51
|
Champagne-Langabeer T, Madu R, Giri S, Stotts AL, Langabeer JR. Opioid prescribing patterns and overdose deaths in Texas. Subst Abus 2019; 42:161-167. [PMID: 31644388 DOI: 10.1080/08897077.2019.1675114] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Opioid use disorder has recently been declared a public health emergency, yet it is unknown whether opioid prescribing patterns have changed over time. Our objective is to examine opioid prescribing behavior and overdose fatalities in one large state prior to state-mandated usage of a prescription drug monitoring program (PDMP). Methods: We relied on de-identified longitudinal data from state and national databases for opioid prescriptions and overdose deaths in Texas between 2013 and 2017. Descriptive statistics and trend analyses were used to assess proportional differences and changes over time. Results: Prescriptions for opioids represented over 45% of the total controlled medications dispensed across the entire period. This equates to roughly 17.7 million opioid prescriptions dispensed per year, or 63.7 opioid prescriptions per 100 persons, slightly less than the reported national average. Hydrocodone was the most widely prescribed opioid (32.9%), followed by tramadol (26.9%) and codeine (21.5%). The overall controlled substance prescribing rate appears to be decreasing in the latest year, and the composition of opioids has shifted. We found a reduction in schedule II medications (such as hydrocodone and fentanyl) and increase in schedule IV medications such as tramadol. At the same time, total overdose fatalities increased 42% during this time, and population-adjusted rates increased 34% to 5.87 deaths per 100,000 persons. Conclusions: While prescribing rates have decreased in Texas, overdose deaths from both legal and illicit opioids are rising, suggesting that changing physician prescribing behavior alone may not be sufficient to curb the epidemic. Policies and community interventions should be considered to address increases in both prescription and illicit opioid deaths.
Collapse
Affiliation(s)
| | - Renita Madu
- School of Public Health, The University of Texas Health Science Center, Houston, Texas, USA
| | - Sharmila Giri
- School of Biomedical Informatics, The University of Texas Health Science Center, Houston, Texas, USA
| | - Angela L Stotts
- Family and Community Medicine, The University of Texas Health Science Center, Houston, Texas, USA
| | - James R Langabeer
- School of Biomedical Informatics, The University of Texas Health Science Center, Houston, Texas, USA.,Department of Emergency Medicine, The University of Texas Health Science Center, Houston, Texas, USA
| |
Collapse
|
52
|
Flexon JL, Stolzenberg L, D'Alessio SJ. The effect of cannabis laws on opioid use. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:152-159. [PMID: 31590091 DOI: 10.1016/j.drugpo.2019.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Many Americans rely on opioids at varying dosages to help ameliorate their suffering. However, empirical evidence is mounting that opioids are ineffective at controlling non-cancer related chronic pain, and many argue the strategies meant to relieve patient suffering are contributing to the growing opioid epidemic. Concurrently, several states now allow the use of medical cannabis to treat a variety of medical conditions, including chronic pain. Needing more exploration is the impact of cannabis laws on general opioid reliance and whether chronic pain sufferers are opting to use cannabis medicinally instead of opioids. METHODS This study investigates the effect of Medical Marijuana Laws (MML)s on opioid use and misuse controlling for a number of relevant factors using data from several years of the National Survey on Drug Use and Health and multivariate logistic regression and longitudinal analysis strategies. RESULTS Results provide evidence that MMLs may be effective at reducing opioid reliance as survey respondents living in states with medical cannabis legislation are much less apt to report using opioid analgesics than people living in states without such laws, net other factors. Results further indicate that the presence of medicinal cannabis legislation appears to have no influence over opioid misuse. CONCLUSION MMLs may ultimately serve to attenuate the consequences of opioid overreliance.
Collapse
Affiliation(s)
- Jamie L Flexon
- Department of Criminology and Criminal Justice, Green School of International and Public Affairs, Florida International University, Modesto A. Maidique Campus, 11200 SW 8th Street, PCA-366A, Miami, FL 33199, USA.
| | - Lisa Stolzenberg
- Department of Criminology and Criminal Justice, Green School of International and Public Affairs, Florida International University, Modesto A. Maidique Campus, 11200 SW 8th Street, PCA-253A, Miami, FL 33199, USA.
| | - Stewart J D'Alessio
- Department of Criminology and Criminal Justice, Green School of International and Public Affairs. Florida International University, Modesto A. Maidique Campus, 11200 SW 8th Street, PCA-263B, Miami, FL 33199, USA.
| |
Collapse
|
53
|
Sears JM, Edmonds AT, Fulton-Kehoe D. Tracking Opioid Prescribing Metrics in Washington State (2012-2017): Differences by County-Level Urban-Rural and Economic Distress Classifications. J Rural Health 2019; 36:152-166. [PMID: 31583779 DOI: 10.1111/jrh.12400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/04/2019] [Accepted: 08/19/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE High-risk opioid prescribing is a critical driver of prescription opioid-related morbidity and mortality. This study explored opioid prescribing patterns across urban-rural and economic distress classifications. Secondarily, this study explored the urban-rural distribution of relevant health services, economic factors, and population characteristics. METHODS County-level opioid prescribing metrics were based on quarterly Washington State Prescription Monitoring Program data (2012-2017). Counties were classified using the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties, and Washington State unemployment-based distressed areas. County-level measures from Area Health Resources Files were used to describe the urban-rural continuum. FINDINGS Persistent economic distress was associated with higher-risk opioid prescribing. The large central metropolitan category had lower-risk opioid prescribing metrics than the other 5 urban-rural categories, which were similar to each other and not ordered by degree of rurality. High-risk prescribing declined over time, without notable trend divergence by either urban-rural or economic distress classifications. CONCLUSIONS The most striking urban-rural differences in opioid prescribing metrics were between large central metropolitan and all other categories; thus, we recommend caution when collapsing urban-rural categories for analysis. Further research is needed regarding geographic and economic patterning of opioid prescribing practices, as well as the dissemination of guidelines and best practices across the urban-rural continuum. Finally, the multiple intertwined burdens faced by rural communities-higher-risk prescribing practices, higher opioid morbidity and mortality rates, and fewer resources for primary care, mental health care, alternative pain treatment, and opioid use disorder treatment-must be addressed as an urgent public health priority.
Collapse
Affiliation(s)
- Jeanne M Sears
- Department of Health Services, University of Washington, Seattle, Washington.,Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, Washington.,Harborview Injury Prevention and Research Center, Seattle, Washington.,Institute for Work & Health, Toronto, Ontario, Canada
| | - Amy T Edmonds
- Department of Health Services, University of Washington, Seattle, Washington
| | - Deborah Fulton-Kehoe
- Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, Washington
| |
Collapse
|
54
|
Gómez-Murcia V, Ribeiro Do Couto B, Gómez-Fernández JC, Milanés MV, Laorden ML, Almela P. Liposome-Encapsulated Morphine Affords a Prolonged Analgesia While Facilitating Extinction of Reward and Aversive Memories. Front Pharmacol 2019; 10:1082. [PMID: 31616299 PMCID: PMC6764324 DOI: 10.3389/fphar.2019.01082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/26/2019] [Indexed: 01/25/2023] Open
Abstract
Morphine is thoroughly used for pain control; however, it has a high addictive potential. Opioid liposome formulations produce controlled drug release and have been thoroughly tested for pain treatment although their role in addiction is still unknown. This study investigated the effects of free morphine and morphine encapsulated in unilamellar and multilamellar liposomes on antinociception and on the expression and extinction of the positive and negative memories associated with environmental cues. The hot plate test was used to measure central pain. The rewarding effects of morphine were analyzed by the conditioned-place preference (CPP) test, and the aversive aspects of naloxone-precipitated morphine withdrawal were evaluated by the conditioned-place aversion (CPA) paradigm. Our results show that encapsulated morphine yields prolonged antinociceptive effects compared with the free form, and that CPP and CPA expression were similar in the free- or encapsulated-morphine groups. However, we demonstrate, for the first time, that morphine encapsulation reduces the duration of reward and aversive memories, suggesting that this technological process could transform morphine into a potentially less addictive drug. Morphine encapsulation in liposomes could represent a pharmacological approach for enhancing extinction, which might lead to effective clinical treatments in drug addiction with fewer side effects.
Collapse
Affiliation(s)
- Victoria Gómez-Murcia
- Department of Pharmacology, Faculty of Medicine, University of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Bruno Ribeiro Do Couto
- Department of Human Anatomy and Psychobiology, Faculty of Psychology, University of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Juan C Gómez-Fernández
- Department of Biochemistry and Molecular Biology A, Faculty of Veterinary, Regional Campus of International Excellence "Campus Mare Nostrum", University of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - María V Milanés
- Department of Pharmacology, Faculty of Medicine, University of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - María L Laorden
- Department of Pharmacology, Faculty of Medicine, University of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Pilar Almela
- Department of Pharmacology, Faculty of Medicine, University of Murcia, IMIB-Arrixaca, Murcia, Spain
| |
Collapse
|
55
|
Li Q, Li X, Wang J, Liu H, Kwong JSW, Chen H, Li L, Chung SC, Shah A, Chen Y, An Z, Sun X, Hemingway H, Tian H, Li S. Diagnosis and treatment for hyperuricemia and gout: a systematic review of clinical practice guidelines and consensus statements. BMJ Open 2019; 9:e026677. [PMID: 31446403 PMCID: PMC6720466 DOI: 10.1136/bmjopen-2018-026677] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Despite the publication of hundreds of trials on gout and hyperuricemia, management of these conditions remains suboptimal. We aimed to assess the quality and consistency of guidance documents for gout and hyperuricemia. DESIGN Systematic review and quality assessment using the appraisal of guidelines for research and evaluation (AGREE) II methodology. DATA SOURCES PubMed and EMBASE (27 October 2016), two Chinese academic databases, eight guideline databases, and Google and Google scholar (July 2017). ELIGIBILITY CRITERIA We included the latest version of international and national/regional clinical practice guidelines and consensus statements for diagnosis and/or treatment of hyperuricemia and gout, published in English or Chinese. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened searched items and extracted data. Four reviewers independently scored documents using AGREE II. Recommendations from all documents were tabulated and visualised in a coloured grid. RESULTS Twenty-four guidance documents (16 clinical practice guidelines and 8 consensus statements) published between 2003 and 2017 were included. Included documents performed well in the domains of scope and purpose (median 85.4%, range 66.7%-100.0%) and clarity of presentation (median 79.2%, range 48.6%-98.6%), but unsatisfactory in applicability (median 10.9%, range 0.0%-66.7%) and editorial independence (median 28.1%, range 0.0%-83.3%). The 2017 British Society of Rheumatology guideline received the highest scores. Recommendations were concordant on the target serum uric acid level for long-term control, on some indications for urate-lowering therapy (ULT), and on the first-line drugs for ULT and for acute attack. Substantially inconsistent recommendations were provided for many items, especially for the timing of initiation of ULT and for treatment for asymptomatic hyperuricemia. CONCLUSIONS Methodological quality needs improvement in guidance documents on gout and hyperuricemia. Evidence for certain clinical questions is lacking, despite numerous trials in this field. Promoting standard guidance development methods and synthesising high-quality clinical evidence are potential approaches to reduce recommendation inconsistencies. PROSPERO REGISTRATION NUMBER CRD42016046104.
Collapse
Affiliation(s)
- Qianrui Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Institute of Health Informatics, University College London, London, UK
| | - Xiaodan Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Wang
- Department of Oto-Rhino-Laryngology, West China Hospital, Sichuan University, Chengdu, China
| | - Hongdie Liu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Joey Sum-Wing Kwong
- Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hao Chen
- The Second Clinical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Ling Li
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Sheng-Chia Chung
- Institute of Health Informatics, University College London, London, UK
| | - Anoop Shah
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
- Health Data Research UK London, University College London, London, UK
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Zhenmei An
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Harry Hemingway
- Institute of Health Informatics, University College London, London, UK
- Health Data Research UK London, University College London, London, UK
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - Haoming Tian
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Division of Population Health and Genomics, Ninewells Hospital and School of Medicine, University of Dundee, Dundee, United Kingdom
| |
Collapse
|
56
|
Islam MM, Wollersheim D. A comparison of opioids and benzodiazepines dispensing in Australia. PLoS One 2019; 14:e0221438. [PMID: 31425552 PMCID: PMC6699700 DOI: 10.1371/journal.pone.0221438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 08/06/2019] [Indexed: 11/19/2022] Open
Abstract
Background Inappropriate utilization of prescription opioids and benzodiazepines is a public health problem. This study examined and compared user-types and trends in dispensing of these medicines, and identified associated factors related to the duration of dispensing in Australia. Methods A random 10% sample of unit-record data of opioids and benzodiazepines dispensed nationally during 2013–2016 was analyzed. Users were categorized into four types: single-quarter (i.e., three months), medium-episodic (dispensed 2–6 quarters), long-episodic (dispensed 7–11 quarters), chronic (dispensed 12–16 quarters). Dispensing quantity was computed in defined daily dose (DDD). Generalized multilevel ordinal models were developed to examine the factors associated with the duration of dispensing. Results There were similarities in terms of trends of dispensing of opioids and benzodiazepines in Australia. Overall, more people were dispensed opioids than benzodiazepines. Around 52% of opioids users and 46% of benzodiazepines users were dispensed these medicines for a single quarter. However, chronic users were dispensed 60% of opioids and 50% of benzodiazepines in DDD/1000 people/day, respectively. On average, 16.6 DDD/1000 people/day of opioids and 14.2 DDD/1000 people/day of benzodiazepines were dispensed in Australia during the study period. Tasmania was dispensed the highest quantity (in DDD/1000 people/day) of these medicines, followed by South Australia and Queensland. Women compared to men, and clients of age-group 20–44, 45–64 and 65+ compared to age-group 0–19, were significantly more likely to have dispensed opioids/benzodiazepine for a relatively long duration. Clients with a history of dispensing of one of these two medicines were significantly more likely to have dispensed the other for a relatively long period. Conclusions There were similarities in patterns of dispensing of opioids and benzodiazepines in terms of user characteristics and structural variables. Consistent use of real-time drug monitoring program and tailored intervention are recommended.
Collapse
Affiliation(s)
- M. Mofizul Islam
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
- * E-mail:
| | - Dennis Wollersheim
- Health Information Management, Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| |
Collapse
|
57
|
Henry SG, Matthias MS. Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review. PAIN MEDICINE 2019; 19:2154-2165. [PMID: 29401356 DOI: 10.1093/pm/pny003] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective Productive patient-clinician communication is an important component of effective pain management, but we know little about how patients and clinicians actually talk about pain in clinical settings and how it might be improved to produce better patient outcomes. The objective of this review was to create a conceptual model of patient-clinician communication about noncancer pain, review and synthesize empirical research in this area, and identify priorities for future research. Methods A conceptual model was developed that drew on existing pain and health communication research. CINAHL, EMBASE, and PubMed were searched to find studies reporting empirical data on patient-clinician communication about noncancer pain; results were supplemented with manual searches. Studies were categorized and analyzed to identify crosscutting themes and inform model development. Results The conceptual model comprised the following components: contextual factors, clinical interaction, attitudes and beliefs, and outcomes. Thirty-nine studies met inclusion criteria and were analyzed based on model components. Studies varied widely in quality, methodology, and sample size. Two provisional conclusions were identified: contrary to what is often reported in the literature, discussions about analgesics are most frequently characterized by patient-clinician agreement, and self-presentation during patient-clinician interactions plays an important role in communication about pain and opioids. Conclusions Published studies on patient-clinician communication about noncancer pain are few and diverse. The conceptual model presented here can help to identify knowledge gaps and guide future research on communication about pain. Investigating the links between communication and pain-related outcomes is an important priority for future research.
Collapse
Affiliation(s)
- Stephen G Henry
- Department of Internal Medicine, University of California Davis, Sacramento, California
| | - Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Department of Communication Studies, Indiana University-Purdue University, Indianapolis, Indiana.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
58
|
Ray-Griffith SL, Morrison B, Stowe ZN. Chronic Pain Prevalence and Exposures during Pregnancy. Pain Res Manag 2019; 2019:6985164. [PMID: 31485284 PMCID: PMC6702808 DOI: 10.1155/2019/6985164] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/15/2019] [Indexed: 11/18/2022]
Abstract
Pregnant women with chronic pain present a unique clinical challenge for both chronic pain and obstetrical providers, and clinical guidelines do not exist. The present study describes the prevalence and management of chronic pain during pregnancy in a perinatal mood disorder clinic. A retrospective chart review of pregnant women who presented to the Women's Mental Health Program at the University of Arkansas for Medical Sciences (UAMS) for an initial evaluation from July 2013 to June 2016 was conducted to obtain demographic and medical information, including pharmacological exposures. Data are described using the mean and standard deviation for continuous data and frequency for categorical data. Pain complaints and medications are presented as counts and percentages. Differences between women with and without chronic pain were assessed by t-tests for continuous variables and chi-square analysis for categorical variables. Of the 156 pregnant women, chronic pain conditions were reported by 44 (28.2%). The most common chronic pain complaints included neck and/or back pain (34.1%) and headaches (31.8%). Of subjects with chronic pain, 95.5% were taking at least one prescription medication (mean = 2.6 ± 2.1, range of 0-10). Acetaminophen (43.2%) and opioids (43.2%) were the most common. The complexity of managing maternal benefits of treatment with the risks of fetal exposures presents a uniquely challenging clinical scenario for healthcare providers.
Collapse
Affiliation(s)
- Shona L. Ray-Griffith
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bethany Morrison
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zachary N. Stowe
- Department of Psychiatry, University of Wisconsin at Madison, Madison, WI, USA
| |
Collapse
|
59
|
Sears JM, Fulton-Kehoe D, Schulman BA, Hogg-Johnson S, Franklin GM. Opioid Overdose Hospitalization Trajectories in States With and Without Opioid-Dosing Guidelines. Public Health Rep 2019; 134:567-576. [PMID: 31365317 PMCID: PMC6852059 DOI: 10.1177/0033354919864362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES High-risk opioid-prescribing practices contribute to a national epidemic of opioid-related morbidity and mortality. The objective of this study was to determine whether the adoption of state-level opioid-prescribing guidelines that specify a high-dose threshold is associated with trends in rates of opioid overdose hospitalizations, for prescription opioids, for heroin, and for all opioids. METHODS We identified 3 guideline states (Colorado, Utah, Washington) and 5 comparator states (Arizona, California, Michigan, New Jersey, South Carolina). We used state-level opioid overdose hospitalization data from 2001-2014 for these 8 states. Data were based on the State Inpatient Databases and provided by the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, via HCUPnet. We used negative binomial panel regression to model trends in annual rates of opioid overdose hospitalizations. We used a multiple-baseline difference-in-differences study design to compare postguideline trends with concurrent trends for comparator states. RESULTS For each guideline state, postguideline trends in rates of prescription opioid and all opioid overdose hospitalizations decreased compared with trends in the comparator states. The mean annual relative percentage decrease ranged from 3.2%-7.5% for trends in rates of prescription opioid overdose hospitalizations and from 5.4%-8.5% for trends in rates of all opioid overdose hospitalizations. CONCLUSIONS These findings provide preliminary evidence that opioid-dosing guidelines may be an effective strategy for combating this public health crisis. Further research is needed to identify the individual effects of opioid-related interventions that occurred during the study period.
Collapse
Affiliation(s)
- Jeanne M. Sears
- Department of Health Services, University of Washington, Seattle, WA,
USA
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
- Institute for Work and Health, Toronto, Ontario, Canada
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
| | - Beryl A. Schulman
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
| | - Sheilah Hogg-Johnson
- Institute for Work and Health, Toronto, Ontario, Canada
- Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario,
Canada
| | - Gary M. Franklin
- Department of Health Services, University of Washington, Seattle, WA,
USA
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
- Washington State Department of Labor and Industries, Tumwater, WA, USA
- Department of Neurology, University of Washington, Seattle, WA, USA
| |
Collapse
|
60
|
Wilson MP, Cucciare MA, Porter A, Chalmers CE, Mullinax S, Mancino M, Oliveto AH. The utility of a statewide prescription drug-monitoring database vs the Current Opioid Misuse Measure for identifying drug-aberrant behaviors in emergency department patients already on opioids. Am J Emerg Med 2019; 38:503-507. [PMID: 31221474 DOI: 10.1016/j.ajem.2019.05.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/07/2019] [Accepted: 05/16/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The most recent guidelines on prescribing opioids from the United States Centers for Disease Control recommend that clinicians not prescribe opioids as first-line therapy for chronic non-cancer pain. If an opioid prescription is considered for a patient already on opioids, prescribers are encouraged to check the statewide prescription drug monitoring database (PDMP). Some additional guidelines recommend screening tools such as the Current Opioid Misuse Measure (COMM) which may also help identify drug-aberrant behaviors. OBJECTIVE To compare the PDMP and the Current Opioid Misuse Measure (COMM), a commonly-recommended screening tool for patients on opioids, in detecting drug-aberrant behaviors in patients already taking opioids at the time of ED presentation. METHODS Patients on opioids were enrolled prospectively in a mixed urban-suburban ED seeing approximately 65,000 patients per year. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratios of the PDMP and COMM were compared against objective criteria of drug-aberrant behaviors as documented in the electronic medical record (EMR) and medical examiner databases. RESULTS Compared to the COMM, the PDMP had similar sensitivity (36% vs 45%) and similar specificity (79% vs 55%), but better positive predictive value, better negative predictive value, and better diagnostic odds ratio. The combination of the PDMP and the COMM did not improve the detection of drug-aberrant behaviors. CONCLUSIONS The PDMP alone is a more useful as a screening instrument than either the COMM or the combination of the PDMP plus COMM in patients already taking opioids at time of ED presentation. However, the PDMP misses a majority of patients with documented drug-aberrant behaviors in the EMR, and should not be used in isolation to justify whether a particular opioid prescription is appropriate.
Collapse
Affiliation(s)
- Michael P Wilson
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| | - Michael A Cucciare
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72205 USA; Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR 72205 USA
| | - Austin Porter
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Arkansas Department of Health, Little Rock, AR, United States of America
| | - Christen E Chalmers
- School of Medicine, University of California, Irvine, United States of America
| | - Samuel Mullinax
- Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Michael Mancino
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Alison H Oliveto
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| |
Collapse
|
61
|
Soliman AM, Surrey ES, Bonafede M, Nelson JK, Vora JB, Agarwal SK. Health Care Utilization and Costs Associated with Endometriosis Among Women with Medicaid Insurance. J Manag Care Spec Pharm 2019; 25:566-572. [PMID: 31039061 PMCID: PMC10397603 DOI: 10.18553/jmcp.2019.25.5.566] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Endometriosis is a painful chronic inflammatory disease caused by endometrial tissue implanting and growing outside the uterus, resulting in pelvic pain symptoms and subfertility. Treatment imposes a substantial economic burden on the patient and health care system. OBJECTIVE To evaluate direct health care utilization and costs among women newly diagnosed with endometriosis compared with age-matched controls in a U.S. Medicaid population. METHODS This retrospective cohort study used deidentified health care claims from the 2007-2015 MarketScan Multi-State Medicaid Database. Women (aged 18-49 years) newly diagnosed with endometriosis (ICD-9-CM 617.xx) during January 2008 through September 2014 were identified (date of first diagnosis = index date). Age-matched women without endometriosis (controls) were selected from the database and assigned index dates matching the distribution for endometriosis patients. Direct health care resource utilization (HCRU) and costs (medical and pharmacy) over the 12-month post-index period (2015 U.S. dollars) were computed by service category (hospitalization, emergency room visits, outpatient services, and prescriptions) and compared between study cohorts using the chi-square test for proportions and t-test for continuous variables. RESULTS The final sample included 15,615 endometriosis patients and 86,829 matched controls. HCRU during the 12-month post-index follow-up period was significantly higher for endometriosis cases compared with controls in all measured categories. Hospital admissions occurred among 33.1% of cases and 7.2% of controls, and 65.8% of endometriosis patients were admitted for endometriosis-related surgery. Emergency room visits occurred in 71.5% of cases, and 42.2% of controls. Mean (SD) office visits were 10.4 (8.5) for endometriosis patients and 5.1 (6.9) for controls. Endometriosis patients had significantly more prescription claims than controls, 45.9 (42.0) versus 25.1 (39.1). Mean total direct health care costs were $13,670 ($29,843) for cases versus $5,779 ($23,614) for controls. All differences between cases and controls were significant at P < 0.001. CONCLUSIONS Health care costs and resource utilization in all measured categories were higher among endometriosis cases than controls. The economic burden of endometriosis among patients with Medicaid insurance is substantial, underscoring the unmet medical need for earlier diagnosis and cost-effective treatments. DISCLOSURES This study was funded by AbbVie and conducted by Truven Health Analytics, an IBM Company. AbbVie participated in developing the study design, data analysis and interpretation, manuscript writing and revisions, and approval for publication. Soliman and Vora are employees of AbbVie and may own AbbVie stock/stock options. Surrey has served in a consulting role on research to AbbVie and is on the speaker bureau for Ferring Laboratories. Bonafede and Nelson are employees of Truven Health Analytics, an IBM Company, which received compensation from AbbVie for the overall conduct of the study and preparation of the manuscript. Agarwal has served in a consulting role on research to AbbVie. Preliminary results of this study were previously presented in a podium session at the 2017 American Society for Reproductive Medicine Scientific Congress and Expo; October 28-November 1, 2017; San Antonio, TX.
Collapse
Affiliation(s)
| | - Eric S. Surrey
- Colorado Center for Reproductive Medicine, Lone Tree, Colorado
| | - Machaon Bonafede
- Truven Health Analytics, an IBM Company, Cambridge, Massachusetts
| | - James K. Nelson
- Truven Health Analytics, an IBM Company, Cambridge, Massachusetts
| | | | - Sanjay K. Agarwal
- Center for Endometriosis Research and Treatment, University of California, San Diego
| |
Collapse
|
62
|
Alford DP, Lazure P, Murray S, Hardesty I, Krause JR, White JL. National Trends in Prescription Opioid Risk Mitigation Practices: Implications for Prescriber Education. PAIN MEDICINE 2019; 20:907-915. [PMID: 30789651 DOI: 10.1093/pm/pny298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To assess national trends in selected prescription opioid risk mitigation practices and associations with prescriber type, state-specific opioid overdose severity, and required pain education. METHODS Analysis of the national SCOPE of Pain registrants' baseline self-report of five safer opioid prescribing practices over three years (March 2013-Februrary 2016). RESULTS Of 6,889 registrants for SCOPE of Pain, 70-94% reported performing each of five opioid risk mitigation practices for "most or all" patients, with 49% doing so for all five practices. Only 28% performed all five practices for "all" patients prescribed opioids. There were few differences among three yearly cohorts. Advanced practice nurses reported performing practices for "all" patients more often than physicians or physician assistants. Clinicians from states with high opioid overdose rates reported significantly higher implementation of most practices, compared with clinicians from states with low rates. CONCLUSIONS Prescribers report low levels of employing five opioid risk mitigation practices for all patients prescribed opioids before attending a safer opioid prescribing training. POLICY IMPLICATIONS Safer opioid prescribing education should transition from knowledge acquisition toward universal implementation of opioid risk mitigation practices.
Collapse
Affiliation(s)
- Daniel P Alford
- The Barry M. Manuel Continuing Medical Education Office, Boston University School of Medicine, Boston, Massachusetts, USA.,Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | | | | | - Ilana Hardesty
- The Barry M. Manuel Continuing Medical Education Office, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Joanna R Krause
- The Barry M. Manuel Continuing Medical Education Office, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julie L White
- The Barry M. Manuel Continuing Medical Education Office, Boston University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
63
|
Roughead EE, Lim R, Ramsay E, Moffat AK, Pratt NL. Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study. BMJ Open 2019; 9:e023990. [PMID: 30992289 PMCID: PMC6500207 DOI: 10.1136/bmjopen-2018-023990] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To determine time to opioid cessation post discharge from hospital in persons who had been admitted to hospital for a surgical procedure and were previously naïve to opioids. DESIGN, SETTING AND PARTICIPANTS Retrospective cohort study using administrative health claims database from the Australian Government Department of Veterans' Affairs (DVA). DVA gold card holders aged between 18 and 100 years who were admitted to hospital for a surgical admission between 1 January 2014 and 30 December 2015 and naïve to opioid therapy prior to admission were included in the study. Gold card holders are eligible for all health services that DVA funds. MAIN OUTCOME MEASURES The outcome of interest was time to cessation of opioids, with follow-up occurring over 12 months. Cessation was defined as a period without an opioid prescription that was equivalent to three times the estimated supply duration. The proportion who became chronic opioid users was defined as those who continued taking opioids for greater than 90 days post discharge. Cumulative incidence function with death as a competing event was used to determine time to cessation of opioids post discharge. RESULTS In 2014-2015, 24 854 persons were admitted for a surgical admission. In total 3907 (15.7%) were discharged on opioids. In total 3.9% of those discharged on opioids became chronic users of opioids. The opioid that the patients were most frequently discharged with was oxycodone; oxycodone alone accounted for 43%, while oxycodone with naloxone accounted for 8%. CONCLUSIONS Opioid initiation post-surgical hospital admission leads to chronic use of opioids in a small percentage of the population. However, given the frequency at which surgical procedures occur, this means that a large number of people in the population may be affected. Post-discharge assessment and follow-up of at-risk patients is important, particularly where psychosocial elements such as anxiety and catastrophising are identified.
Collapse
Affiliation(s)
| | - Renly Lim
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | | | | | | |
Collapse
|
64
|
Roy P, Jackson AH, Baxter J, Brett B, Winter M, Hardesty I, Alford DP. Utilizing a Faculty Development Program to Promote Safer Opioid Prescribing for Chronic Pain in Internal Medicine Resident Practices. PAIN MEDICINE 2019; 20:707-716. [PMID: 30649546 DOI: 10.1093/pm/pny292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To implement a skills-based faculty development program (FDP) to improve Internal Medicine faculty's clinical skills and resident teaching about safe opioid prescribing. DESIGN An FDP for Internal Medicine attendings that included a one-hour didactic presentation followed immediately by an Objective Structured Clinical Examination (OSCE) that focused on assessing and managing opioid misuse risk, opioid treatment outcomes (benefits and harms), and aberrant opioid use behaviors. The evaluation compared pre- and three-months-post-FDP changes in faculty's safe opioid prescribing knowledge, attitudes, confidence (clinical and teaching), and self-reported resident teaching. RESULTS The 25 Internal Medicine faculty participants had a mean of 13 years in clinical practice, including 10 years precepting residents. During the three months post-FDP, faculty treated a mean of 22 patients with chronic pain on long-term opioids and precepted a mean of seven residents caring for patients on long-term opioids. At three months post-FDP, there were significant improvements in correct responses to knowledge questions (68% to 79% P = 0.008), "high-level" confidence in safer opioid prescribing clinical practice (43.5% to 82.6% P = 0.007) and resident teaching (45.8% to 83.3%, P = 0.007), and improvements in alignment of desired attitudes toward safer opioid prescribing. There were nonsignificant increases in self-reported safe opioid prescribing resident teaching. CONCLUSIONS A skills-based faculty development program that includes a lecture followed by an OSCE can improve Internal Medicine faculty safe opioid prescribing knowledge, attitudes, and clinical and teaching confidence. Improving resident teaching may require additional training in safe opioid prescribing teaching skills.
Collapse
Affiliation(s)
- Payel Roy
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Angela H Jackson
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Jeffrey Baxter
- Department of Family Medicine, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Belle Brett
- Brett Consulting Group, Somerville, Massachusetts
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Ilana Hardesty
- The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Daniel P Alford
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.,The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
65
|
Schieber LZ, Guy GP, Seth P, Young R, Mattson CL, Mikosz CA, Schieber RA. Trends and Patterns of Geographic Variation in Opioid Prescribing Practices by State, United States, 2006-2017. JAMA Netw Open 2019; 2:e190665. [PMID: 30874783 PMCID: PMC6484643 DOI: 10.1001/jamanetworkopen.2019.0665] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Risk of opioid use disorder, overdose, and death from prescription opioids increases as dosage, duration, and use of extended-release and long-acting formulations increase. States are well suited to respond to the opioid crisis through legislation, regulations, enforcement, surveillance, and other interventions. OBJECTIVE To estimate temporal trends and geographic variations in 6 key opioid prescribing measures in 50 US states and the District of Columbia. DESIGN, SETTING, AND PARTICIPANTS Population-based cross-sectional analysis of opioid prescriptions filled nationwide at US retail pharmacies between January 1, 2006, and December 31, 2017. Data were obtained from the IQVIA Xponent database. All US residents who had an opioid prescription filled at a US retail pharmacy were included. MAIN OUTCOMES AND MEASURES Primary outcomes were annual amount of opioids prescribed in morphine milligram equivalents (MME) per person; mean duration per prescription in days; and 4 separate prescribing rates-for prescriptions 3 or fewer days, those 30 days or longer, those with a high daily dosage (≥90 MME), and those with extended-release and long-acting formulations. RESULTS Between 2006 and 2017, an estimated 233.7 million opioid prescriptions were filled in retail pharmacies in the United States each year. For all states combined, 4 measures decreased: (1) mean (SD) amount of opioids prescribed (mean [SD] decrease, 12.8% [12.6%]) from 628.4 (178.0) to 543.4 (158.6) MME per person, a statistically significant decrease in 23 states; (2) high daily dosage (mean [SD] decrease, 53.1% [13.6%]) from 12.3 (3.4) to 5.6 (1.7) per 100 persons, a statistically significant decrease in 49 states; (3) short-term (≤3 days) duration (mean [SD] decrease, 43.1% [9.4%]) from 18.0 (5.4) to 10.0 (2.5) per 100 persons, a statistically significant decrease in 48 states; and (4) extended-release and long-acting formulations (mean [SD] decrease, 14.7% [13.7%]) from 7.2 (1.9) to 6.0 (1.7) per 100 persons, a statistically significant decrease in 27 states. Two measures increased, each associated with the duration of prescription dispensed: (1) mean (SD) prescription duration (mean [SD] increase, 37.6% [6.9%]) from 13.0 (1.2) to 17.9 (1.4) days, a statistically significant increase in every state; and (2) prescriptions for a term of 30 days or longer (mean [SD] increase, 37.7% [28.9%]) from 18.3 (7.7) to 24.9 (10.7) per 100 persons, a statistically significant increase in 39 states. Two- to 3-fold geographic differences were observed across states, measured by comparing the ratio of each state's 90th to 10th percentile for each measure. CONCLUSIONS AND RELEVANCE In this study, across 12 years, the mean duration and prescribing rate for long-term prescriptions of opioids increased, whereas the amount of opioids prescribed per person and prescribing rate for high-dosage prescriptions, short-term prescriptions, and extended-release and long-acting formulations decreased. Some decreases were significant, but results were still high. Two- to 3-fold state variation in 5 measures occurred in most states. This information may help when state-specific intervention programs are being designed.
Collapse
Affiliation(s)
- Lyna Z. Schieber
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gery P. Guy
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Puja Seth
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Randall Young
- Division of Toxicology and Human Health Sciences, Agency for Toxic Substances and Disease Registry, Atlanta, Georgia
| | - Christine L. Mattson
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christina A. Mikosz
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard A. Schieber
- Division of Public Health Information and Dissemination, Center for Surveillance, Epidemiology, and Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
66
|
Salz T, Lavery JA, Lipitz-Snyderman AN, Boudreau DM, Moryl N, Gillespie EF, Korenstein D. Trends in Opioid Use Among Older Survivors of Colorectal, Lung, and Breast Cancers. J Clin Oncol 2019; 37:1001-1011. [PMID: 30817249 DOI: 10.1200/jco.18.00938] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer survivors may be at increased risk for opioid-related harms. Trends in opioid use over time since diagnosis are unknown. METHODS Using data from SEER and Medicare, we conducted multilevel logistic regression analyses to compare chronic opioid use (≥ 90 consecutive days) among opioid-naïve survivors of colorectal, lung, and breast cancers diagnosed from 2008 to 2013 and matched with noncancer controls. Among cases and controls with chronic use, we compared rates of high-dose opioid use (average ≥ 90 morphine milligram equivalents daily). RESULTS We included 46,789 survivors and 138,136 noncancer controls. In the first year after the index date (survivor's diagnosis date), chronic use among colorectal and lung cancer survivors exceeded chronic use among controls (colorectal cancer: odds ratio, 1.34; 95% CI, 1.22 to 1.47; lung cancer: odds ratio, 2.55; 95% CI, 2.34 to 2.77). Differences in chronic use between survivors and controls declined each year after the index date. Chronic use among breast cancer survivors was less than that of controls each year after the index date. Survivors with chronic use were more likely to have a high daily dose than controls with chronic use in the first 3 to 5 years. CONCLUSION Among three large populations of older cancer survivors, chronic opioid use varied by cancer. However, by 6 years after diagnosis, survivors were no longer more likely to be chronic users than controls. Strategies for appropriate pain management during and after cancer treatment should take into account the risks associated with chronic high-dose opioid use.
Collapse
Affiliation(s)
- Talya Salz
- 1 Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Denise M Boudreau
- 2 Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Natalie Moryl
- 1 Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | |
Collapse
|
67
|
Schubart JR, Schilling A, Schaefer E, Bascom R, Francomano C. Use of prescription opioid and other drugs among a cohort of persons with Ehlers-Danlos syndrome: A retrospective study. Am J Med Genet A 2019; 179:397-403. [PMID: 30624009 DOI: 10.1002/ajmg.a.61031] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/18/2018] [Accepted: 12/11/2018] [Indexed: 01/14/2023]
Abstract
Against the backdrop of increased opioid prescribing in the United States and the associated high rate of side effects, dependence, and addiction, our study examined how opioids and other medications are being used among persons with Ehlers-Danlos syndrome (EDS). EDS is a set of heritable connective tissue disorders with high symptom burden, including chronic pain. Prescription medication use among persons with EDS was compared to a cohort of matched controls using 10 years of administrative claims data from a large database of privately insured patients (2005-2014). Our dataset included 4,294 persons with EDS, ages 5-62 years old. In both adults and children, we found that the percentage of persons with a prescription drug claim was higher in the EDS cohort for all prescription drug classes examined. Among children, opioid use was double in the EDS cohort compared to the control group (27.5% vs. 13.5%); in adults, it was nearly double in EDS patients (62% vs. 34.1%). Among persons who were prescribed opioids, those with EDS had higher cumulative dosages over a 2-year time period versus controls. Our study aids in understanding opioid and prescription drug use patterns in a vulnerable population with high symptom burden and chronic pain that is often severe.
Collapse
Affiliation(s)
- Jane R Schubart
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.,Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Amber Schilling
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Eric Schaefer
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Rebecca Bascom
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.,Department of Medicine, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Clair Francomano
- Ehlers-Danlos Society Center for Clinical Care and Research, Greater Baltimore Medical Center, Baltimore, Maryland
| |
Collapse
|
68
|
Allegri N, Mennuni S, Rulli E, Vanacore N, Corli O, Floriani I, De Simone I, Allegri M, Govoni S, Vecchi T, Sandrini G, Liccione D, Biagioli E. Systematic Review and Meta‐Analysis on Neuropsychological Effects of Long‐Term Use of Opioids in Patients With Chronic Noncancer Pain. Pain Pract 2018; 19:328-343. [DOI: 10.1111/papr.12741] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 09/05/2018] [Accepted: 10/05/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Nicola Allegri
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
| | | | - Eliana Rulli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Nicola Vanacore
- IRCCS Mondino Foundation Pavia Italy
- National Centre of Epidemiology National Institute of Health Rome Italy
| | - Oscar Corli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Irene Floriani
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Irene De Simone
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Massimo Allegri
- Pain Therapy Service Policlinico Monza Monza Italy
- Italian Pain Group Milan Italy
| | - Stefano Govoni
- Department of Drug Sciences University of Pavia Pavia Italy
| | - Tomaso Vecchi
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
- IRCCS Mondino Foundation Pavia Italy
| | - Giorgio Sandrini
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
- IRCCS Mondino Foundation Pavia Italy
| | - Davide Liccione
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
| | - Elena Biagioli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| |
Collapse
|
69
|
Rhon DI, Snodgrass SJ, Cleland JA, Sissel CD, Cook CE. Predictors of chronic prescription opioid use after orthopedic surgery: derivation of a clinical prediction rule. Perioper Med (Lond) 2018; 7:25. [PMID: 30479746 PMCID: PMC6249901 DOI: 10.1186/s13741-018-0105-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/24/2018] [Indexed: 01/19/2023] Open
Abstract
Background Prescription opioid use at high doses or over extended periods of time is associated with adverse outcomes, including dependency and abuse. The aim of this study was to identify mediating variables that predict chronic opioid use, defined as three or more prescriptions after orthopedic surgery. Methods Individuals were ages between 18 and 50 years and undergoing arthroscopic hip surgery between 2004 and 2013. Two categories of chronic opioid use were calculated based on individuals (1) having three or more unique opioid prescriptions within 2 years and (2) still receiving opioid prescriptions > 1 year after surgery. Univariate elationships were identified for each predictor variable, then significant variables (P > 0.15) were entered into a multivariate logistic regression model to identify the most parsimonious group of predictor variables for each chronic opioid use classification. Likelihood ratios were derived from the most robust groups of variables. Results There were 1642 participants (mean age 32.5 years, SD 8.2, 54.1% male). Nine predictor variables met the criteria after bivariate analysis for potential inclusion in each multivariate model. Eight variables: socioeconomic status (from enlisted rank family), prior use of opioid medication, prior use of non-opioid pain medication, high health-seeking behavior before surgery, a preoperative diagnosis of insomnia, mental health disorder, or substance abuse were all predictive of chronic opioid use in the final model (seven variables for three or more opioid prescriptions; four variables for opioid use still at 1 year; all< 0.05). Post-test probability of having three or more opioid prescriptions was 93.7% if five of seven variables were present, and the probability of still using opioids after 1 year was 69.6% if three of four variables were present. Conclusion A combination of variables significantly predicted chronic opioid use in this cohort. Most of these variables were mediators, indicating that modifying them may be feasible, and the potential focus of interventions to decrease the risk of chronic opioid use, or at minimum better inform opioid prescribing decisions. This clinical prediction rule needs further validation.
Collapse
Affiliation(s)
- Daniel I Rhon
- 1Center for the Intrepid, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam, Houston, TX 78234 USA.,2Doctoral Program in Physical Therapy, Baylor University, San Antonio, TX USA.,3School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW Australia
| | - Suzanne J Snodgrass
- 3School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW Australia
| | - Joshua A Cleland
- 4Department of Physical Therapy, Franklin Pierce University, Manchester, NH USA
| | - Charles D Sissel
- 5Program Analysis and Evaluation Division, US Army Medical Command, Joint Base San Antonio - Fort Sam Houston, San Antonio, TX 78234 USA
| | - Chad E Cook
- 6Division of Physical Therapy, Department of Orthopedics, Duke University, Duke MSK, Duke Clinical Research Institute, Durham, NC USA
| |
Collapse
|
70
|
Rash JA, Buckley N, Busse JW, Campbell TS, Corace K, Cooper L, Flusk D, Iorio A, Lavoie KL, Poulin PA, Skidmore B. Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review. Syst Rev 2018; 7:189. [PMID: 30424800 PMCID: PMC6234680 DOI: 10.1186/s13643-018-0858-7] [Citation(s) in RCA: 6] [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] [Received: 04/18/2018] [Accepted: 10/29/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Evidence from diverse areas of medicine (e.g., cardiovascular disease, diabetes) indicates that healthcare providers (HCPs) often do not adhere to clinical practice guidelines (CPGs) despite a clear indication to implement recommendations-a phenomenon commonly termed clinical inertia. There are a variety of reasons for clinical inertia, but HCP-related factors (e.g., knowledge, motivation, agreement with guidelines) are the most salient and amenable to intervention aimed to improve adherence. CPGs have been developed to support the safe and effective prescription of opioid medication for the management of chronic non-cancer pain. The extent of physician uptake and adherence to such guidelines is not yet well understood. The purpose of this review is to synthesize the published evidence about knowledge, attitudes, beliefs, and practices that HCPs hold regarding the prescription of opioids for chronic non-cancer pain. METHODS An experienced information specialist will perform searches of CINAHL, Embase, MEDLINE, and PsycINFO bibliographic databases. The Cochrane library, PROSPERO, and the Joanna Briggs Institute will be searched for systematic reviews. Searches will be performed from inception to the present. Quantitative and qualitative study designs that report on HCP knowledge, attitudes, beliefs, or practices in North America will be eligible for inclusion. Studies reporting on interventions to improve HCP adherence to opioid prescribing CPGs will also be eligible for inclusion. Two trained graduate-level research assistants will independently screen articles for inclusion, perform data extraction, and perform risk of bias and quality assessment using recommended tools. Confidence in qualitative evidence will be evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation-Confidence in the Evidence from Qualitative Reviews (GRADE-CERQual) approach. Confidence in quantitative evidence will be assessed using the GRADE approach. DISCUSSION The ultimate goal of this work is to support interventions aiming to optimize opioid prescribing practices in order to prevent opioid-related morbidity and mortality without restricting a HCP's ability to select the most appropriate treatment for an individual patient. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018091640 .
Collapse
Affiliation(s)
- Joshua A. Rash
- Department of Psychology, Memorial University of Newfoundland, 230 Elizabeth Ave, St. John’s, NL A1B 3X9 Canada
| | - Norman Buckley
- Department of Anesthesia, McMaster University, Hamilton, ON Canada
| | - Jason W. Busse
- Department of Anesthesia, McMaster University, Hamilton, ON Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON Canada
- The Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, ON Canada
| | | | - Kim Corace
- The Royal Ottawa Mental Health Centre, Ottawa, ON Canada
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- University of Ottawa Institute of Mental Health Research, Ottawa, ON Canada
| | - Lynn Cooper
- Canadian Injured Workers Alliance, Thunder Bay, ON Canada
| | - David Flusk
- Department of Anesthesia, Memorial University of Newfoundland, St. John’s, NL Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
| | - Kim L. Lavoie
- Department of Psychology, University of Quebec at Montreal, Montreal, QC Canada
- Montreal Behavioral Medicine Centre (MBMC), Centre intégrée universitaire de santé et services sociaux de Nord de l’Ile de Montreal (CIUSSS-NIM), Hopital du Sacre-Coeur de Montreal, Montreal, QC Canada
| | - Patricia A. Poulin
- The Ottawa Hospital Research Institute, Ottawa, ON Canada
- The Ottawa Hospital Pain Clinic, Ottawa, ON Canada
- School of Psychology and Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON Canada
| | - B. Skidmore
- Independent Information Specialist, Ottawa, ON Canada
| |
Collapse
|
71
|
Razouki Z, Khokhar BA, Philpot LM, Ebbert JO. Attributes, Attitudes, and Practices of Clinicians Concerned with Opioid Prescribing. PAIN MEDICINE 2018; 20:1934-1941. [DOI: 10.1093/pm/pny204] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Many clinicians who prescribe opioids for chronic noncancer pain (CNCP) express concerns about opioid misuse, addiction, and physiological dependence. We evaluated the association between the degree of clinician concerns (highly vs less concerned), clinician attributes, other attitudes and beliefs, and opioid prescribing practices.
Methods
A web-based survey of clinicians at a multispecialty medical practice.
Results
Compared with less concerned clinicians, clinicians highly concerned with opioid misuse, addiction, and physiological dependence were more confident prescribing opioids (risk ratio [RR] = 1.34, 95% confidence interval [CI] = 1.08–1.67) but were more reluctant to do so (RR = 1.13, 95% CI = 1.03–1.25). They were more likely to report screening patients for substance use disorder (RR = 1.18, 95% CI = 1.01–1.37) and to discontinue prescribing opioids to a patient due to aberrant opioid use behaviors (RR = 1.30, 95% CI = 1.13–1.50). They were also less likely to prescribe benzodiazepines and opioids concurrently (RR = 0.40, 95% CI = 0.25–0.65). Highly concerned clinicians were more likely to work in clinics which engage in “best practices” for opioid prescribing requiring urine drug screening (RR = 4.65, 95% CI = 2.51–8.61), prescription monitoring program review (RR = 2.90, 95% CI = 1.84–4.56), controlled substance agreements (RR = 4.88, 95% CI = 2.64–9.03), and other practices. Controlling for clinician concern, prescribing practices were also associated with clinician confidence, reluctance, and satisfaction.
Conclusions
Highly concerned clinicians are more confident but more reluctant to prescribe opioids. Controlling for clinician concern, confidence in care and reluctance to prescribe opioids were associated with more conservative prescribing practices.
Collapse
Affiliation(s)
| | - Bushra A Khokhar
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | - Lindsey M Philpot
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
- Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
72
|
Vettese TE, Thati N, Roxas R. Effective Chronic Pain Management and Responsible Opioid Prescribing: Aligning a Resident Workshop to a Protocol for Improved Outcomes. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2018; 14:10756. [PMID: 30800956 PMCID: PMC6342398 DOI: 10.15766/mep_2374-8265.10756] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/23/2018] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Effective chronic pain management is a core competency of internal medicine. Opioid use in the United States, both therapeutic and nonmedical in origin, has dramatically increased, as has the number of deaths due to opioid overdose. Despite this, formal training in pain management and responsible opioid prescribing is lacking for internal medicine residents. METHODS Our educational workshop for PGY 1-PGY 3 internal medicine residents was designed to provide a functional knowledge base and improve motivation to change behaviors in chronic pain management and responsible opioid prescribing. A secondary aim was to align our intervention with our new clinic opioid-prescribing protocol with the goal of increasing the adoption of opioid risk-reduction strategies in our resident clinic, specifically, use of urine drug screening (UDS). We collected data using pre- and postsession knowledge and motivation to change questionnaires as well as pre- and postintervention data regarding UDS in our ambulatory clinic. RESULTS Sixty-three residents participated in a workshop session. Based on pre- to posttest results, medical knowledge of principles of responsible opioid prescribing increased overall (p = .01). Most residents reported high motivation to change behaviors around management of chronic pain and opioid prescribing. There was also a significant postintervention ordering of UDS in patients on long-term opioid therapy. DISCUSSION Our workshop resulted in a short-term improvement in knowledge of principles of responsible opioid prescribing, a significant motivation to change behaviors, and increased adoption of opioid risk-reduction strategies in our resident clinic.
Collapse
Affiliation(s)
- Theresa E. Vettese
- Associate Professor, Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine
| | - Neelima Thati
- Assistant Professor, Division of General Medicine, Department of Internal Medicine, Wayne State University School of Medicine
| | - Renato Roxas
- Assistant Professor, Division of General Medicine, Department of Internal Medicine, Wayne State University School of Medicine
| |
Collapse
|
73
|
Bohnert ASB, Guy GP, Losby JL. Opioid Prescribing in the United States Before and After the Centers for Disease Control and Prevention's 2016 Opioid Guideline. Ann Intern Med 2018; 169:367-375. [PMID: 30167651 PMCID: PMC6176709 DOI: 10.7326/m18-1243] [Citation(s) in RCA: 285] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In response to adverse outcomes from prescription opioids, the Centers for Disease Control and Prevention (CDC) released the Guideline for Prescribing Opioids for Chronic Pain in March 2016. OBJECTIVE To test the hypothesis that the CDC guideline release corresponded to declines in specific opioid prescribing practices. DESIGN Interrupted time series analysis of monthly prescribing measures from the IQVIA transactional data warehouse and Real-World Data Longitudinal Prescriptions population-level estimates based on retail pharmacy data. Population size was determined by U.S. Census monthly estimates. SETTING United States, 2012 to 2017. PATIENTS Persons prescribed opioid analgesics. MEASUREMENTS Outcomes included opioid dosage, days supplied, overlapping benzodiazepine prescriptions, and the overall rate of prescribing. RESULTS The rate of high-dosage prescriptions (≥90 morphine equivalent milligrams per day) was 683 per 100 000 persons in January 2012 and declined by 3.56 (95% CI, -3.79 to -3.32) per month before March 2016 and by 8.00 (CI, -8.69 to -7.31) afterward. Likewise, the percentage of patients with overlapping opioid and benzodiazepine prescriptions was 21.04% in January 2012 and declined by 0.02% (CI, -0.04% to -0.01%) per month before the CDC guideline release and by 0.08% (CI, -0.08% to -0.07%) per month afterward. The overall opioid prescribing rate was 6577 per 100 000 persons in January 2012 and declined by 23.48 (CI, -26.18 to -20.78) each month before the guideline release and by 56.74 (CI, -65.96 to -47.53) per month afterward. LIMITATION No control population; inability to determine the appropriateness of opioid prescribing. CONCLUSION Several opioid prescribing practices were decreasing before the CDC guideline, but the time of its release was associated with a greater decline. Guidelines may be effective in changing prescribing practices. PRIMARY FUNDING SOURCE CDC.
Collapse
Affiliation(s)
- Amy S B Bohnert
- University of Michigan and Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan (A.S.B.)
| | - Gery P Guy
- Centers for Disease Control and Prevention, Atlanta, Georgia (G.P.G., J.L.L.)
| | - Jan L Losby
- Centers for Disease Control and Prevention, Atlanta, Georgia (G.P.G., J.L.L.)
| |
Collapse
|
74
|
Gaiennie CC, Dols JD. Implementing Evidence-Based Opioid Prescription Practices in a Primary Care Setting. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
75
|
Zgierska AE, Vidaver RM, Smith P, Ales MW, Nisbet K, Boss D, Tuan WJ, Hahn DL. Enhancing system-wide implementation of opioid prescribing guidelines in primary care: protocol for a stepped-wedge quality improvement project. BMC Health Serv Res 2018; 18:415. [PMID: 29871625 PMCID: PMC5989454 DOI: 10.1186/s12913-018-3227-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/22/2018] [Indexed: 01/07/2023] Open
Abstract
Background Systematic implementation of guidelines for opioid therapy management in chronic non-cancer pain can reduce opioid-related harms. However, implementation of guideline-recommended practices in routine care is subpar. The goal of this quality improvement (QI) project is to assess whether a clinic-tailored QI intervention improves the implementation of a health system-wide, guideline-driven policy on opioid prescribing in primary care. This manuscript describes the protocol for this QI project. Methods A health system with 28 primary care clinics caring for approximately 294,000 primary care patients developed and implemented a guideline-driven policy on long-term opioid therapy in adults with opioid-treated chronic non-cancer pain (estimated N = 3980). The policy provided multiple recommendations, including the universal use of treatment agreements, urine drug testing, depression and opioid misuse risk screening, and standardized documentation of the chronic pain diagnosis and treatment plan. The project team drew upon existing guidelines, feedback from end-users, experts and health system leadership to develop a robust QI intervention, targeting clinic-level implementation of policy-directed practices. The resulting multi-pronged QI intervention included clinic-wide and individual clinician-level educational interventions. The QI intervention will augment the health system’s “routine rollout” method, consisting of a single educational presentation to clinicians in group settings and a separate presentation for staff. A stepped-wedge design will enable 9 primary care clinics to receive the intervention and assessment of within-clinic and between-clinic changes in adherence to the policy items measured by clinic-level electronic health record-based measures and process measures of the experience with the intervention. Discussion Developing methods for a health system-tailored QI intervention required a multi-step process to incorporate end-user feedback and account for the needs of targeted clinic team members. Delivery of such tailored QI interventions has the potential to enhance uptake of opioid therapy management policies in primary care. Results from this study are anticipated to elucidate the relative value of such QI activities. Electronic supplementary material The online version of this article (10.1186/s12913-018-3227-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Aleksandra E Zgierska
- Department of Family Medicine and Community Health, Wisconsin Research and Education Network, School of Medicine and Public Health, University of Wisconsin-Madison, 1100 Delaplaine Court, Madison, WI, 53715, USA.
| | - Regina M Vidaver
- Department of Family Medicine and Community Health, Wisconsin Research and Education Network, School of Medicine and Public Health, University of Wisconsin-Madison, 1100 Delaplaine Court, Madison, WI, 53715, USA
| | - Paul Smith
- Department of Family Medicine and Community Health, Wisconsin Research and Education Network, School of Medicine and Public Health, University of Wisconsin-Madison, 1100 Delaplaine Court, Madison, WI, 53715, USA
| | - Mary W Ales
- Interstate Postgraduate Medical Association, P.O. Box 5474, Madison, WI, 53705, USA
| | - Kate Nisbet
- Interstate Postgraduate Medical Association, P.O. Box 5474, Madison, WI, 53705, USA
| | - Deanne Boss
- Department of Family Medicine and Community Health, Wisconsin Research and Education Network, School of Medicine and Public Health, University of Wisconsin-Madison, 1100 Delaplaine Court, Madison, WI, 53715, USA
| | - Wen-Jan Tuan
- Department of Family Medicine and Community Health, Wisconsin Research and Education Network, School of Medicine and Public Health, University of Wisconsin-Madison, 1100 Delaplaine Court, Madison, WI, 53715, USA
| | - David L Hahn
- Department of Family Medicine and Community Health, Wisconsin Research and Education Network, School of Medicine and Public Health, University of Wisconsin-Madison, 1100 Delaplaine Court, Madison, WI, 53715, USA
| |
Collapse
|
76
|
Perrey D, Zhang D, Nguyen T, Carroll FI, Ko MC, Zhang Y. Synthesis of Enantiopure PZM21, A Novel Biased Agonist of the Mu-Opioid Receptor. European J Org Chem 2018; 2018:4006-4012. [PMID: 32831629 DOI: 10.1002/ejoc.201800517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PZM21 (1) was recently reported as a biased agonist of the mu-opioid receptor (MOR) with improved antinociceptive effects but reduced side effects than traditional opioid-based analgesics. The original synthesis of PZM21 with the desired (S,S) configuration required the separation of diastereomeric mixture in the final step using chiral HPLC. We have designed a concise synthesis of 1 in the enantiomeric pure form starting with commercially available L-alanine and via a chiral aziridine as a key intermediate. The final product 1 as the (S,S) diastereomer was obtained in 7 steps in 22.5% yield from L-alanine. This synthetic strategy could be readily applied to the development of PZM21 analogs at the thiophenyl position.
Collapse
Affiliation(s)
- David Perrey
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, NC 27709, USA
| | - Dehui Zhang
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, NC 27709, USA
| | - Thuy Nguyen
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, NC 27709, USA
| | - F Ivy Carroll
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, NC 27709, USA
| | - Mei-Chuan Ko
- Department of Physiology and Pharmacology, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Yanan Zhang
- Center for Drug Discovery, Research Triangle Institute, Research Triangle Park, NC 27709, USA
| |
Collapse
|
77
|
Dunn KE, Barrett FS, Fingerhood M, Bigelow GE. Opioid Overdose History, Risk Behaviors, and Knowledge in Patients Taking Prescribed Opioids for Chronic Pain. PAIN MEDICINE 2018; 18:1505-1515. [PMID: 27651504 DOI: 10.1093/pm/pnw228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective More than 100 million adults in the United States experience chronic pain, and prescription opioids are the third most widely prescribed class of medications. Current opioid overdose prevention efforts almost exclusively target illicit opioid users, and little is known about the experience of overdose among patients being treated for chronic pain (CP) with a prescription opioid. Methods Patients experiencing CP for three or more months and receiving a prescription opioid for pain management (N = 502) completed a self-report survey that asked questions about opioid overdose history, past 30-day risk factors, and knowledge of opioid overdose, overdose risk, and naloxone. Results Approximately one in five CP participants reported experiencing a lifetime overdose. CP participants reported engaging in several behaviors associated with overdose risk and were unlikely to have been trained to administer naloxone. Fewer than 50% of participants answered any knowledge item correctly. The likelihood of having experienced an overdose increased as the scores on the SOAPP-R and DSM-5 opioid use disorder checklist increased, and a SOAPP-R score of 7 or higher or meeting DSM-5 mild opioid use disorder criteria were significantly associated with reporting a lifetime overdose (85% and 84% of participants who experienced an overdose, respectively). Conclusions Opioid overdose occurs at a high rate among CP participants, and this group is relatively uninformed about risk factors for overdose. Established SOAPP-R and DSM thresholds provide an opportunity to identify participants at elevated risk for having experienced an opioid overdose. These data support development of additional concentrated efforts to prevent overdose among chronic pain patients.
Collapse
Affiliation(s)
- Kelly E Dunn
- Departments of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine Baltimore, MD, USA
| | - Frederick S Barrett
- Departments of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine Baltimore, MD, USA
| | - Michael Fingerhood
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA 21224
| | - George E Bigelow
- Departments of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine Baltimore, MD, USA
| |
Collapse
|
78
|
Qin B, Chen H, Gao W, Zhao LB, Zhao MJ, Qin HX, Chen W, Chen L, Yang MX. Efficacy, acceptability, and tolerability of antidepressant treatments for patients with post-stroke depression: a network meta-analysis. ACTA ACUST UNITED AC 2018; 51:e7218. [PMID: 29742266 PMCID: PMC5972011 DOI: 10.1590/1414-431x20187218] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/30/2018] [Indexed: 11/22/2022]
Abstract
The aim of this study was to investigate the efficacy, acceptability, and
tolerability of antidepressants in treating post-stroke depression (PSD) by
performing a network meta-analysis of randomized controlled trials of the
current literature. Eligible studies were retrieved from online databases, and
relevant data were extracted. The primary outcome was efficacy as measured by
the mean change in overall depressive symptoms. Secondary outcomes included
discontinued treatment for any reason and specifically due to adverse events.
Fourteen trials were eligible, which included 949 participants and 9
antidepressant treatments. Few significant differences were found for all
outcomes. For the primary outcome, doxepin, paroxetine, and nortriptyline were
significantly more effective than a placebo [standardized mean differences:
−1.93 (95%CI=−3.56 to −0.29), −1.39 (95%CI=−2.59 to −0.21), and −1.25
(95%CI=−2.46 to −0.04), respectively]. Insufficient evidence exists to select a
preferred antidepressant for treating patients with post-stroke depression, and
our study provides little evidence that paroxetine may be the potential choice
when starting treatment for PSD. Future studies with paroxetine and larger
sample sizes, multiple medical centers, and sufficient intervention durations is
needed for improving the current evidence.
Collapse
Affiliation(s)
- B Qin
- Affiliated Liuzhou People's Hospital, Department of Neurology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - H Chen
- Affiliated Liuzhou People's Hospital, Department of Neurology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - W Gao
- Affiliated Liuzhou People's Hospital, Department of Neurology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - L B Zhao
- Yongchuan Hospital, Department of Neurology, Chongqing Medical University, Chongqing, China
| | - M J Zhao
- The Second Affiliated Hospital, Department of Pharmacy, Xinxiang Medical University, Xinxiang, China
| | - H X Qin
- Affiliated Liuzhou People's Hospital, Department of Neurology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - W Chen
- Affiliated Liuzhou People's Hospital, Department of Neurology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - L Chen
- Affiliated Liuzhou People's Hospital, Department of Neurology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - M X Yang
- Affiliated Liuzhou People's Hospital, Department of Neurology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| |
Collapse
|
79
|
Wang N, Zhang Z, Lv J. Fentanyl inhibits proliferation and invasion via enhancing miR-302b expression in esophageal squamous cell carcinoma. Oncol Lett 2018; 16:459-466. [PMID: 29928433 DOI: 10.3892/ol.2018.8616] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 01/17/2018] [Indexed: 12/21/2022] Open
Abstract
Fentanyl is one of the most commonly used intravenous anesthetic agents during cancer resection surgery, but the effect of fentanyl on esophageal squamous cell carcinoma (ESCC) remains unclear. The aim of the present study was to investigate the involvement of microRNA 302b (miR-302b) in the anti-proliferation and anti-invasion effects of fentanyl in ESCC. In the present study, the effects of fentanyl on cell proliferation, apoptosis and invasion were detected using MTT assays, flow cytometry and Transwell assays in ESCC Eca109 and TE1 cell lines. Subsequently, expression of miR-302b was determined using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). RT-qPCR and western blot analysis were performed in order to evaluate the expression of ErbB4, a target of miR-302b. Furthermore, anti-miR were used to inhibit miR-302b in fentanyl-treated ESCC cells in order to evaluate the role of miR-302b in the effect of fentanyl on malignant behaviors. Fentanyl inhibited the proliferation of Eca109 and TE1 cells in a dose- and time-dependent manner. Following exposure to fentanyl for 48 h, Eca109 and TE1 cells exhibited increased apoptosis and decreased invasion. Furthermore, fentanyl upregulated miR-302b expression, but downregulated ErbB4 expression. Finally, loss of miR-302b using the anti-miR technique reversed the effect of fentanyl on cell proliferation, apoptosis and invasion in the two ESCC cell lines. Taken together, the results of the present study indicated that fentanyl inhibits the proliferation and invasion of ESCC cells through upregulation of miR-302b.
Collapse
Affiliation(s)
- Ning Wang
- Department of Anesthesiology, Second Affiliated Hospital, Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710002, P.R. China
| | - Zhenni Zhang
- Department of Anesthesiology, Second Affiliated Hospital, Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710002, P.R. China
| | - Jianrui Lv
- Department of Anesthesiology, Second Affiliated Hospital, Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710002, P.R. China
| |
Collapse
|
80
|
Abstract
Chronic pain is a common problem, affecting more than 100 million people in the United States, and primary care providers are highly likely to encounter patients on chronic opioid therapy. Initial encounters with a new patient already on high-dose opioids can be difficult and lead to apprehension for both patient and provider. This article describes how to use current opioid prescribing guidelines, conduct a comprehensive pain assessment, and implement risk mitigation strategies to improve patient safety and effectively manage this patient population.
Collapse
|
81
|
Shipton EA, Shipton EE, Shipton AJ. A Review of the Opioid Epidemic: What Do We Do About It? Pain Ther 2018; 7:23-36. [PMID: 29623667 PMCID: PMC5993689 DOI: 10.1007/s40122-018-0096-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Indexed: 01/24/2023] Open
Abstract
The opioid epidemic, with its noticeable increase in opioid prescriptions and related misuse, abuse and resultant deaths in the previous 12 years, is a particularly North American phenomenon. Europe, and particularly low- and middle-income countries, appear to be less influenced by this problem. There is undisputable value in using opioids not only in the treatment of acute pain, but in cancer pain as well. However, opioids are progressively being prescribed more and more for chronic non-cancer pain, despite inadequate data on their efficacy. In this paper, we describe the current prevalence of opioid misuse in a number of countries and the rationale for the commencement of opioid therapy. The safe initiation and monitoring of opioid therapy as well as the need for concurrent use of interdisciplinary multimodal therapy is discussed. The possible consequences of long-term use and predictors of high opioid use and overdose are presented. In particular, the management of opioid use disorders and the prevention of opioid abuse and dependence in the young, the old and the pregnant are discussed. Measures to prevent overprescribing and to alleviate risk are described, including the tapering of opioids and the use of opioid deterrents. Finally, the paper looks at the future development of pioneering medications and technologies to potentially treat abuse. In those parts of the world with an opioid epidemic, coroners and medical examiners, private and public health agencies, and agencies that enforce the law need to cooperate in an effort to slow down and reverse the indiscriminate use of prescribing opioids in the long-term for chronic non-cancer pain. Ongoing research is needed to create ways to minimise risks of opioid use, and to provide evidence for effective strategies for treating chronic pain.
Collapse
Affiliation(s)
- Edward A Shipton
- Department of Anaesthesia, University of Otago, Christchurch, New Zealand.
| | - Elspeth E Shipton
- Department of Anaesthesia, University of Otago, Christchurch, New Zealand
| | - Ashleigh J Shipton
- Department of Anaesthesia, University of Otago, Christchurch, New Zealand
| |
Collapse
|
82
|
de Heer EW, Dekker J, Beekman ATF, van Marwijk HWJ, Holwerda TJ, Bet PM, Roth J, Timmerman L, van der Feltz-Cornelis CM. Comparative Effect of Collaborative Care, Pain Medication, and Duloxetine in the Treatment of Major Depressive Disorder and Comorbid (Sub)Chronic Pain: Results of an Exploratory Randomized, Placebo-Controlled, Multicenter Trial (CC:PAINDIP). Front Psychiatry 2018; 9:118. [PMID: 29674981 PMCID: PMC5895661 DOI: 10.3389/fpsyt.2018.00118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/20/2018] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Evidence exists for the efficacy of collaborative care (CC) for major depressive disorder (MDD), for the efficacy of the consequent use of pain medication against pain, and for the efficacy of duloxetine against both MDD and neuropathic pain. Their relative effectiveness in comorbid MDD and pain has never been established so far. This study explores the effectiveness of CC with pain medication and duloxetine, and CC with pain medication and placebo, compared with duloxetine alone, on depressive and pain symptoms. This study was prematurely terminated because of massive reorganizations and reimbursement changes in mental health care in the Netherlands during the study period and is therefore of exploratory nature. METHODS Three-armed, randomized, multicenter, placebo-controlled trial at three specialized mental health outpatient clinics with patients who screened positive for MDD. Interventions lasted 12 weeks. Pain medication was administered according to an algorithm that avoids opiate prescription as much as possible, where paracetamol, COX inhibitors, and pregabalin are offered as steps before opiates are considered. Patients who did not show up for three or more sessions were registered as non-compliant. Explorative, intention-to-treat and per protocol, multilevel regression analyses were performed. The trial is listed in the trial registration (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1089; NTR number: NTR1089). RESULTS Sixty patients completed the study. Patients in all treatment groups reported significantly less depressive and pain symptoms after 12 weeks. CC with placebo condition showed the fastest decrease in depressive symptoms compared with the duloxetine alone group (b = -0.78; p = 0.01). Non-compliant patients (n = 31) did not improve over the 12-week period, in contrast to compliant patients (n = 29). Pain outcomes did not differ between the three groups. CONCLUSION In MDD and pain, patient's compliance and placebo effects are more important in attaining effect than choice of one of the treatments. Active pain management with COX inhibitors and pregabalin as alternatives to tramadol or other opiates might provide an attractive alternative to the current WHO pain ladder as it avoids opiate prescription as much as possible. The generalizability is limited due to the small sample size. Larger studies are needed.
Collapse
Affiliation(s)
- Eric W. de Heer
- GGz Breburg, Clinical Centre of Excellence for Body, Mind and Health, Tilburg, Netherlands
- Tranzo Department, Tilburg School of Behavioral and Social Sciences, Tilburg University, Tilburg, Netherlands
| | - Jack Dekker
- Faculty of Behavioral and Movement Sciences, VU University, Amsterdam, Netherlands
- Arkin, Mental Health Institute, Amsterdam, Netherlands
| | - Aartjan T. F. Beekman
- Department of Psychiatry, VU University Medical Centre, Amsterdam, Netherlands
- GGz inGeest, Mental Health Institute, Amsterdam, Netherlands
| | - Harm W. J. van Marwijk
- EMGO Institute for Health and Care Research (EMGO+), Amsterdam, Netherlands
- Department of General Practice, VU University Medical Centre, Amsterdam, Netherlands
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom
| | | | - Pierre M. Bet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Centre, Amsterdam, Netherlands
| | - Joost Roth
- GGz inGeest, Mental Health Institute, Amsterdam, Netherlands
| | - Lotte Timmerman
- GGz Breburg, Clinical Centre of Excellence for Body, Mind and Health, Tilburg, Netherlands
| | - Christina M. van der Feltz-Cornelis
- GGz Breburg, Clinical Centre of Excellence for Body, Mind and Health, Tilburg, Netherlands
- Tranzo Department, Tilburg School of Behavioral and Social Sciences, Tilburg University, Tilburg, Netherlands
| |
Collapse
|
83
|
Mosher H, Herzig SJ, Danovitch I, Boutsicaris C, Hassamal S, Wittnebel K, Dashti A, Nuckols T. The Evaluation of Medical Inpatients Who Are Admitted on Long-term Opioid Therapy for Chronic Pain. J Hosp Med 2018; 13:249-255. [PMID: 29240853 DOI: 10.12788/jhm.2889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Individuals who are on long-term opioid therapy (LTOT) for chronic noncancer pain are frequently admitted to the hospital with acute pain, exacerbations of chronic pain, or comorbidities. Consequently, hospitalists find themselves faced with complex treatment decisions in the context of uncertainty about the effectiveness of LTOT as well as concerns about risks of overdose, opioid use disorders, and adverse events. Our multidisciplinary team sought to synthesize guideline recommendations and primary literature relevant to assessing medical inpatients on LTOT, with the objective of assisting practitioners in balancing effective pain treatment and opioid risk reduction. We identified no primary studies or guidelines specific to assessing medical inpatients on LTOT. Recommendations from outpatient guidelines on LTOT and guidelines on pain management in acute-care settings include the following: evaluate both pain and functional status, differentiate acute from chronic pain, investigate the preadmission course of opioid therapy, obtain a psychosocial history, screen for mental health conditions, screen for substance use disorders, check state prescription drug monitoring databases, order urine drug immunoassays, detect use of sedative-hypnotics, and identify medical conditions associated with increased risk of overdose and adverse events. Although approaches to assessing medical inpatients on LTOT can be extrapolated from related guidelines, observational studies, and small studies in surgical populations, more work is needed to address these critical topics for inpatients on LTOT.
Collapse
Affiliation(s)
- Hilary Mosher
- Department of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Iowa City VA Medical Center, Iowa City, Iowa, USA
| | - Shoshana J Herzig
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Itai Danovitch
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christina Boutsicaris
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sameer Hassamal
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karl Wittnebel
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Azadeh Dashti
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Teryl Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
- RAND Corporation, Santa Monica, California, USA
| |
Collapse
|
84
|
Chang HY, Murimi I, Faul M, Rutkow L, Alexander GC. Impact of Florida's prescription drug monitoring program and pill mill law on high-risk patients: A comparative interrupted time series analysis. Pharmacoepidemiol Drug Saf 2018; 27:422-429. [PMID: 29488663 PMCID: PMC6664298 DOI: 10.1002/pds.4404] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 01/10/2018] [Accepted: 01/18/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE We quantified the effects of Florida's prescription drug monitoring program and pill mill law on high-risk patients. METHODS We used QuintilesIMS LRx Lifelink data to identify patients receiving prescription opioids in Florida (intervention state, N: 1.13 million) and Georgia (control state, N: 0.54 million). The preintervention, intervention, and postintervention periods were July 2010 to June 2011, July 2011 to September 2011, and October 2011 to September 2012. We identified 3 types of high-risk patients: (1) concomitant users: patients with concomitant use of benzodiazepines and opioids; (2) chronic users: long-term, high-dose, opioid users; and (3) opioid shoppers: patients receiving opioids from multiple sources. We compared changes in opioid prescriptions between Florida and Georgia before and after policy implementation among high-risk/low-risk patients. Our monthly measures included (1) average morphine milligram equivalent per transaction, (2) total opioid volume across all prescriptions, (3) average days supplied per transaction, and (4) total number of opioid prescriptions dispensed. RESULTS Among opioid-receiving individuals in Florida, 6.62% were concomitant users, 1.96% were chronic users, and 0.46% were opioid shoppers. Following policy implementation, Florida's high-risk patients experienced relative reductions in morphine milligram equivalent (opioid shoppers: -1.08 mg/month, 95% confidence interval [CI] -1.62 to -0.54), total opioid volume (chronic users: -4.58 kg/month, CI -5.41 to -3.76), and number of dispensed opioid prescriptions (concomitant users: -640 prescriptions/month, CI -950 to -340). Low-risk patients generally did not experience statistically significantly relative reductions. CONCLUSIONS Compared with Georgia, Florida's prescription drug monitoring program and pill mill law were associated with large relative reductions in prescription opioid utilization among high-risk patients.
Collapse
Affiliation(s)
- Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Irene Murimi
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mark Faul
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA, USA
| | - Lainie Rutkow
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| |
Collapse
|
85
|
Abstract
PURPOSE OF REVIEW The aim of this paper is to review psychiatric manifestations, comorbidities, and psychopharmacological management in individuals with acute porphyria (AP). RECENT FINDINGS Recent literature begins to clarify associations between AP, schizophrenia, bipolar disorder, and other psychopathology. Broad psychiatric symptoms have been associated to acute porphyria (AP) and correspond to a spectrum of heterogeneous manifestations such as anxiety, affective alterations, behavioral changes, personality, and psychotic symptoms. These symptoms may be difficult to identify as being related to porphyria since symptoms may arise at any time during the disease process. In addition, these patients may present psychiatric conditions secondary to the disease, such as adjustment disorder and substance use disorders. Timely diagnosis and appropriate treatment of psychiatric manifestations positively impact the course of the disease.
Collapse
|
86
|
Mücke M, Conrad R, Marinova M, Cuhls H, Elsner F, Rolke R, Radbruch L. [Dose-finding for treatment with a transdermal fentanyl patch : Titration with oral transmucosal fentanyl citrate and morphine sulfate]. Schmerz 2017; 30:560-567. [PMID: 27072143 DOI: 10.1007/s00482-016-0106-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
To date, no studies investigating titration with oral transmucosal fentanyl for the dose-finding of transdermal fentanyl treatment have been published. In an open randomized study 60 patients with chronic malignant (n = 39) or nonmalignant pain (n = 21), who required opioid therapy according to step three of the guidelines of the World Health Organization (WHO), were investigated. In two groups of 30 patients each titration with immediate release morphine (IRM) or oral transmucosal fentanyl citrate (OTFC) was undertaken. For measurement purposes the Brief Pain Inventory (BPI) and Minimal Documentation System (MIDOS) were used. After a 24-h titration phase, in which patients documented the intensity of pain, nausea, and tiredness, treatment with transdermal fentanyl was evaluated over a 10-day period by means of the necessary dose adaptation (responder ≤ 1 dose adaptation; conversion formula 1:1 [OTFC group] vs 100:1 [IRM group]).The pain reduction over the first 24 h (titration phase) did not differ significantly between the groups. The number of responders (17 OTFC vs. 21 IRM) over the 10-day period did not show any difference either. In both groups there was a significant reduction in pain intensity (p < 0.001). Over the course of the study, there were significantly more drop-outs because of adverse effects in the OTFC group than in the IRM group (8 vs 1, p = 0.028).Oral transmucosal fentanyl citrate can be applied for the titration of transdermal fentanyl, but it does not show any clinically relevant advantage. For example, the risk of side effects-induced drop-outs was greater in the present study. Whether the unnecessary opioid switching to treat chronic pain and breakthrough pain is advantageous with regard to minimizing conversion errors cannot be definitively answered within the scope of this study.
Collapse
Affiliation(s)
- M Mücke
- Klinik für Palliativmedizin, Universitätsklinikum Bonn, Bonn, Deutschland. .,Institut für Hausarztmedizin, Universitätsklinikum Bonn, Bonn, Deutschland.
| | - R Conrad
- Klinik und Poliklinik für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - M Marinova
- Radiologische Klinik, Universitätsklinikum Bonn, Bonn, Deutschland
| | - H Cuhls
- Klinik für Palliativmedizin, Universitätsklinikum Bonn, Bonn, Deutschland
| | - F Elsner
- Klinik für Palliativmedizin, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - R Rolke
- Klinik für Palliativmedizin, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - L Radbruch
- Klinik für Palliativmedizin, Universitätsklinikum Bonn, Bonn, Deutschland.,Zentrum für Palliativmedizin, Malteser Krankenhaus Seliger Gerhard Bonn/Rhein-Sieg, Bonn, Deutschland
| |
Collapse
|
87
|
Els C, Jackson TD, Hagtvedt R, Kunyk D, Sonnenberg B, Lappi VG, Straube S. High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017; 10:CD012299. [PMID: 29084358 PMCID: PMC6485814 DOI: 10.1002/14651858.cd012299.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue where opioids are routinely used for pain management. There are concerns that the use of high doses of opioids for chronic non-cancer pain lacks evidence of effectiveness and may increase the risk of adverse events. OBJECTIVES To describe the evidence from Cochrane Reviews and Overviews regarding the efficacy and safety of high-dose opioids (here defined as 200 mg morphine equivalent or more per day) for chronic non-cancer pain. METHODS We identified Cochrane Reviews and Overviews through a search of the Cochrane Database of Systematic Reviews (The Cochrane Library). The date of the last search was 18 April 2017. Two review authors independently assessed the search results. We planned to analyse data on any opioid agent used at high dose for two weeks or more for the treatment of chronic non-cancer pain in adults. MAIN RESULTS We did not identify any reviews or overviews meeting the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses where all doses were analysed as a single group; no data for high dose only could be extracted. AUTHORS' CONCLUSIONS There is a critical lack of high-quality evidence regarding how well high-dose opioids work for the management of chronic non-cancer pain in adults, and regarding the presence and severity of adverse events. No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Trials typically used doses below our cut-off; we need to know the efficacy and harm of higher doses, which are often used in clinical practice.
Collapse
Affiliation(s)
- Charl Els
- University of AlbertaDepartment of PsychiatryEdmontonAlbertaCanada
| | - Tanya D Jackson
- University of AlbertaDepartment of Medicine, Division of Preventive MedicineEdmontonAlbertaCanada
| | - Reidar Hagtvedt
- University of AlbertaAOIS, Alberta School of BusinessEdmontonAlbertaCanada
| | - Diane Kunyk
- University of AlbertaFaculty of NursingEdmontonAlbertaCanada
| | - Barend Sonnenberg
- Workers' Compensation Board of AlbertaMedical ServicesEdmontonAlbertaCanada
| | - Vernon G Lappi
- University of AlbertaDepartment of Medicine, Division of Preventive MedicineEdmontonAlbertaCanada
| | - Sebastian Straube
- University of AlbertaDepartment of Medicine, Division of Preventive MedicineEdmontonAlbertaCanada
| | | |
Collapse
|
88
|
Els C, Jackson TD, Kunyk D, Lappi VG, Sonnenberg B, Hagtvedt R, Sharma S, Kolahdooz F, Straube S. Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017; 10:CD012509. [PMID: 29084357 PMCID: PMC6485910 DOI: 10.1002/14651858.cd012509.pub2] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chronic pain is common and can be challenging to manage. Despite increased utilisation of opioids, the safety and efficacy of long-term use of these compounds for chronic non-cancer pain (CNCP) remains controversial. This overview of Cochrane Reviews complements the overview entitled 'High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews'. OBJECTIVES To provide an overview of the occurrence and nature of adverse events associated with any opioid agent (any dose, frequency, or route of administration) used on a medium- or long-term basis for the treatment of CNCP in adults. METHODS We searched the Cochrane Database of Systematic Reviews (the Cochrane Library) Issue 3, 2017 on 8 March 2017 to identify all Cochrane Reviews of studies of medium- or long-term opioid use (2 weeks or more) for CNCP in adults aged 18 and over. We assessed the quality of the reviews using the AMSTAR criteria (Assessing the Methodological Quality of Systematic Reviews) as adapted for Cochrane Overviews. We assessed the quality of the evidence for the outcomes using the GRADE framework. MAIN RESULTS We included a total of 16 reviews in our overview, of which 14 presented unique quantitative data. These 14 Cochrane Reviews investigated 14 different opioid agents that were administered for time periods of two weeks or longer. The longest study was 13 months in duration, with most in the 6- to 16-week range. The quality of the included reviews was high using AMSTAR criteria, with 11 reviews meeting all 10 criteria, and 5 of the reviews meeting 9 out of 10, not scoring a point for either duplicate study selection and data extraction, or searching for articles irrespective of language and publication type. The quality of the evidence for the generic adverse event outcomes according to GRADE ranged from very low to moderate, with risk of bias and imprecision being identified for the following generic adverse event outcomes: any adverse event, any serious adverse event, and withdrawals due to adverse events. A GRADE assessment of the quality of the evidence for specific adverse events led to a downgrading to very low- to moderate-quality evidence due to risk of bias, indirectness, and imprecision.We calculated the equivalent milligrams of morphine per 24 hours for each opioid studied (buprenorphine, codeine, dextropropoxyphene, dihydrocodeine, fentanyl, hydromorphone, levorphanol, methadone, morphine, oxycodone, oxymorphone, tapentadol, tilidine, and tramadol). In the 14 Cochrane Reviews providing unique quantitative data, there were 61 studies with a total of 18,679 randomised participants; 12 of these studies had a cross-over design with two to four arms and a total of 796 participants. Based on the 14 selected Cochrane Reviews, there was a significantly increased risk of experiencing any adverse event with opioids compared to placebo (risk ratio (RR) 1.42, 95% confidence interval (CI) 1.22 to 1.66) as well as with opioids compared to a non-opioid active pharmacological comparator, with a similar risk ratio (RR 1.21, 95% CI 1.10 to 1.33). There was also a significantly increased risk of experiencing a serious adverse event with opioids compared to placebo (RR 2.75, 95% CI 2.06 to 3.67). Furthermore, we found significantly increased risk ratios with opioids compared to placebo for a number of specific adverse events: constipation, dizziness, drowsiness, fatigue, hot flushes, increased sweating, nausea, pruritus, and vomiting.There was no data on any of the following prespecified adverse events of interest in any of the included reviews in this overview of Cochrane Reviews: addiction, cognitive dysfunction, depressive symptoms or mood disturbances, hypogonadism or other endocrine dysfunction, respiratory depression, sexual dysfunction, and sleep apnoea or sleep-disordered breathing. We found no data for adverse events analysed by sex or ethnicity. AUTHORS' CONCLUSIONS A number of adverse events, including serious adverse events, are associated with the medium- and long-term use of opioids for CNCP. The absolute event rate for any adverse event with opioids in trials using a placebo as comparison was 78%, with an absolute event rate of 7.5% for any serious adverse event. Based on the adverse events identified, clinically relevant benefit would need to be clearly demonstrated before long-term use could be considered in people with CNCP in clinical practice. A number of adverse events that we would have expected to occur with opioid use were not reported in the included Cochrane Reviews. Going forward, we recommend more rigorous identification and reporting of all adverse events in randomised controlled trials and systematic reviews on opioid therapy. The absence of data for many adverse events represents a serious limitation of the evidence on opioids. We also recommend extending study follow-up, as a latency of onset may exist for some adverse events.
Collapse
Affiliation(s)
- Charl Els
- University of AlbertaDepartment of PsychiatryEdmontonAlbertaCanada
| | - Tanya D Jackson
- University of AlbertaDepartment of Medicine, Division of Preventive MedicineEdmontonAlbertaCanada
| | - Diane Kunyk
- University of AlbertaFaculty of NursingEdmontonAlbertaCanada
| | - Vernon G Lappi
- University of AlbertaDepartment of Medicine, Division of Preventive MedicineEdmontonAlbertaCanada
| | - Barend Sonnenberg
- Workers' Compensation Board of AlbertaMedical ServicesEdmontonAlbertaCanada
| | - Reidar Hagtvedt
- University of AlbertaAOIS, Alberta School of BusinessEdmontonAlbertaCanada
| | - Sangita Sharma
- Department of Medicine, University of AlbertaIndigenous and Global Health Research GroupEdmontonAlbertaCanada
| | - Fariba Kolahdooz
- Department of Medicine, University of AlbertaIndigenous and Global Health Research GroupEdmontonAlbertaCanada
| | - Sebastian Straube
- University of AlbertaDepartment of Medicine, Division of Preventive MedicineEdmontonAlbertaCanada
| | | |
Collapse
|
89
|
Brennan PL, Del Re AC, Henderson PT, Trafton JA. Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration. Transl Behav Med 2017; 6:605-612. [PMID: 27384953 DOI: 10.1007/s13142-016-0423-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
This study provides an example of how healthcare system-wide progress in implementation of opioid-therapy guideline recommendations can be longitudinally assessed and then related to subsequent opioid-prescribed patient health and safety outcomes. Using longitudinal linear mixed effects analyses, we determined that in the Department of Veterans Affairs (VA) healthcare system (n = 141 facilities), over the 4-year interval from 2010 to 2013, a key opioid therapy guideline recommendation, urine drug screening (UDS), increased from 29 to 42 %, with an average within-facility increase rate of 4.5 % per year. Higher levels of UDS implementation from 2010 to 2013 were associated with lower risk of suicide and drug overdose events among VA opioid-prescribed patients in 2013, even after adjusting for patients' 2012 demographic characteristics and medical and mental health comorbidities. Findings suggest that VA clinicians and healthcare policymakers have been responsive to the 2010 VA/Department of Defense (DOD) UDS treatment guideline recommendation, resulting in improved patient safety for VA opioid-prescribed patients.
Collapse
Affiliation(s)
- Penny L Brennan
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park Division, 795 Willow Road, Menlo Park, CA, 94025, USA.
| | - Aaron C Del Re
- Program Evaluation and Resource Center, VA Palo Alto Health Care System, Menlo Park Division, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Patricia T Henderson
- Program Evaluation and Resource Center, VA Palo Alto Health Care System, Menlo Park Division, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Jodie A Trafton
- Program Evaluation and Resource Center, VA Palo Alto Health Care System, Menlo Park Division, 795 Willow Road, Menlo Park, CA, 94025, USA
| |
Collapse
|
90
|
Survey of Physician Perspective towards Management of Pain for Chronic Conditions in the Emergency Department. ACTA ACUST UNITED AC 2017; 1:55-70. [PMID: 34528027 DOI: 10.22606/mcmr.2017.13002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Sickle cell disease (SCD) pain is often acute-on-chronic, likening it to other chronic acute-on-chronic pain conditions. Pain treatment of SCD was already reported as inadequate prior to the current opioid epidemic, but attitudes underlying treatment were understudied. Understanding these attitudes prior to the current epidemic would be revealing. Therefore in 1997, before the current opioid epidemic, we surveyed physicians' attitudes toward pain management and treatment preferences for acute pain exacerbations in the Emergency Department in SCD versus those of chronic pancreatitis and chronic low back pain, two other acute-on-chronic pain diseases. Thirty-nine residency trainees were surveyed in a level one triage hospital. Resident estimates of the rate of opioid addiction in SCD were higher than estimates in both chronic pancreatitis and chronic low back pain. Most residents relied on their personal clinical experience rather than external sources of data or knowledge as the most important driver when they managed chronic pain. This survey research shows that, predating the current opioid epidemic, there was both a backdrop of opioid-phobia and a bias against treating SCD pain compared to other chronic pain conditions among our sample. Repeating this survey research among current training physicians, along with surveys of other attitudes, would provide useful comparisons.
Collapse
|
91
|
Hunnicutt JN, Chrysanthopoulou SA, Ulbricht CM, Hume AL, Tjia J, Lapane KL. Prevalence of Long-Term Opioid Use in Long-Stay Nursing Home Residents. J Am Geriatr Soc 2017; 66:48-55. [PMID: 28940193 DOI: 10.1111/jgs.15080] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND/OBJECTIVES Overall and long-term opioid use among older adults have increased since 1999. Less is known about opioid use in older adults in nursing homes (NHs). DESIGN Cross-sectional. SETTING U.S. NHs (N = 13,522). PARTICIPANTS Long-stay NH resident Medicare beneficiaries with a Minimum Data Set 3.0 (MDS) assessment between April 1, 2012, and June 30, 2012, and 120 days of follow-up (N = 315,949). MEASUREMENTS We used Medicare Part D claims to measure length of opioid use in the 120 days from the index assessment (short-term: ≤30 days, medium-term: >30-89 days, long-term: ≥90 days), adjuvants (e.g., anticonvulsants), and other pain medications (e.g., corticosteroids). MDS assessments in the follow-up period were used to measure nonpharmacological pain management use. Modified Poisson models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for age, gender, race and ethnicity, cognitive and physical impairment, and long-term opioid use. RESULTS Of all long-stay residents, 32.4% were prescribed any opioid, and 15.5% were prescribed opioids long-term. Opioid users (versus nonusers) were more commonly prescribed pain adjuvants (32.9% vs 14.9%), other pain medications (25.5% vs 11.0%), and nonpharmacological pain management (24.5% vs 9.3%). Long-term opioid use was higher in women (aPR = 1.21, 95% CI = 1.18-1.23) and lower in racial and ethnic minorities (non-Hispanic blacks vs whites: APR = 0.93, 95% CI = 0.90-0.94) and those with severe cognitive impairment (vs no or mild impairment, aPR = 0.82, 95% CI = 0.79-0.83). CONCLUSION One in seven NH residents was prescribed opioids long-term. Recent guidelines on opioid prescribing for pain recommend reducing long-term opioid use, but this is challenging in NHs because residents may not benefit from nonpharmacological and nonopioid interventions. Studies to address concerns about opioid safety and effectiveness (e.g., on pain and functional status) in NHs are needed.
Collapse
Affiliation(s)
- Jacob N Hunnicutt
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Stavroula A Chrysanthopoulou
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Christine M Ulbricht
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Anne L Hume
- Department of Family Medicine, Alpert Medical School, Brown University, Memorial Hospital of Rhode Island, Providence, Rhode Island.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
| | - Jennifer Tjia
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| |
Collapse
|
92
|
Abstract
Prior to statutory changes in prescriptive authority for controlled substances, this study examined the knowledge gaps and prescribing limitations of Florida advanced registered nurse practitioners regarding opioids. Study results revealed statistically significant knowledge gaps in the areas of federal and state guidelines; opioid classes and proper doses; risk assessment skills; monitoring of treatment; and confidence in dealing with challenges of opioid prescribing.
Collapse
|
93
|
Liebschutz JM, Xuan Z, Shanahan CW, LaRochelle M, Keosaian J, Beers D, Guara G, O'Connor K, Alford DP, Parker V, Weiss RD, Samet JH, Crosson J, Cushman PA, Lasser KE. Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial. JAMA Intern Med 2017; 177:1265-1272. [PMID: 28715535 PMCID: PMC5710574 DOI: 10.1001/jamainternmed.2017.2468] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines. OBJECTIVE To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices. INTERVENTIONS Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only. MAIN OUTCOMES AND MEASURES Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language. RESULTS Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001). CONCLUSIONS AND RELEVANCE A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01909076.
Collapse
Affiliation(s)
- Jane M Liebschutz
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Ziming Xuan
- Boston University School of Public Health, Boston, Massachusetts
| | - Christopher W Shanahan
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Marc LaRochelle
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Julia Keosaian
- Boston University School of Public Health, Boston, Massachusetts
| | - Donna Beers
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - George Guara
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Kristen O'Connor
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Daniel P Alford
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Victoria Parker
- Boston University School of Public Health, Boston, Massachusetts
| | - Roger D Weiss
- McLean Hospital, Belmont, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jeffrey H Samet
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
| | - Julie Crosson
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Dorchester House Community Health Center, Boston, Massachusetts
| | - Phoebe A Cushman
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
| |
Collapse
|
94
|
Wynn BO, Buttorff C, Meza E, Taylor EA, Mulcahy AW. Implementing a Drug Formulary for California's Workers' Compensation Program. RAND HEALTH QUARTERLY 2017; 6:4. [PMID: 28845356 PMCID: PMC5568149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
California Assembly Bill 1124 required the state's Division of Workers' Compensation in the Department of Industrial Relations to establish a drug formulary for all injured workers covered by the state's workers' compensation program. Such formularies serve to reinforce safe and effective prescribing patterns for practitioners and payers. In California, the formulary will need to be consistent with the Medical Treatment Utilization Schedule guidelines that define medically appropriate care for California's injured workers, create incentives to encourage prescribing of medically appropriate drugs, and reduce the administrative burdens associated with utilization review and medical necessity disputes. The objective of this study is to support the Division of Workers' Compensation in establishing the formulary. The authors compare and evaluate the strengths and weaknesses of four existing formularies and the formulary used by California's Medicaid program. The authors then analyze the issues involved in structuring the drug formulary for California to be consistent with the treatment guidelines, explore related policies that should be addressed in implementing the formulary, and offer recommendations.
Collapse
|
95
|
Varrassi G, Hanna M, Macheras G, Montero A, Montes Perez A, Meissner W, Perrot S, Scarpignato C. Multimodal analgesia in moderate-to-severe pain: a role for a new fixed combination of dexketoprofen and tramadol. Curr Med Res Opin 2017; 33:1165-1173. [PMID: 28326850 DOI: 10.1080/03007995.2017.1310092] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Untreated and under-treated pain represent one of the most pervasive health problems, which is worsening as the population ages and accrues risk for pain. Multiple treatment options are available, most of which have one mechanism of action, and cannot be prescribed at unlimited doses due to the ceiling of efficacy and/or safety concerns. Another limitation of single-agent analgesia is that, in general, pain is due to multiple causes. Combining drugs from different classes, with different and complementary mechanism(s) of action, provides a better opportunity for effective analgesia at reduced doses of individual agents. Therefore, there is a potential reduction of adverse events, often dose-related. Analgesic combinations are recommended by several organizations and are used in clinical practice. Provided the two agents are combined in a fixed-dose ratio, the resulting medication may offer advantages over extemporaneous combinations. CONCLUSIONS Dexketoprofen/tramadol (25 mg/75 mg) is a new oral fixed-dose combination offering a comprehensive multimodal approach to moderate-to-severe acute pain that encompasses central analgesic action, peripheral analgesic effect and anti-inflammatory activity, together with a good tolerability profile. The analgesic efficacy of dexketoprofen/tramadol combination is complemented by a favorable pharmacokinetic and pharmacodynamic profile, characterized by rapid onset and long duration of action. This has been well documented in both somatic- and visceral-pain human models. This review discusses the available clinical evidence and the future possible applications of dexketoprofen/tramadol fixed-dose combination that may play an important role in the management of moderate-to-severe acute pain.
Collapse
Affiliation(s)
- Giustino Varrassi
- a European League Against Pain, Zurich and Rome , Switzerland and Italy
| | - Magdi Hanna
- b Analgesics and Pain Research Unit (APRU), King's College Hospital , London , UK
| | | | - Antonio Montero
- d Anaesthesiology & Surgery Department , Hospital Arnau de Vilanova , Lleida , Spain
| | - Antonio Montes Perez
- e Anaesthesiology Department , Hospitales Mar-Eseranza , Barcelona , Spain
- f Universitat Autonoma de Barcelona
| | - Winfried Meissner
- g Department of Anaesthesiology and Intensive Care , Jena University Hospital , Jena , Germany
| | - Serge Perrot
- h Centre de la Douleur, Université Paris Descartes, INSERM U987, Hopital Cochin , Paris , France
| | - Carmelo Scarpignato
- i Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Pharmacology , University of Parma , Parma , Italy
| |
Collapse
|
96
|
Pergolizzi JV, LeQuang JA, Berger GK, Raffa RB. The Basic Pharmacology of Opioids Informs the Opioid Discourse about Misuse and Abuse: A Review. Pain Ther 2017; 6:1-16. [PMID: 28341939 PMCID: PMC5447545 DOI: 10.1007/s40122-017-0068-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Indexed: 02/01/2023] Open
Abstract
Morphine and other opioids are widely used to manage moderate to severe acute pain syndromes, such as pain associated with trauma or postoperative pain, and they have been used to manage chronic pain, even chronic nonmalignant pain. However, recent years have seen a renewed recognition of the potential for overuse, misuse, and abuse of opioids. Therefore, prescribing opioids is challenging for healthcare providers in that clinical effectiveness must be balanced against negative outcomes-with the possibility that neither are achieved perfectly. The current discourse about the dual 'epidemics' of under-treatment of legitimate pain and the over-prescription of opioids is clouded by inadequate or inaccurate understanding of opioid drugs and the endogenous pain pathways with which they interact. An understanding of the basic pharmacology of opioids helps inform the clinician and other stakeholders about these simultaneously under- and over-used agents.
Collapse
Affiliation(s)
| | | | | | - Robert B Raffa
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| |
Collapse
|
97
|
Meng Z, Yu J, Acuff M, Luo C, Wang S, Yu L, Huang R. Tolerability of Opioid Analgesia for Chronic Pain: A Network Meta-Analysis. Sci Rep 2017; 7:1995. [PMID: 28515426 PMCID: PMC5435686 DOI: 10.1038/s41598-017-02209-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/07/2017] [Indexed: 12/17/2022] Open
Abstract
Aim of this study was to study the tolerability of opioid analgesia by performing a network meta-analysis (NMA) of randomized-controlled trials (RCTs) which investigated effectiveness of opioids for the management of chronic pain. Research articles reporting outcomes of RCT/s comparing 2 or more opioid analgesics for the management of chronic pain were obtained by database search. Bayesian NMAs were performed to combine direct comparisons between treatments with that of indirect simulated evidence. Study endpoints were: incidence of adverse events, incidence of constipation, trial withdrawal rate, and patient satisfaction with treatment. Outcomes were also compared with conventional meta-analyses. Thirty-two studies investigating 10 opioid drugs fulfilled the eligibility criteria. Tapentadol treatment was top-ranking owing to lower incidence of overall adverse events, constipation, and least trial withdrawal rate. Tapentadol was followed by oxycodone-naloxone combination in providing better tolerability and less trial withdrawal rate. Patient satisfaction was found to be higher with oxycodone-naloxone followed by fentanyl and tapentadol. These results were in agreement with those achieved with conventional meta-analyses. Tapentadol and oxycodone-naloxone are found to exhibit better tolerability characteristics in comparison with other opioid drugs for the management of chronic pain and are associated with low trial withdrawal rate and better patient satisfaction.
Collapse
Affiliation(s)
- Zengdong Meng
- Department of Orthopaedics, First People's Hospital of YunNan Province, YunNan, P.R. China
| | - Jing Yu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Acuff
- Rusk Rehabilitation Center, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Chong Luo
- Department of Orthopaedics, First People's Hospital of YunNan Province, YunNan, P.R. China
| | - Sanrong Wang
- Department of Rehabilitation Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.,Department of Pain Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Lehua Yu
- Department of Rehabilitation Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.,Department of Pain Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Rongzhong Huang
- Department of Rehabilitation Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China. .,Department of Pain Medicine, The second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.
| |
Collapse
|
98
|
Abstract
BACKGROUND Health systems may play an important role in identification of patients at-risk of opioid medication overdose. However, standard measures for identifying overdose risk in administrative data do not exist. OBJECTIVE Examine the association between opioid medication overdose and 2 validated measures of nonmedical use of prescription opioids within claims data. RESEARCH DESIGN A longitudinal retrospective cohort study that estimated associations between overdose and nonmedical use. SUBJECTS Adult Pennsylvania Medicaid program 2007-2012 patients initiating opioid treatment who were: nondual eligible, without cancer diagnosis, and not in long-term care facilities or receiving hospice. MEASURES Overdose (International Classification of Disease, ninth edition, prescription opioid poisonings codes), opioid abuse (opioid use disorder diagnosis while possessing an opioid prescription), opioid misuse (a composite indicator of number of opioid prescribers, number of pharmacies, and days supplied), and dose exposure during opioid treatment episodes. RESULTS A total of 372,347 Medicaid enrollees with 583,013 new opioid treatment episodes were included in the cohort. Opioid overdose was higher among those with abuse (1.5%) compared with those without (0.2%, P<0.001). Overdose was higher among those with probable (1.8%) and possible (0.9%) misuse compared with those without (0.2%, P<0.001). Abuse [adjusted rate ratio (ARR), 1.52; 95% confidence interval (CI), 1.10-2.10), probable misuse (ARR, 1.98; 95% CI, 1.46-2.67), and possible misuse (ARR, 1.76; 95% CI, 1.48-2.09) were associated with significantly more events of opioid medication overdose compared with those without. CONCLUSIONS Claims-based measures can be used by health systems to identify individuals at-risk of overdose who can be targeted for restrictions on opioid prescribing, dispensing, or referral to treatment.
Collapse
|
99
|
Bautista CA, Iosif AM, Wilsey BL, Melnikow JA, Crichlow A, Henry SG. Factors Associated with Opioid Dose Increases: A Chart Review of Patients' First Year on Long-Term Opioids. PAIN MEDICINE (MALDEN, MASS.) 2017; 18:908-916. [PMID: 27477581 PMCID: PMC5285485 DOI: 10.1093/pm/pnw185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective To examine encounter-level factors associated with opioid dose increases during patients' first year on opioid therapy for chronic pain. Design Case-control study analyzing all opioid prescriptions for patients with chronic pain during their first year after opioid initiation. Cases were patients who experienced an overall dose escalation of ≥ 30 mg morphine equivalents over the 1-year period; controls did not experience overall dose escalation. Main measures were encounter type, opioid dose change, documented prescribing rationale, documentation of guideline-concordant opioid-prescribing practices. Two coders reviewed all encounters associated with opioid prescriptions. Analysis of factors associated with dose increases and provider documentation of prescribing rationale was conducted using multiple logistic regression. Results There were 674 encounters coded for 66 patients (22 cases, 44 controls). Fifty-three percent of opioid prescriptions were associated with telephone encounters; 13% were associated with e-mail encounters. No prescribing rationale was documented for 43% of all opioid prescriptions and 25% of dose increases. Likelihood of dose increase and documentation of prescribing rationale did not significantly differ for cases versus controls. Compared with face-to-face encounters, dose increases were significantly less likely for telephone (OR 0.18, 95% CI 0.11-0.28) and e-mail (OR 0.23, 95% CI 0.12-0.47) encounters; documentation of prescribing rationale was significantly more likely for e-mail (OR 5.06, 95% CI 1.87-13.72) and less likely for telephone (OR 0.30, 95% CI 0.18-0.51) encounters. Conclusion Most opioid prescriptions were written without face-to-face encounters. One quarter of dose increases contained no documented prescribing rationale. Documented encounter-level factors were not significantly associated with overall opioid dose escalation.
Collapse
Affiliation(s)
- Christopher A. Bautista
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Ana-Maria Iosif
- Department of Public Health Sciences, University of California Davis, Davis, California
| | - Barth L. Wilsey
- VA Northern California Health Care System, Mather, California
- Department of Physical Medicine and Rehabilitation, University of California Davis School of Medicine, Sacramento, California
| | - Joy A. Melnikow
- University of California Davis Center for Healthcare Policy and Research, Sacramento, California
- Department of Family and Community Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Althea Crichlow
- University of California Davis Center for Healthcare Policy and Research, Sacramento, California
| | - Stephen G. Henry
- University of California Davis Center for Healthcare Policy and Research, Sacramento, California
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| |
Collapse
|
100
|
Häuser W, Schug S, Furlan AD. The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continents. Pain Rep 2017; 2:e599. [PMID: 29392214 PMCID: PMC5741305 DOI: 10.1097/pr9.0000000000000599] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION A marked rise in opioid prescriptions for patients with chronic noncancer pain (CNCP) with a parallel increase in opioid abuse/misuse, and resulting deaths was noted in the Unites states in the past decade (opioid epidemic). In response, the US Center of Diseases Control (CDC) developed a guideline for prescribing of opioids for patients with CNCP. OBJECTIVES To assess (1) if there is an opioid epidemic in Australia, Canada, and Germany (2) to compare Australian, Canadian, German, and Center of Diseases Control guidelines recommendations for long-term opioid therapy for CNCP. METHODS National evidence-based guidelines and PubMed were searched for recommendations for opioid prescriptions for CNCP. RESULTS There are signs of an opioid epidemic in Australia and Canada, but not in Germany. Guidelines in all 4 countries provide similar recommendations: opioids are not the first-line therapy for patients with CNCP; regular clinical assessments of benefits and harms are necessary; excessive doses should be avoided (recommended morphine equivalent daily doses range from 50 to 200 mg/d); stopping rules should be followed. All guidelines do not recommend the use of opioids in chronic pain conditions without an established nociceptive or neuropathic cause such as fibromyalgia and primary headache. CONCLUSION Implementation of opioid prescribing guidelines should ensure that physicians prescribe opioids only for appropriate indications in limited doses for selected patients and advice patients on their safe use. These measures could contribute to reduce prescription opioid misuse/abuse and deaths.
Collapse
Affiliation(s)
- Winfried Häuser
- Department Internal Medicine 1, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Stephan Schug
- Pharmacology, Pharmacy and Anaesthesiology Unit, School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Andrea D Furlan
- Department of Medicine, University of Toronto, Institute for Work & Health, Toronto Rehab-UHN, Toronto, ON, Canada
| |
Collapse
|