The prescribed opioids difficulties scale: a patient-centered assessment of problems and concerns

Inhibitory effect of bacopasides on spontaneous morphine withdrawal induced depression in mice

Bacopa monnieri is a perennial herb with a world known image as a nootropic. We investigated the effect of Bacopa monnieri methanolic extract (Mt Ext BM) 10, 20, and 30 mg/kg body weight (b.w) on acquisition and expression of morphine withdrawal induced depression in mice. Locally available Bacopa monnieri (BM) was screened for contents of Bacoside A3, Bacopasaponin C, and Bacopaside II using HPLC with UV. Morphine dependence was induced in mice using twice daily escalating chronic morphine treatments (20-65 mg/kg b.w) for eight consecutive days. Morphine withdrawal induced depression was assayed in animals using forced swimming test (FST), three days after last morphine injection. The HPLC analysis revealed that Mt-ext BM contained Bacoside A3 as major component, i.e. 4 µg in each mg of extract. The chronic treatment with Met Ext BM 10, 20, and 30 mg/kg b.w. dosing significantly inhibited opioid withdrawal induced depression in mice. These findings imply a newer potential role of Bacopa monnieri in the clinical management of opioid withdrawal induced depression which can be attributed to Bacoside A3.

A research agenda for enhancing appropriate opioid prescribing in primary care

The challenges facing patients and providers in managing ongoing opioid analgesic therapy for chronic pain are complex. Benefit of long-term opioid therapy, for which there are scant data, must be balanced against myriad potential undesired outcomes, including safety problems, ranging from mild toxicities to overdose and death; inadequate efficacy, which may mean continued patient suffering and unwarranted exposure to toxicities; and misuse of these potent medications. To help patients and providers navigate these challenges and optimize therapy, we present a research agenda in which we first characterize appropriate ongoing opioid prescribing and then describe three areas where quality improvement work is needed: 1) developing brief validated measures of patient-reported safety, efficacy, and misuse that improve outcomes; 2) designing evidence-based algorithms to guide changes in therapy when issues related to safety, efficacy or misuse are identified; and 3) promoting use of patient-centered, multi-modal treatment plans.

Chronic pain and the development of a symptom checklist: a pilot study

BACKGROUND

There is currently no instrument to systematically assess the range of symptoms/problems and their bothersomeness in patients with chronic non-cancer pain (CNPN). Systematic assessment and prioritizing may target treatments and improve outcomes.

METHODS

The authors developed a checklist of symptoms and problems, the Copenhagen Symptom Checklist (CSC), presented clinically by patients. Fifty-three items representing biological, psychological and social areas were selected. Symptom/problem severity was rated on a 5-point scale anchored at 0 = 'not at all' and 4 = 'severe'. Patients ranked the five most bothersome symptoms/problems and could add five open-ended items. Patients completed the CSC after the first visit at the multidisciplinary pain centre.

RESULTS

One hundred and twelve consecutive patients completed the CSC. Eighty-nine percent scored pain as rather severe or very severe (score = 3 plus score = 4), followed by reduction in physical activity (67%), fatigue (66%) and sleep disturbance (53%). Pain and fatigue, but not reduction in physical activity, were given highest priority. Cognitive problems were important to a third of the patients. Depressive symptoms, cognitive problems and worry explained 17.5% of the total variance. Patients filled in the CSC without important loss of information, but a minority prioritized more than three areas or used the free text alternative.

CONCLUSIONS

Patients prioritized pain and fatigue as the most burdensome symptoms, but reduction in physical activity and sleep problems were also highly ranked. Patients were positive to the idea of symptom reporting; however, the 53-item number in this version of CSC is larger than may be necessary.

Instruments to assess patient-reported safety, efficacy, or misuse of current opioid therapy for chronic pain: a systematic review

The purpose of this systematic review was to summarize and critically appraise research developing or validating instruments to assess patient-reported safety, efficacy, and/or misuse in ongoing opioid therapy for chronic pain. Our search included the following datasets: OvidSP MEDLINE (1946-August 2012), OvidSP PsycINFO (1967-August 2012), Elsevier Scopus (1947-August 2012), OvidSP HaPI (1985-August 2012), and EBSCO CINAHL (1981-August 2012). Eligible studies were published in English and pertained to adult, nonsurgical/interventional populations. Two authors independently assessed inclusion criteria. Each study was evaluated by 2 authors to assess the sources and content of items, types of psychometric tests, their results, and quality of diagnostic accuracy testing, when applicable. Of 1874 citations found in the initial search, we identified 14 studies meeting our inclusion criteria, describing 9 different instruments. Individual items were derived from surveys of content experts, literature reviews, and adapted non-patient-reported items. Misuse-related items were most prevalent (60/144; 42%), followed by safety (47/144; 33%), with efficacy having the fewest items (17/144; 12%). The studies employed a wide variety of psychometric tests, with most demonstrating statistical significance, but several potential sources of bias and generalizability limitations were identified. Lack of testing in clinical practice limited assessment of feasibility. The dearth of safety and efficacy items and lack of testing in clinical practice demonstrates areas for further research.

Depression and ambivalence toward chronic opioid therapy for chronic noncancer pain

OBJECTIVES

Chronic opioid therapy (COT) for chronic noncancer pain (CNCP) is characterized by both high rates of patient-initiated discontinuation and by perceived helpfulness among those who sustain opioid use. This study examines predictors of the desire to cut down or stop opioid therapy among patients receiving COT who report that opioids are helpful for relieving pain.

METHODS

We conducted a cross-sectional survey of 1737 selected patients receiving COT for CNCP who perceived opioids to be helpful in relieving their pain. Ambivalence about opioid use was assessed by agreement/disagreement with a statement indicating that they would like to stop or cut down the use of prescribed opioid medications. Depression was measured with the 8-item Patient Health Questionnaire.

RESULTS

A high percentage (43.3%) of survey respondents who found opioids helpful also reported the desire to stop or cut down opioids. Half of these patients reporting the desire to stop or cut down were clinically depressed, compared with a third of those not wanting to stop or cut down, a highly significant difference after controlling for covariates (P<0.0001). The group wanting to stop or cut down opioid use also reported significantly higher levels of opioid-related psychosocial problems and opioid control concerns.

DISCUSSION

There are high rates of ambivalence about opioid use among COT recipients who consider opioids helpful for pain relief. Depressed patients are more likely to be ambivalent about use of prescribed opioids. Eliciting patient ambivalence may be helpful in patients who are not benefiting from long-term opioid use as an initial step toward consideration of discontinuation.

Prescribed opioid difficulties, depression and opioid dose among chronic opioid therapy patients

BACKGROUND

Chronic opioid therapy has increased dramatically, as have complications related to prescription opioids. Little is known about the problems and concerns attributed to opioids by patients receiving different opioid doses.

METHODS

We surveyed 1883 patients who were receiving chronic opioid therapy for chronic noncancer pain. Opioid regimen characteristics were ascertained from electronic pharmacy records. Patient-reported opioid-related problems and concerns were measured using the Prescription Opioid Difficulties Scale. Depression was assessed with the Patient Health Questionnaire.

RESULTS

Patients prescribed higher opioid doses reported modestly higher pain intensity and pain impact. After adjustment, patients on higher doses attributed higher levels of psychosocial problems and control concerns to prescribed opioids (P<.0001). They also had higher levels of depression and were more likely to meet criteria for clinical depression. Over 60% of patients receiving 120+ mg daily (morphine equivalent) were clinically depressed, a 2.6-fold higher risk (95% confidence interval: 1.5-4.4) than patients on low-dose regimens (<20 mg daily).

CONCLUSIONS

Higher opioid doses were associated with somewhat higher pain severity and higher levels of patient-reported opioid-related psychosocial problems, control concerns and depression. These findings may result from patient selection for high-dose therapy or problems caused by higher-dose opioids.

Time-scheduled vs. pain-contingent opioid dosing in chronic opioid therapy

Some expert guidelines recommend time-scheduled opioid dosing over pain-contingent dosing for patients receiving chronic opioid therapy (COT). The premise is that time-scheduled dosing results in more stable opioid blood levels and better pain relief, fewer adverse effects, less reinforcement of pain behaviors, and lower addiction risk. We report results of a survey of 1781 patients receiving COT for chronic noncancer pain, in which 967 reported time-scheduled opioid dosing only and 325 reported pain-contingent opioid dosing only. Opioid-related problems and concerns were assessed with the Prescribed Opioids Difficulties Scale. We hypothesized that respondents using time-scheduled opioid dosing would report significantly fewer problems and concerns than those using pain-contingent dosing. Patients receiving time-scheduled dosing received substantially higher average daily opioid doses than those using pain-contingent dosing (97.2 vs. 37.2mg average daily dose morphine equivalents, P < .0001). Contrary to expectation, time-scheduled opioid dosing was associated with higher levels of patient opioid control concerns than pain-contingent dosing (6.2 vs. 4.8, P=.008), after adjusting for patient and drug regimen differences. Opioid-related psychosocial problems were somewhat greater among patients using time-scheduled dosing, but this difference was nonsignificant after controlling for patient and drug regimen differences (5.9 vs. 5.0, P=.14). Time-scheduled dosing typically involved higher dosage levels and was associated with higher levels of patient concerns about opioid use. Controlled comparative effectiveness research is needed to assess benefits and risks of time-scheduled opioid dosing relative to pain-contingent opioid dosing among COT patients in ambulatory care. Patients with time-scheduled dosing received higher opioid dosage than patients with pain-contingent dosing. Time-scheduled dosing was associated with greater opioid control concerns than pain-contingent dosing.

Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management

How we frame our thoughts about chronic opioid therapy greatly influences our ability to practice patient-centered care. Even providers who strive to be nonjudgmental may approach clinical decision-making about opioids by considering if the pain is real or they can trust the patient. Not only does this framework potentially lead to poor or unshared decision-making, it likely adds to provider and patient discomfort by placing the provider in the position of a police officer or a judge. Similarly, providers often find themselves making deals with patients using a positional bargaining approach. Even if a compromise is reached, this framework can potentially inadvertently weaken the therapeutic relationship by encouraging the idea that the patient and provider have opposing goals. Reframing the issue can allow the provider to be in a more therapeutic role. As recommended in the American Pain Society/American Academy of Pain Medicine guidelines, providers should decide whether the benefits of opioid therapy are likely to outweigh the harms for a specific patient (or sometimes, for society) at a specific time. This article discusses how providers can use a benefit-to-harm framework to make and communicate decisions about the initiation, continuation, and discontinuation of opioids for managing chronic nonmalignant pain. Such an approach focuses decisions and discussions on judging the treatment, not the patient. It allows the provider and the patient to ally together and make shared decisions regarding a common goal. Moving to a risk-benefit framework may allow providers to provide more patient-centered care, while also increasing provider and patient comfort with adequately monitoring for harm.