine, University of California, San Francisco, San Francisco, California, USA
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Arteta J, Cobos B, Hu Y, Jordan K, Howard K. Evaluation of How Depression and Anxiety Mediate the Relationship Between Pain Catastrophizing and Prescription Opioid Misuse in a Chronic Pain Population. PAIN MEDICINE 2017; 17:295-303. [PMID: 26235471 DOI: 10.1111/pme.12886] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE We investigated the extent to which anxiety and depression mediate the relationship between pain catastrophizing and the risk of prescription opioid misuse in chronic pain patients. METHODS 215 patients with chronic occupational musculoskeletal disorders completed self-report measures upon admission to a functional restorational program. A bootstrap multivariate regression analysis was conducted to assess how depression and anxiety mediated the relationship between pain catastrophizing and prescription opioid misuse. RESULTS Catastrophizing, anxiety, and depression predicted higher risk for prescription opioid misuse. Furthermore, anxiety and depression acted as mediators while controlling for the effects of gender and age. Finally, it was found that the effects of catastrophizing on risk for prescription opioid misuse were completely eliminated by those of depression. CONCLUSION Due to the partially independent relationship of anxiety and catastrophizing, it is recommended that treatments for chronic pain patients employ techniques addressing both behaviors. The relationship between depression and catastrophizing requires more research since it was observed that their effects were confounded.
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Lovejoy TI, Dobscha SK, Turk DC, Weimer MB, Morasco BJ. Correlates of prescription opioid therapy in Veterans with chronic pain and history of substance use disorder. ACTA ACUST UNITED AC 2016; 53:25-36. [PMID: 27005461 DOI: 10.1682/jrrd.2014.10.0230] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 04/02/2015] [Indexed: 11/05/2022]
Abstract
Patients with a history of substance use disorder (SUD) are more likely to be prescribed opioid medications for chronic pain than patients without an SUD history; however, little is known about prescription opioid therapy in populations composed exclusively of patients with SUD. This study examined correlates of prescription opioid therapy in 214 Veterans with chronic noncancer pain and an SUD history. Participants completed psychosocial questionnaires and participated in a structured mental health diagnostic interview, and medical diagnoses and opioid pharmacy data were abstracted from their Department of Veterans Affairs electronic medical records. Participants were categorized into three groups based on opioid prescriptions in the past 90 d: no opioid therapy (n = 134), short-term (<90 d) opioid therapy (n = 31), or long-term (>/= 90 d) opioid therapy (n = 49). Relative to participants prescribed no or short-term opioid therapy, participants who were prescribed long-term opioid therapy had a greater number of pain diagnoses; reported higher levels of pain severity, interference, and catastrophizing; and endorsed lower chronic pain self-efficacy. In a multivariate model, number of pain diagnoses and pain interference were associated with a greater likelihood of being prescribed long-term opioid therapy after controlling for demographic and clinical characteristics. Findings highlight the poor pain-related functioning in patients with SUD histories who are prescribed long-term opioid therapy.
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Affiliation(s)
- Travis I Lovejoy
- Mental Health and Clinical Neurosciences Division and Center to Improve Veteran Involvement in Care, Department of Veterans Affairs Portland Health Care System, Portland, OR; and Department of Psychiatry, Oregon Health and Science University, Portland, OR
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Higher Prescription Opioid Dose is Associated With Worse Patient-Reported Pain Outcomes and More Health Care Utilization. THE JOURNAL OF PAIN 2016; 18:437-445. [PMID: 27993558 DOI: 10.1016/j.jpain.2016.12.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/28/2016] [Accepted: 12/06/2016] [Indexed: 01/24/2023]
Abstract
Some previous research has examined pain-related variables on the basis of prescription opioid dose, but data from studies involving patient-reported outcomes have been limited. This study examined the relationships between prescription opioid dose and self-reported pain intensity, function, quality of life, and mental health. Participants were recruited from 2 large integrated health systems, Kaiser Permanente Northwest (n = 331) and VA Portland Health Care System (n = 186). To be included, participants had to have musculoskeletal pain diagnoses and be receiving stable doses of long-term opioid therapy. We divided participants into 3 groups on the basis of current prescription opioid dose in daily morphine equivalent dose (MED): low dose (5-20 mg MED), moderate dose (20.1-50 mg MED), and higher dose (50.1-120 mg MED) groups. A statistically significant trend emerged where higher prescription opioid dose was associated with moderately sized effects including greater pain intensity, more impairments in functioning and quality of life, poorer self-efficacy for managing pain, greater fear avoidance, and more health care utilization. Rates of potential alcohol and substance use disorders also differed among groups. Findings from this evaluation reveal significant differences in pain-related and substance-related factors on the basis of prescription opioid dose. PERSPECTIVE This study included 517 patients who were prescribed long-term opioid therapy and compared differences on pain- and mental health-related variables on the basis of prescription opioid dose. Findings reveal small- to medium-sized differences on pain-related variables, alcohol and substance use, and health care utilization on the basis of the dose of opioid prescribed.
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89
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Chaudhary S, Compton P. Use of risk mitigation practices by family nurse practitioners prescribing opioids for the management of chronic nonmalignant pain. Subst Abus 2016; 38:95-104. [DOI: 10.1080/08897077.2016.1265038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Sahil Chaudhary
- Department of Health Systems Administration, Georgetown University, Washington, DC, USA
| | - Peggy Compton
- Department of Advanced Nursing Practice, Georgetown University, Washington, DC, USA
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90
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Baker TE, Chang G. The use of auricular acupuncture in opioid use disorder: A systematic literature review. Am J Addict 2016; 25:592-602. [PMID: 28051842 DOI: 10.1111/ajad.12453] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 09/08/2016] [Accepted: 09/11/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Opioid use disorder (OUD) is a chronic disease with significant personal, societal, and public health consequences. Even for the minority who receive the most effective evidence-based treatments, morbidity, and mortality remain significant. These facts, along with the recovery movement calling for individualized, holistic, culturally sensitive care, have led to the exploration of adjunctive interventions including acupuncture. Despite hundreds of international trials, however, there is a lack of consensus regarding its efficacy in OUD due in large part to methodological issues of trials to date. In response to these issues, the National Acupuncture Detoxification Association (NADA) developed an operationalized manual auricular acupuncture protocol that has since become the most widely used in the US. This systematic review is the first to focus explicitly on randomized trials utilizing the NADA protocol as a complementary intervention to address OUD. METHODS The methods utilized to identify studies for inclusion are based on a 2009 protocol developed by the Cochrane Collaboration. RESULTS Four trials met inclusion criteria. Despite methodological issues, results indicate that while the NADA protocol may not be effective in reducing acute opiate craving or withdrawal, it may be effectively utilized as an adjunctive treatment to increase treatment retention and decrease methadone detoxification and maintenance dosages in OUD. CONCLUSION AND SCIENTIFIC SIGNIFICANCE Incorporation of the NADA protocol into existing evidence-based treatment approaches may facilitate recovery and, through its impact on treatment retention and completion, indirectly impact morbidity, and mortality in individuals with OUD. Given the limitations of the current review, conclusions are tentative and directions for future research are discussed. (Am J Addict 2016;25:592-602).
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Affiliation(s)
- Tanya E Baker
- Veterans Affairs Boston Healthcare System, Department of Psychiatry, Brockton, Massachusetts
| | - Grace Chang
- Veterans Affairs Boston Healthcare System, Department of Psychiatry, Brockton, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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91
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Ilgen MA, Bohnert ASB, Chermack S, Conran C, Jannausch M, Trafton J, Blow FC. A randomized trial of a pain management intervention for adults receiving substance use disorder treatment. Addiction 2016; 111:1385-93. [PMID: 26879036 DOI: 10.1111/add.13349] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 07/22/2015] [Accepted: 02/10/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Chronic pain is difficult to treat in individuals with substance use disorders and, when not resolved, can have a negative impact on substance use disorder treatment outcomes. This study tested the efficacy of a psychosocial pain management intervention, ImPAT (improving pain during addiction treatment), that combines pain management with content related to managing pain without substance use. DESIGN Single-site, parallel-groups randomized controlled trial comparing ImPAT to a supportive psychoeducational control (SPC) condition; follow-up assessments occurred at 3, 6 and 12 months. SETTING The Ann Arbor VA Substance Use Disorder treatment program, USA. PARTICIPANTS Veterans Health Administration patients {n = 129; mean [standard deviation (SD)], age = 51.7 (9.5); 115 of 129 (89%) male; ImPAT (n = 65); SPC (n = 64)}. INTERVENTION ImPAT combines principles of cognitive-behavioral therapy and acceptance-based approaches to pain management with content related to avoiding the use of substances as a coping mechanism for pain. The SPC used a psychoeducational attention control treatment for alcoholism modified to cover other substances in addition to alcohol. MEASUREMENTS Primary: Pain intensity over 12 months; secondary: pain-related functioning, frequency of alcohol and drug use over 12 months. FINDINGS Primary: randomization to the ImPAT intervention versus SPC predicted significantly lower pain intensity {β [standard error (SE)] = -0.71 (0.29); 95% confidence interval (CI) = -1.29, -0.12}; secondary: relative to the SPC condition, those who received ImPAT also reported improved pain-related functioning [β (SE) = 0.27 (0.11); 95% CI = 0.05, 0.49] and lower frequency of alcohol consumption [β (SE) = -0.77; 95% CI = -1.34, -0.20]. No differences were found between conditions on frequency of drug use over follow-up. CONCLUSIONS For adults with pain who are enrolled in addictions treatment, receipt of a psychological pain management intervention (improving pain during addiction treatment) reduced pain and alcohol use and improves pain-related functioning over 12 months relative to a matched-attention control condition.
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Affiliation(s)
- Mark A Ilgen
- VA Center for Clinical Management Research (CCMR), Veterans Health Administration, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research (CCMR), Veterans Health Administration, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Stephen Chermack
- VA Center for Clinical Management Research (CCMR), Veterans Health Administration, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Carly Conran
- School of Literature, Science and Arts, University of Michigan, Ann Arbor, MI, USA
| | - Mary Jannausch
- VA Center for Clinical Management Research (CCMR), Veterans Health Administration, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Jodie Trafton
- VA Program Evaluation and Resource Center (PERC), Veterans Health Administration, Menlo Park, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA
| | - Frederic C Blow
- VA Center for Clinical Management Research (CCMR), Veterans Health Administration, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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92
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Morasco BJ, Greaves DW, Lovejoy TI, Turk DC, Dobscha SK, Hauser P. Development and Preliminary Evaluation of an Integrated Cognitive-Behavior Treatment for Chronic Pain and Substance Use Disorder in Patients with the Hepatitis C Virus. PAIN MEDICINE 2016; 17:2280-2290. [PMID: 28025362 DOI: 10.1093/pm/pnw076] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Individuals with the hepatitis C virus (HCV) have high rates of both chronic pain and substance use disorder (SUD). Despite high comorbidity, there are limited data available on effective methods of treatment for co-occurring chronic pain and SUD. In this study, we sought to develop and conduct preliminary testing of an integrated cognitive-behavior therapy (CBT) for chronic pain and SUD in patients with HCV. DESIGN Descriptive, including pretreatment, posttreatment, and follow-up testing. SETTING AND PATIENTS Outpatient clinic as part of one VA Medical Center. PARTICIPANTS Veterans with chronic pain, SUD, and HCV. INTERVENTION Eight-session integrated group CBT for chronic pain and SUD in patients with HCV. METHODS Participants completed standardized measures of pain, function, depression severity, and alcohol and substance use at baseline, post-treatment, and 3-month follow-up. RESULTS Generalized estimating equations identified improvements in pain interference, reducing cravings for alcohol and other substances, and decreasing past-month alcohol and substance use. The proportion of participants who met diagnostic criteria for current SUD demonstrated a four-fold decrease over the course of the study from 24% at baseline to 15% at post-treatment and 6% at 3-month follow-up. On response to a global impression of change, 94% of participants noted improvement from baseline. CONCLUSIONS Results from this pilot study suggest that a customized CBT for patients with both chronic pain and SUD (CBT-cp.sud) may be beneficial in improving important pain and addiction-related outcomes in patients with HCV. Larger scale investigations of this intervention appear warranted.
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Affiliation(s)
- Benjamin J Morasco
- *Center to Improve Veteran Involvement in Care .,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - David W Greaves
- Mental Health and Clinical Neurosciences Division, VA Portland Health Care System, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Travis I Lovejoy
- *Center to Improve Veteran Involvement in Care.,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine and Center for Pain Research on Impact, Measurement, & Effectiveness, University of Washington, Seattle, Washington
| | - Steven K Dobscha
- *Center to Improve Veteran Involvement in Care.,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Peter Hauser
- VISN 22 Network Office and Division of Mental Health, Long Beach VA Medical Center, California.,Department of Psychiatry, University of California San Diego.,Department of Psychiatry and Human Behavior, University of California-Irvine, California, USA
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93
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Treatment Approaches for Patients With Opioid Use Disorder and Chronic Noncancer Pain: a Literature Review. ADDICTIVE DISORDERS & THEIR TREATMENT 2016. [DOI: 10.1097/adt.0000000000000078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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94
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95
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Dobscha SK, Lovejoy TI, Morasco BJ, Kovas AE, Peters DM, Hart K, Williams JL, McFarland BH. Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain. THE JOURNAL OF PAIN 2016; 17:824-35. [PMID: 27058162 DOI: 10.1016/j.jpain.2016.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
UNLABELLED Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes. PERSPECTIVE This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon.
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Dawn M Peters
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kyle Hart
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - J Lucas Williams
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon; Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
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96
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Wittenberg E, Bray JW, Aden B, Gebremariam A, Nosyk B, Schackman BR. Measuring benefits of opioid misuse treatment for economic evaluation: health-related quality of life of opioid-dependent individuals and their spouses as assessed by a sample of the US population. Addiction 2016; 111:675-84. [PMID: 26498740 PMCID: PMC5034732 DOI: 10.1111/add.13219] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/16/2015] [Accepted: 09/28/2015] [Indexed: 11/28/2022]
Abstract
AIMS To understand how the general public views the quality of life effects of opioid misuse and opioid use disorder on an individual and his/her spouse, measured in terms used in economic evaluations. DESIGN Cross-sectional internet survey of a US population-representative respondent panel conducted December 2013-January 2014. SETTING United States. PARTICIPANTS A total of 2054 randomly selected adults; 51.1% male (before weighting). MEASUREMENTS Mean (95% confidence interval) and median health 'utility' for six opioid misuse and treatment outcomes: active injection misuse; active prescription misuse; methadone maintenance therapy at initiation and when stabilized in treatment; and buprenorphine therapy at initiation and when stabilized. Utility is a numerical representation of health-related quality of life used in economic evaluations to 'adjust' estimated survival to include peoples' preferences for health states. Utilities are determined by surveying the general population to estimate the value they assign to particular health states on a scale where 0 = the value of being dead and 1.0 = the value of being in perfect health. Spouse spillover utility is assigned to a spouse of an individual who is in a particular health state. FINDINGS Mean individual utility ranged from 0.574 [95% confidence interval (CI) = 0.538, 0.611] for active injection opioid misuse to 0.766 for stabilized buprenorphine therapy (95% CI = 0.738, 0.795), with other states in between. Female respondents assigned higher utility to the active prescription misuse and buprenorphine therapy at initiation states than did males (P < 0.05); all other states did not differ by respondent gender. Mean spousal utilities were significantly lower than 1.0 but mostly higher than individual utility, and were similar between male and female respondents. CONCLUSIONS In the opinion of the US public, injection opioid misuse results in worse health-related quality of life than prescription misuse, and methadone therapy results in worse health-related quality of life than buprenorphine therapy. Spouses are negatively affected by their partner's opioid misuse and early treatment.
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Affiliation(s)
- Eve Wittenberg
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jeremy W. Bray
- Department of Economics, University of North Carolina at Greensboro, Greensboro, NC, USA
| | - Brandon Aden
- Department of Healthcare Policy and Research and Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | | | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research and Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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97
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González-Sepúlveda M, Pozo OJ, Marcos J, Valverde O. Chronic pain causes a persistent anxiety state leading to increased ethanol intake in CD1 mice. J Psychopharmacol 2016; 30:188-203. [PMID: 26681793 DOI: 10.1177/0269881115622238] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Mood disorders and chronic pain are closely linked, but limited progress has been made in understanding the role of chronic and neuropathic pain in the aetiopathogenesis of depression. To explore the pathological mechanisms that mediate the association between pain and depressive-like behaviours, we studied the time-dependent effect of neuropathic pain on the development of anxiety-like and despair behaviours in CD1 mice. We analysed behavioural data, neuroinflammation reactions and changes in neurotransmitter (glutamate and serotonin) levels in the mouse prefrontal cortex. Sciatic-operated mice displayed long-lasting anxiety-like and despair behaviours, starting 5 and 20 days after partial sciatic nerve ligation, respectively. Glutamatergic neurotransmission and IL-1β cytokine expression were enhanced in the prefrontal cortex of mice with neuropathic pain. We found no change in serotonin metabolism, cytokine IL-6 or brain-derived neurotrophic factor levels. While sciatic-operated mice exposed to intermittent ethanol intake (20% v/v) using the drinking in the dark procedure consumed higher amounts of ethanol than sham-operated mice, thermal allodynia and despair behaviour were not attenuated by ethanol consumption. Our findings reveal an association between glutamatergic neurotransmission and pain-induced mood disorders, and indicate that moderate ethanol consumption does not relieve nociceptive and depressive behaviours associated with chronic pain in mice.
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Affiliation(s)
- Marta González-Sepúlveda
- Grup de Recerca en Neurobiologia del Comportament (GReNeC), Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, PRBB, Barcelona, Spain
| | - Oscar J Pozo
- Bioanalysis Research Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Josep Marcos
- Bioanalysis Research Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, PRBB, Barcelona, Spain
| | - Olga Valverde
- Grup de Recerca en Neurobiologia del Comportament (GReNeC), Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, PRBB, Barcelona, Spain Neuroscience Research Programme, IMIM-Hospital del Mar Research Institute, Barcelona, Spain
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98
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Lin LA, Bohnert ASB, Price AM, Jannausch M, Bonar EE, Ilgen MA. Pain acceptance and opiate use disorders in addiction treatment patients with comorbid pain. Drug Alcohol Depend 2015; 157:136-42. [PMID: 26530502 DOI: 10.1016/j.drugalcdep.2015.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/08/2015] [Accepted: 10/11/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Studies from pain treatment settings indicate that poor acceptance of pain may be an important and modifiable risk factor for higher severity of opioid use. However, the degree to which pain acceptance relates to opioid use severity in the addiction treatment population is unknown. In this study of addiction treatment patients with co-morbid pain, we examined correlates of severity of opiate (heroin and prescription opioid) use, with a particular focus on the role of pain acceptance. METHODS Patients in residential addiction treatment with comorbid pain (N=501) were stratified into low, moderate and high severity of opiate use. Demographic and clinical characteristics were compared across opiate severity categories. RESULTS 72% (N=360) of the participants had symptoms that were consistent with an opiate use disorder. Younger age, Caucasian race, female gender, cocaine use and lower pain acceptance were associated with higher severity of opiate use, whereas pain intensity was not. Controlling for demographic and other risk factors, such as substance use and pain intensity, higher pain acceptance was associated with lower odds of severe prescription opioid (AOR 0.50, 95% CI 0.38-0.68 for a one SD increase in pain acceptance) and heroin use (AOR 0.57, 95% CI 0.44-0.75 for a one SD increase in pain acceptance). CONCLUSIONS Problematic opiate use is common in addictions treatment patients with chronic pain. Lower pain acceptance is related to greater opiate use severity, and may be an important modifiable target for interventions to successfully treat both pain and opiate use disorders.
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Affiliation(s)
- Lewei Allison Lin
- University of Michigan, Department of Psychiatry, North Campus Research Complex, 2800 Plymouth Road, Ann Arbor, MI 48109, United States.
| | - Amy S B Bohnert
- University of Michigan, Department of Psychiatry, North Campus Research Complex, 2800 Plymouth Road, Ann Arbor, MI 48109, United States
| | - Amanda M Price
- University of Michigan, Department of Psychiatry, North Campus Research Complex, 2800 Plymouth Road, Ann Arbor, MI 48109, United States
| | - Mary Jannausch
- University of Michigan, Department of Psychiatry, North Campus Research Complex, 2800 Plymouth Road, Ann Arbor, MI 48109, United States
| | - Erin E Bonar
- University of Michigan, Department of Psychiatry, North Campus Research Complex, 2800 Plymouth Road, Ann Arbor, MI 48109, United States
| | - Mark A Ilgen
- University of Michigan, Department of Psychiatry, North Campus Research Complex, 2800 Plymouth Road, Ann Arbor, MI 48109, United States
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99
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Hefner K, Sofuoglu M, Rosenheck R. Concomitant cannabis abuse/dependence in patients treated with opioids for non-cancer pain. Am J Addict 2015; 24:538-45. [PMID: 26246069 DOI: 10.1111/ajad.12260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/06/2015] [Accepted: 07/03/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cannabis use is common among patients taking prescription opioids, although rates of concomitant cannabis use disorder (CUD) have been largely unexamined. CUD may increase safety risks in those taking opioid pain medications but it is unknown whether cannabis and opioids function as substitutes (cannabis use is associated with less prescription opioid use), or rather as complements (cannabis is associated with increased use of prescription opioids). METHODS We examined rates of CUD in a national sample of Veterans Health Administration (VHA) patients (n = 1,316,464) with non-cancer pain diagnoses receiving opioid medications in fiscal year 2012. Using bivariate analysis to identify potentially confounding variables associated with CUD (e.g., psychotropic medication, other substance use disorders) in this population, we then utilized logistic regression to examine rates of cannabis use disorder among individuals receiving different numbers of opioid prescriptions (0, 1-2, 3-10, 11-19, 20+). RESULTS Descriptive analysis, largely confirmed by logistic regression, demonstrated that greater numbers of prescription opioid fills were associated with greater likelihood of CUD. This relationship was reduced somewhat for those receiving the most opioid prescriptions (20+) in the logistic regression, which controlled for potentially confounding variables. DISCUSSION AND CONCLUSIONS These results warrant increased attention to CUDs among patients receiving numerous opioid prescriptions. Increasing legalization of cannabis is likely to further increase use and abuse of cannabis in patients prescribed opioids. SCIENTIFIC SIGNIFICANCE These findings suggest that clinicians should be alert to concomitant CUD and prescription opioid use, as these substances appear to complement each other.
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Affiliation(s)
- Kathryn Hefner
- Veterans Health Administration Mental Illness Research, Education and Clinical Center (MIRECC), West Haven, Connecticut.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Mehmet Sofuoglu
- Veterans Health Administration Mental Illness Research, Education and Clinical Center (MIRECC), West Haven, Connecticut.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Robert Rosenheck
- Veterans Health Administration Mental Illness Research, Education and Clinical Center (MIRECC), West Haven, Connecticut.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
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100
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Witkiewitz K, Vowles KE, McCallion E, Frohe T, Kirouac M, Maisto SA. Pain as a predictor of heavy drinking and any drinking lapses in the COMBINE study and the UK Alcohol Treatment Trial. Addiction 2015; 110:1262-71. [PMID: 25919978 PMCID: PMC4503502 DOI: 10.1111/add.12964] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 01/20/2015] [Accepted: 04/20/2015] [Indexed: 01/28/2023]
Abstract
AIMS To test the association between pain and heavy drinking lapses during and following treatment for alcohol use disorders (AUD). DESIGN Secondary data analysis of data from two clinical trials for AUD. SETTING AND PARTICIPANTS Participants included 1383 individuals from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study in the United States [69.0% male, 76.8% non-Hispanic White average age=44.4, standard deviation (SD) = 10.2] and 742 individuals from the UK Alcohol Treatment Trial (UKATT) in the United Kingdom [74.1% male, 95.6% White, average age=41.6 (SD=10.1)]. MEASUREMENTS Form-90 (a structured assessment interview) was used to assess the primary outcome: time to first heavy drinking day. The Short Form Health Survey and Quality of Life measures were used to assess pain interference and pain intensity. FINDINGS Pain was a significant predictor of heavy drinking lapses during treatment in UKATT [odds ratio (OR)=1.19, 95% confidence interval (CI)=1.08, 1.32, P=0.0003] and COMBINE (OR=1.12, 95% CI=1.03, 1.21, P=0.009), and was a significant predictor of heavy drinking lapses following treatment in COMBINE (OR=1.163, 95% CI=1.15, 1.17, P<0.00001). After controlling for other relapse risk factors (e.g. dependence severity, self-efficacy, temptation, psychiatric distress), pain remained a significant predictor of heavy drinking lapses during treatment in UKATT (OR=1.19, 95% CI=1.06, 1.34, P=0.004) and following treatment in COMBINE (OR=1.44, 95% CI=1.07, 1.92, P=0.01). CONCLUSIONS Among people treated for alcohol use disorder, being in physical pain appears to predict heavy drinking lapses during or after treatment.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Center on Alcoholism, Substance Abuse and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Kevin E Vowles
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | | | - Tessa Frohe
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Center on Alcoholism, Substance Abuse and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Megan Kirouac
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Center on Alcoholism, Substance Abuse and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Stephen A Maisto
- Department of Psychology, Syracuse University, Syracuse, NY, USA
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