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Associations Between Physical Pain, Pain Management, and Frequency of Nonmedical Prescription Opioid Use Among Young Adults: A Sex-specific Analysis. J Addict Med 2017; 11:266-272. [PMID: 28514234 DOI: 10.1097/adm.0000000000000318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to determine sex-specific associations between experiences of physical pain, pain management, and frequency of nonmedical prescription opioid (NMPO) use among young adults. METHODS Among participants enrolled in the Rhode Island Young Adult Prescription Drug Study, we identified associations between physical pain in the past 6 months, pain history, pain management, polysubstance use, and weekly NMPO use. In sex-specific models, independent correlates of weekly NMPO use were identified via modified stepwise Poisson regression. RESULTS Of 199 participants, the mean age was 24.6, and 65.3% were male. The racial composition was 16.6% black, 60.8% white, and 22.1% mixed or other race. A total of 119 (59.8%) participants reported weekly or greater NMPO use. The majority of male (86.2%) and female (84.1%) participants reported ever experiencing severe pain. A majority of males (72.3%) and females (81.2%) reported that they engaged in NMPO use to treat their physical pain, and one-quarter (26.9%) of males and one-third (36.2%) of females had been denied a prescription from a doctor to treat severe pain. Among males, frequent NMPO use was independently associated with white race (P < 0.001) and reporting greater physical pain (P = 0.002). Among females, older age (P = 0.002) and monthly or greater nonmedical benzodiazepine use (P = 0.001) were independently associated with weekly NMPO use. CONCLUSIONS Among young men in Rhode Island, physical pain may be related to frequent NMPO use. More research is needed to identify sex-specific, pain-related factors that are linked with NMPO use to improve harm reduction and pain management interventions.
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Muir H, Seymour F. Screening tools to assess risk of opioid abuse in the Canadian primary healthcare setting. Nurse Pract 2017; 42:45-50. [PMID: 28346282 DOI: 10.1097/01.npr.0000508172.41410.3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Opioid therapy for patients with chronic pain is increasing in frequency along with rates of opioid abuse. Many screening tools are available to assess for the risk of opioid abuse. NPs should use screening tools that are cross-validated for use in chronic pain patients in the Canadian primary healthcare setting.
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Affiliation(s)
- Hollie Muir
- Hollie Muir is an NP at the Oromocto Health Centre, Oromocto, N.B., Canada. Fran Seymour is a senior teaching associate and NP at the University of New Brunswick, Frederickton, N.B., Canada
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Bennett AS, Golub A, Elliott L. A behavioral typology of opioid overdose risk behaviors among recent veterans in New York City. PLoS One 2017; 12:e0179054. [PMID: 28594892 PMCID: PMC5464624 DOI: 10.1371/journal.pone.0179054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 05/23/2017] [Indexed: 12/01/2022] Open
Abstract
Objective To identify meaningful classes of opioid-using military veterans in terms of self-reported opioid overdose risk behaviors. Method The study recruited a sample of 218 military veterans in the NYC area who were discharged from active duty service after September 11, 2001 and reported past-month opioid use. Survey data including measures of mental health, social stressors, substance use, and opioid-related overdose risk behaviors were analyzed using Latent Class Analysis (LCA). Results A five group solution had excellent fit scores and interpretability. Factor analysis confirmed the existence of two major dimensions of variation: non-adherence and heroin use. The five groups included lower-risk prescription opioid users, non-adherent prescription opioid users and heroin users. The non-adherent prescription opioid users and heroin user classes were both further subdivided into “occasional” and “regular” use categories. In addition to endorsing a greater number of overdose risk behaviors, users in the regular use classes were more likely to screen positive for alcohol and substance use disorders, reported greater self-medicating opioid use to relieve anxiety, reported greater problems with physical pain, were more likely to have had mental health, alcohol and drug treatment, and were less likely to be employed or in school. Heroin users also were less likely to report stable housing. Conclusions Findings indicate that opioid overdose risk classes are grounded in contextual factors related to experiences of psychological, physiological, and social adjustment pain and distress which should be addressed in tailored interventions targeting opioid users’ unique constellations of risk behaviors and comorbid conditions.
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Affiliation(s)
- Alex S. Bennett
- National Development and Research Institutes Inc., New York, New York, United States of America
- Affiliated Investigator, Center for Drug Use and HIV/HCV Research, Rory Meyers College of Nursing, New York University, New York, New York, United States of America
- * E-mail:
| | - Andrew Golub
- National Development and Research Institutes Inc., New York, New York, United States of America
| | - Luther Elliott
- National Development and Research Institutes Inc., New York, New York, United States of America
- Affiliated Investigator, Center for Drug Use and HIV/HCV Research, Rory Meyers College of Nursing, New York University, New York, New York, United States of America
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Setnik B, Roland CL, Barsdorf AI, Brooks A, Coyne KS. The content validation of the Self-Reported Misuse, Abuse and Diversion of Prescription Opioids (SR-MAD) instrument for use in patients with acute or chronic pain. Curr Med Res Opin 2017; 33:1067-1076. [PMID: 28277862 DOI: 10.1080/03007995.2017.1300142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Establishing content validity is an essential component of instrument development. OBJECTIVE To assess the content validity and patient interpretation of the Self-Reported Misuse, Abuse and Diversion of Prescription Opioids (SR-MAD) instrument. METHODS A cross-sectional, qualitative study was conducted in patients with chronic or acute pain. Patients were recruited from three patient groups (opioid naïve, known opioid abusers, and chronic opioid non-abusers). After patients completed the SR-MAD, they participated in an in-person cognitive interview to assess the patient's understanding of the instrument. Descriptive statistics and content analysis were performed. RESULTS Fifty-seven patients (Wave 1: 20; Wave 2: 37) were enrolled and completed the SR-MAD and cognitive interview. Mean age was 54.5 ± 13.7 years (range 25-84) with 12.5 years of living with pain. The most common chronic pain conditions were back pain (68%), neck pain (32%), and osteoarthritis (25%). Overall, most patients understood the meaning of each question and were able to describe each item using their own words. Many patients reported that some questions were not applicable to them but understood the meaning of the questions as well as the need to ask questions about misuse, abuse, and diversion of opioid medications. Minor revisions to the SR-MAD wording, response options, recall period, and the definition of "opioid", were recommended by the patients in both waves. LIMITATIONS Given its qualitative design, this study has a small sample size. Additionally, quantitative validation of the SR-MAD is needed. CONCLUSION The SR-MAD, developed based on expert consensus and revised with patient input, is a 15-item self-report instrument that can be used to identify and monitor prescription opioid abuse, misuse, and diversion.
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Affiliation(s)
- Beatrice Setnik
- a INC Research , Raleigh , NC , USA
- b Department of Pharmacology and Toxicology , University of Toronto , Toronto , Ontario , Canada
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Measures That Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: ACTTION Critique and Recommended Considerations. THE JOURNAL OF PAIN 2017; 18:1287-1294. [PMID: 28479207 DOI: 10.1016/j.jpain.2017.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/20/2017] [Accepted: 03/30/2017] [Indexed: 11/20/2022]
Abstract
Accurate assessment of inappropriate medication use events (ie, misuse, abuse, and related events) occurring in clinical trials is an important component in evaluating a medication's abuse potential. A meeting was convened to review all instruments measuring such events in clinical trials according to previously published standardized terminology and definitions. Only 2 approaches have been reported that are specifically designed to identify and classify misuse, abuse, and related events occurring in clinical trials, rather than to measure an individual's risk of using a medication inappropriately: the Self-Reported Misuse, Abuse, and Diversion (SR-MAD) instrument and the Misuse, Abuse, and Diversion Drug Event Reporting System (MADDERS). The conceptual basis, strengths, and limitations of these methods are discussed. To our knowledge, MADDERS is the only system available to comprehensively evaluate inappropriate medication use events prospectively to determine the underlying intent. MADDERS can also be applied retrospectively to completed trial data. SR-MAD can be used prospectively; additional development may be required to standardize its implementation and fully appraise the intent of inappropriate use events. Additional research is needed to further demonstrate the validity and utility of MADDERS as well as SR-MAD. PERSPECTIVE Identifying a medication's abuse potential requires assessing inappropriate medication use events in clinical trials on the basis of a standardized event classification system. The strengths and limitations of the 2 published methods designed to evaluate inappropriate medication use events are reviewed, with recommended considerations for further development and current implementation.
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106
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Arteta J, Cobos B, Hu Y, Jordan K, Howard K. Evaluation of How Depression and Anxiety Mediate the Relationship Between Pain Catastrophizing and Prescription Opioid Misuse in a Chronic Pain Population. PAIN MEDICINE 2017; 17:295-303. [PMID: 26235471 DOI: 10.1111/pme.12886] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE We investigated the extent to which anxiety and depression mediate the relationship between pain catastrophizing and the risk of prescription opioid misuse in chronic pain patients. METHODS 215 patients with chronic occupational musculoskeletal disorders completed self-report measures upon admission to a functional restorational program. A bootstrap multivariate regression analysis was conducted to assess how depression and anxiety mediated the relationship between pain catastrophizing and prescription opioid misuse. RESULTS Catastrophizing, anxiety, and depression predicted higher risk for prescription opioid misuse. Furthermore, anxiety and depression acted as mediators while controlling for the effects of gender and age. Finally, it was found that the effects of catastrophizing on risk for prescription opioid misuse were completely eliminated by those of depression. CONCLUSION Due to the partially independent relationship of anxiety and catastrophizing, it is recommended that treatments for chronic pain patients employ techniques addressing both behaviors. The relationship between depression and catastrophizing requires more research since it was observed that their effects were confounded.
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Gardiner P, Lestoquoy AS, Gergen-Barnett K, Penti B, White LF, Saper R, Fredman L, Stillman S, Lily Negash N, Adelstein P, Brackup I, Farrell-Riley C, Kabbara K, Laird L, Mitchell S, Bickmore T, Shamekhi A, Liebschutz JM. Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression. Contemp Clin Trials 2016; 54:25-35. [PMID: 27979754 DOI: 10.1016/j.cct.2016.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 12/07/2016] [Accepted: 12/10/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Given the public health crisis of opioid overprescribing for pain, there is a need for evidence-based non pharmacological treatment options that effectively reduce pain and depression. We aim to examine the effectiveness of the Integrative Medical Group Visits (IMGV) model in reducing chronic pain and depressive symptoms, as well as increasing pain self-management. METHODS This paper details the study design and implementation of an ongoing randomized controlled trial of the IMGV model as compared to primary care visits. The research aims to determine if the IMGV model is effective in achieving: a) a reduction in self-reported pain and depressive symptoms and 2) an improvement in the self-management of pain, through increasing pain self-efficacy and reducing use of self-reported pain medication. We intend to recruit 154 participants to be randomized in our intervention, the IMGV model (n=77) and to usual care (n=77). CONCLUSIONS Usual care of chronic pain through pharmacological treatment has mixed evidence of efficacy and may not improve quality of life or functional status. We aim to conduct a randomized controlled trial to evaluate the effectiveness of the IMGV model as compared to usual care in reducing self-reported pain and depressive symptoms as well as increasing pain management skills.
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Affiliation(s)
- Paula Gardiner
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States.
| | - Anna Sophia Lestoquoy
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Katherine Gergen-Barnett
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Brian Penti
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Robert Saper
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Lisa Fredman
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Sarah Stillman
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - N Lily Negash
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | | | - Ivy Brackup
- DotHouse Health Center, Dorchester, MA, United States
| | | | - Karim Kabbara
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Lance Laird
- Division of Graduate Medical Sciences, Boston University School of Medicine, Boston, MA, United States
| | - Suzanne Mitchell
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Timothy Bickmore
- College of Computer & Information Science, Northeastern University, Boston, MA, United States
| | - Ameneh Shamekhi
- College of Computer & Information Science, Northeastern University, Boston, MA, United States
| | - Jane M Liebschutz
- Clinical Addictions Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine and Public Health, Boston, MA, United States
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Setnik B, Roland CL, Pixton GC, Sommerville KW. Prescription opioid abuse and misuse: gap between primary-care investigator assessment and actual extent of these behaviors among patients with chronic pain. Postgrad Med 2016; 129:5-11. [PMID: 27782769 DOI: 10.1080/00325481.2017.1245585] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To compare the results of two open-label primary care-based studies that examined investigator assessment of patient risk for prescription opioid misuse, abuse, and diversion relative to patient self-reports and urine drug tests (UDTs). METHODS Risk assessment data from two open-label, multicenter, primary care-based US studies in patients with chronic pain were compared. RESULTS In one study (n = 1487), 54.4% of patients were at moderate, 24.8% at high, and 20.8% at low risk based on patients' self-reports at baseline on the Screener and Opioid Assessment for Patients with Pain®-Revised questionnaire. Investigators assigned 1.3% of patients as high risk despite 5.0% self-reporting prior illicit drug use and 15.3% with positive UDT(s) for an illicit drug at baseline. In the second study (n = 684), few patients were considered by investigators to be at high risk for misuse (1.6%), abuse (1.8%), or diversion (1.0%). However, 10.4% of patients reported prior illicit drug use; 23.4% had at least one abnormal baseline UDT; 60% of 537 patients reported on the Self-Reported Misuse, Abuse, and Diversion questionnaire they took more opioids than prescribed; and 10.9% reported chewing/crushing opioids in the past. Of patients completing the Current Opioid Misuse Measure, 40.6% were classified as having aberrant behaviors. CONCLUSION A comparison of risk assessment across two studies indicates a tendency for investigators to assess patients as lower risk for opioid-related aberrant behaviors despite a significant proportion self-reporting aberrant behavior and/or presenting with illicit UDTs. These consistent findings underline the importance of appropriate implementation of objective measures and self-reporting tools when evaluating risk in patients. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov identifiers: NCT00640042 and NCT01179191.
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Affiliation(s)
| | - Carl L Roland
- b Department of Clinical Sciences and Outcomes & Evidence , Pfizer Inc , Durham , NC , USA
| | - Glenn C Pixton
- c Department of Statistics , Pfizer Inc , Durham , NC , USA
| | - Kenneth W Sommerville
- d Department of Clinical Research , GW Pharmaceuticals , Research Triangle Park , NC , USA.,e Department of Neurology , Duke University Medical Center , Durham , NC , USA
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Lin CWC, McLachlan AJ, Latimer J, Day RO, Billot L, Koes BW, Maher CG. OPAL: a randomised, placebo-controlled trial of opioid analgesia for the reduction of pain severity in people with acute spinal pain. Trial protocol. BMJ Open 2016; 6:e011278. [PMID: 27558901 PMCID: PMC5013345 DOI: 10.1136/bmjopen-2016-011278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Low back pain and neck pain are extremely prevalent and are responsible for an enormous burden of disease globally. Strong analgesics, such as opioid analgesics, are recommended by clinical guidelines for people with acute low back pain or neck pain who are slow to recover and require more pain relief. Opioid analgesics are widely and increasingly used, but there are no strong efficacy data supporting the use of opioid analgesics for acute low back pain or neck pain. Concerns regarding opioid use are further heightened by the risks of adverse events, some of which can be serious (eg, dependency, misuse and overdose). METHODS AND ANALYSIS OPAL is a randomised, placebo-controlled, triple-blinded trial that will investigate the judicious use of an opioid analgesic in 346 participants with acute low back pain and/or neck pain who are slow to recover. Participants will be recruited from general practice and randomised to receive the opioid analgesic (controlled release oxycodone plus naloxone up to 20 mg per day) or placebo in addition to guideline-based care (eg, reassurance and advice of staying active) for up to 6 weeks. Participants will be followed-up for 3 months for effectiveness outcomes. The primary outcome will be pain severity. Secondary outcomes will include physical functioning and time to recovery. Medication-related adverse events will be assessed and a cost-effectiveness analysis will be conducted. We will additionally assess long-term use and risk of misuse of opioid analgesics for up to 12 months. ETHICS AND DISSEMINATION Ethical approval has been obtained. Trial results will be disseminated by publications and conference presentations, and via the media. TRIAL REGISTRATION NUMBER ACTRN12615000775516: Pre-results.
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Affiliation(s)
- Chung-Wei Christine Lin
- The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy and The Centre for Education and Research on Ageing (CERA), The University of Sydney and Concord Hospital, Sydney, New South Wales, Australia
| | - Jane Latimer
- The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Ric O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney and Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Laurent Billot
- The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
| | - Chris G Maher
- The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Nikulina V, Guarino H, Acosta MC, Marsch LA, Syckes C, Moore SK, Portenoy RK, Cruciani RA, Turk DC, Rosenblum A. Patient vs provider reports of aberrant medication-taking behavior among opioid-treated patients with chronic pain who report misusing opioid medication. Pain 2016; 157:1791-1798. [PMID: 27082008 PMCID: PMC4949142 DOI: 10.1097/j.pain.0000000000000583] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training.
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Affiliation(s)
- Valentina Nikulina
- Queens College, CUNY; Department of Psychology, 6530 Kissena Boulevard, Flushing, NY 11367, T: (718) 997-3215; F: (718) 997-3257; http://www.qc.cuny.edu/Academics/Degrees/DMNS/Psychology/Pages/default.aspx
| | - Honoria Guarino
- National Development and Research Institutes, Inc., New York, NY
| | | | - Lisa A. Marsch
- Dartmouth Center for Technology and Behavioral Health, Lebanon, NH
| | - Cassandra Syckes
- National Development and Research Institutes, Inc., New York, NY
| | - Sarah K. Moore
- Dartmouth Center for Technology and Behavioral Health, Lebanon, NH
| | | | | | | | - Andrew Rosenblum
- National Development and Research Institutes, Inc., New York, NY
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Carroll CP, Lanzkron S, Haywood C, Kiley K, Pejsa M, Moscou-Jackson G, Haythornthwaite JA, Campbell CM. Chronic Opioid Therapy and Central Sensitization in Sickle Cell Disease. Am J Prev Med 2016; 51:S69-77. [PMID: 27320469 PMCID: PMC5379857 DOI: 10.1016/j.amepre.2016.02.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/22/2016] [Accepted: 02/12/2016] [Indexed: 01/04/2023]
Abstract
Chronic opioid therapy (COT) for chronic non-cancer pain is frequently debated, and its effectiveness is unproven in sickle cell disease (SCD). The authors conducted a descriptive study among 83 adult SCD patients and compared the severity of disease and pain symptoms among those who were prescribed COT (n=29) with those who were not using COT. All patients completed baseline laboratory pain assessment and questionnaires between January 2010 and June 2014. Thereafter, participants recorded daily pain, crises, function, and healthcare utilization for 90 days using electronic diaries. Analyses were conducted shortly after the final diary data collection period. Patients on COT did not differ on age, sex, or measures of disease severity. However, patients on COT exhibited greater levels of clinical pain (particularly non-crisis); central sensitization; and depression and increased diary measures of pain severity, function, and healthcare utilization on crisis and non-crisis diary days, as well as a greater proportion of days in crisis. Including depressive symptoms in multivariate models did not change the associations between COT and pain, interference, central sensitization, or utilization. Additionally, participants not on COT displayed the expected positive relationship between central sensitization and clinical pain, whereas those on COT demonstrated no such relationship, despite having both higher central sensitization and higher clinical pain. Overall, the results point out a high symptom burden in SCD patients on COT, including those on high-dose COT, and suggest that nociceptive processing in SCD patients on COT differs from those who are not.
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Affiliation(s)
- C Patrick Carroll
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Sophie Lanzkron
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carlton Haywood
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kasey Kiley
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Megan Pejsa
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jennifer A Haythornthwaite
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Butler SF, Zacharoff KL, Charity S, Black RA, Chung E, Barreveld A, Clark MS, Jamison RN. Impact of an Electronic Pain and Opioid Risk Assessment Program: Are There Improvements in Patient Encounters and Clinic Notes? PAIN MEDICINE 2016; 17:2047-2060. [PMID: 27102526 DOI: 10.1093/pm/pnw033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE A comprehensive electronic self-report assessment, called PainCAS® (Clinical Assessment System), was developed and implemented in three clinics. PainCAS captures demographic information, pain assessment, quality-of-life variables, and contains validated, electronic versions of screeners for risk of aberrant opioid-related behaviors (the SOAPP and COMM). This investigation sought to determine the impact of PainCAS on documentation of pain and opioid risk evaluations. Exploratory hypotheses examined changes in the content of the patient-provider interaction and any impact on outcome. METHODS In study 1, chart reviews were conducted between pain patients who completed the electronic program (N = 89) and controls who represented standard of care (N = 120). In study 2, two groups of chronic pain patients (treatment-as-usual Control condition = 75, PainCAS Experimental condition = 72) were interviewed after completing their index clinic visit and completed mailed questionnaires 3 months later. RESULTS Results revealed significantly more key, pain-relevant chart elements documented in charts of patients who completed the PainCAS than those using a traditional paper questionnaire (Study 1; <0.001). In Study 2, the Experimental group reported more discussion about legal issues, substance use history, and medication safety compared with the Control group (p < 0.05). Satisfaction questionnaire responses supported provider and patient perceived benefit from using PainCAS. However, as expected, no differences were found between conditions on outcome measures of pain, mood, and function. CONCLUSIONS Results indicate that use of the PainCAS electronic pain assessment improves documentation of chart elements in clinic notes and is associated with increased discussion of key, pain-relevant topics during the clinical visit.
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Affiliation(s)
| | | | | | | | | | - Antje Barreveld
- Pain Management Center, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Molly S Clark
- University of Mississippi Medical Center, Family Medicine, Jackson, Mississippi
| | - Robert N Jamison
- Pain Management Center, Brigham and Women's Hospital, Harvard Medical School, Chestnut Hill, Massachusetts, USA
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Efficacy of the Opioid Compliance Checklist to Monitor Chronic Pain Patients Receiving Opioid Therapy in Primary Care. THE JOURNAL OF PAIN 2016; 17:414-23. [DOI: 10.1016/j.jpain.2015.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 12/31/2022]
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114
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Wallwork RS, Chipidza FE, Stern TA. Obstacles to the Prescription and Use of Opioids. Prim Care Companion CNS Disord 2016; 18:15f01900. [PMID: 27247832 PMCID: PMC4874752 DOI: 10.4088/pcc.15f01900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022] Open
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Larance B, Bruno R, Lintzeris N, Degenhardt L, Black E, Brown A, Nielsen S, Dunlop A, Holland R, Cohen M, Mattick RP. Development of a brief tool for monitoring aberrant behaviours among patients receiving long-term opioid therapy: The Opioid-Related Behaviours In Treatment (ORBIT) scale. Drug Alcohol Depend 2016; 159:42-52. [PMID: 26710979 DOI: 10.1016/j.drugalcdep.2015.11.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Early identification of problems is essential in minimising the unintended consequences of opioid therapy. This study aimed to develop a brief scale that identifies and quantifies recent aberrant behaviour among diverse patient populations receiving long-term opioid treatment. METHOD 40 scale items were generated via literature review and expert panel (N=19) and tested in surveys of: (i) N=41 key experts, and (ii) N=426 patients prescribed opioids >3 months (222 pain patients and 204 opioid substitution therapy (OST) patients). We employed item and scale psychometrics (exploratory factor analyses, confirmatory factor analyses and item-response theory statistics) to refine items to a brief scale. RESULTS Following removal of problematic items (poor retest-reliability or wording, semantic redundancy, differential item functioning, collinearity or rarity) iterative factor analytic procedures identified a 10-item unifactorial scale with good model fit in the total sample (N=426; CFI=0.981, TLI=0.975, RMSEA=0.057), and among pain (CFI=0.969, TLI=0.960, RMSEA=0.062) and OST subgroups (CFI=0.989, TFI=0.986, RMSEA=0.051). The 10 items provided good discrimination between groups, demonstrated acceptable test-retest reliability (ICC 0.80, 95% CI 0.60-0.89; Cronbach's alpha=0.89), were moderately correlated with related constructs, including opioid dependence (SDS), depression and stress (DASS subscales) and Social Relationships and Environment domains of the WHO-QoL, and had strong face validity among advising clinicians. CONCLUSIONS The Opioid-Related Behaviours In Treatment (ORBIT) scale is brief, reliable and validated for use in diverse patient groups receiving opioids. The ORBIT has potential applications as a checklist to prompt clinical discussions and as a tool to quantify aberrant behaviour and assess change over time.
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Affiliation(s)
- Briony Larance
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia.
| | - Raimondo Bruno
- School of Medicine, University of Tasmania, Sandy Bay Campus, Hobart, Tasmania 7001, Australia
| | - Nicholas Lintzeris
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, 591 South Dowling Street, Surry Hills, NSW 2010, Australia; University of Sydney, Camperdown, NSW 2050, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia; School of Population and Global Health, The University of Melbourne, Parkville, VIC 3010, Australia; Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia; Department of Global Health, School of Public Health, University of Washington, 325 9th Avenue, Seattle, WA 98104, USA
| | - Emma Black
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia
| | - Amanda Brown
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia; University of Sydney, Camperdown, NSW 2050, Australia
| | - Adrian Dunlop
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, Australia; School of Medicine and Public Health, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Rohan Holland
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, Australia
| | - Milton Cohen
- St Vincent's Clinical School, UNSW Australia, Darlinghurst, NSW 2010, Australia
| | - Richard P Mattick
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia
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Anderson MA, Akshintala V, Albers KM, Amann ST, Belfer I, Brand R, Chari S, Cote G, Davis BM, Frulloni L, Gelrud A, Guda N, Humar A, Liddle RA, Slivka A, Gupta RS, Szigethy E, Talluri J, Wassef W, Wilcox CM, Windsor J, Yadav D, Whitcomb DC. Mechanism, assessment and management of pain in chronic pancreatitis: Recommendations of a multidisciplinary study group. Pancreatology 2016; 16:83-94. [PMID: 26620965 PMCID: PMC4761301 DOI: 10.1016/j.pan.2015.10.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/29/2015] [Accepted: 10/31/2015] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Pain in patients with chronic pancreatitis (CP) remains the primary clinical complaint and source of poor quality of life. However, clear guidance on evaluation and treatment is lacking. METHODS Pancreatic Pain working groups reviewed information on pain mechanisms, clinical pain assessment and pain treatment in CP. Levels of evidence were assigned using the Oxford system, and consensus was based on GRADE. A consensus meeting was held during PancreasFest 2012 with substantial post-meeting discussion, debate, and manuscript refinement. RESULTS Twelve discussion questions and proposed guidance statements were presented. Conference participates concluded: Disease Mechanism: Pain etiology is multifactorial, but data are lacking to effectively link symptoms with pathologic feature and molecular subtypes. Assessment of Pain: Pain should be assessed at each clinical visit, but evidence to support an optimal approach to assessing pain character, frequency and severity is lacking. MANAGEMENT There was general agreement on the roles for endoscopic and surgical therapies, but less agreement on optimal patient selection for medical, psychological, endoscopic, surgical and other therapies. CONCLUSIONS Progress is occurring in pain biology and treatment options, but pain in patients with CP remains a major problem that is inadequately understood, measured and managed. The growing body of information needs to be translated into more effective clinical care.
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Affiliation(s)
| | | | - Kathryn M Albers
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Inna Belfer
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Randall Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Suresh Chari
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greg Cote
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Brian M Davis
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nalini Guda
- Department of Gastroenterology, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jyothsna Talluri
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wahid Wassef
- Department of Medicine, University of Massachusetts, Worcester, MA, USA
| | - C Mel Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Cell Biology & Molecular Physiology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA.
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Abstract
OBJECTIVE Prescription opioid abuse and dependence have escalated rapidly in the United States over the past 20 years, leading to high rates of overdose deaths and a dramatic increase in the number of people seeking treatment for opioid dependence. The authors review the scope of the abuse and overdose epidemic, prescription practices, and the assessment, treatment, and prevention of prescription opioid misuse and dependence. METHOD The authors provide an overview of the literature from 2006 to the present, with the twin goals of highlighting advances in prevention and treatment and identifying remaining gaps in the science. RESULTS A number of policy and educational initiatives at the state and federal government level have been undertaken in the past 5 years to help providers and consumers, respectively, prescribe and use opioids more responsibly. Initial reports suggest that diversion and abuse levels have begun to plateau, likely as a result of these initiatives. While there is a large body of research suggesting that opioid substitution coupled with psychosocial interventions is the best treatment option for heroin dependence, there is limited research focusing specifically on the treatment of prescription opioid dependence. In particular, the treatment of chronic pain in individuals with prescription opioid use disorders is underexplored. CONCLUSIONS While policy and educational initiatives appear to be effective in decreasing prescription opioid abuse and misuse, research focusing on the development and evaluation of treatments specific to prescription opioid dependence and its common comorbidities (e.g., chronic pain, depression) is critically needed.
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Affiliation(s)
- Kathleen T Brady
- From the Addiction Sciences Division, Institute of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; and the Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Jenna L McCauley
- From the Addiction Sciences Division, Institute of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; and the Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Sudie E Back
- From the Addiction Sciences Division, Institute of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; and the Ralph H. Johnson Veterans Affairs Medical Center, Charleston
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Abstract
Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.
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Jurcik DC, Sundaram AH, Jamison RN. Chronic pain, negative affect, and prescription opioid abuse. Curr Opin Psychol 2015. [DOI: 10.1016/j.copsyc.2015.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zhao Y, Li Y, Zhang X, Lou F. Translation and validation of the Chinese version of the Current Opioid Misuse Measure (COMM) for patients with chronic pain in Mainland China. Health Qual Life Outcomes 2015; 13:147. [PMID: 26374505 PMCID: PMC4572659 DOI: 10.1186/s12955-015-0329-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 08/23/2015] [Indexed: 01/20/2023] Open
Abstract
Background Management of prescription opioids misuse and abuse problems among chronic pain patients has been increasingly important worldwide and little literature concerning prescription opioids can be found in mainland China so far. Methods The Current Opioid Misuse Measure (COMM) was translated into Chinese following Brislin’s model of cross-culture translation and was completed by a convenience sample of 180 patients with chronic pain recruited from two major hospitals in Jinan, Shandong province. Data were analyzed using internal consistency, test-retest reliability, exploratory factor analysis and confirmatory factor analysis. Results The internal consistency coefficient for the total score of the COMM was 0.85 and item-total correlations of all items were above 0.20. Besides, the test-retest reliability was satisfactory with an ICC of 0.91 (95 % CI = 0.65-0.98). Four principal components were extracted, accounting for 65.30 % of the variance, and the factor loadings of all 17 items were above 0.40. Conclusions The Chinese version of COMM showed satisfactory reliability and validity, and could be used as a screening tool to evaluate and monitor current aberrant drug-related behavior among Chinese patients with chronic pain.
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Affiliation(s)
- Yang Zhao
- School of Nursing, Shandong University, No.44, Wenhuaxi Road, Jinan, Shandong Province, 250012, People's Republic of China. .,Nursing Faculty, Tianjin Medical College, No. 14 Liulin Road, Tianjin, 300222, People's Republic of China.
| | - Yuli Li
- School of Nursing, Shandong University, No.44, Wenhuaxi Road, Jinan, Shandong Province, 250012, People's Republic of China.
| | - Xuekun Zhang
- School of Nursing, Shandong University, No.44, Wenhuaxi Road, Jinan, Shandong Province, 250012, People's Republic of China.
| | - Fenglan Lou
- School of Nursing, Shandong University, No.44, Wenhuaxi Road, Jinan, Shandong Province, 250012, People's Republic of China.
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Wilson M, Roll JM, Corbett C, Barbosa-Leiker C. Empowering Patients with Persistent Pain Using an Internet-based Self-Management Program. Pain Manag Nurs 2015; 16:503-14. [DOI: 10.1016/j.pmn.2014.09.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 09/10/2014] [Accepted: 09/24/2014] [Indexed: 11/16/2022]
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Ashrafioun L, Bohnert ASB, Jannausch M, Ilgen MA. Evaluation of the current opioid misuse measure among substance use disorder treatment patients. J Subst Abuse Treat 2015; 55:15-20. [PMID: 25800105 PMCID: PMC4456230 DOI: 10.1016/j.jsat.2015.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 02/02/2015] [Accepted: 02/22/2015] [Indexed: 10/23/2022]
Abstract
The Current Opioid Misuse Measure (COMM) has demonstrated promising psychometric properties among pain clinic and primary care patients. Given the high prevalence of the nonmedical use of prescription opioids among substance use disorder patients, the COMM may also be useful in substance use disorder treatment settings. The purpose of this study was to assess the factor structure and validity of the COMM in a sample of substance use disorder patients. Participants (n = 351) were recruited from a large residential substance use disorder treatment center and completed the COMM and several questionnaires assessing various substance use and health functioning characteristics. Factor analyses yielded a two-factor solution; however, each of the items in the second factor cross-loaded onto the first factor and just one factor was retained. To provide support for this new 11-item COMM, we found that higher scores on this COMM were associated with greater drug use severity, greater endorsement of positive, negative, and pain relief outcome expectancies related to opioid use, increased pain intensity, and decreased physical and mental health functioning. These findings provide initial support for the psychometric properties of this version of the COMM adapted for substance use disorder treatment settings. Given its promising psychometric properties, the 11 items of the COMM to evaluate the nonmedical use of prescription opioids have potential utility among substance use disorder patients. The COMM could be used to examine nonmedical use over the course of treatment and to aid treatment planning. It could also be used in research as an outcome measure.
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Affiliation(s)
- Lisham Ashrafioun
- Bowling Green State University, Department of Psychology, 207 Psychology Building, Bowling Green, OH 43403; VA Ann Arbor Healthcare System, Mental Health Service, 2215 Fuller Rd., Ann Arbor, MI 48105.
| | - Amy S B Bohnert
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Department of Veterans Affairs Healthcare System, Ann Arbor MI, North Campus Research Complex, 2800 Plymouth Rd Building 14, Ann Arbor, MI 48109; Department of Psychiatry, University of Michigan, Ann Arbor, MI, North Campus Research Complex, 2800 Plymouth Rd Building 10, Ann Arbor, MI 48109
| | - Mary Jannausch
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Department of Veterans Affairs Healthcare System, Ann Arbor MI, North Campus Research Complex, 2800 Plymouth Rd Building 14, Ann Arbor, MI 48109; Department of Psychiatry, University of Michigan, Ann Arbor, MI, North Campus Research Complex, 2800 Plymouth Rd Building 10, Ann Arbor, MI 48109
| | - Mark A Ilgen
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Department of Veterans Affairs Healthcare System, Ann Arbor MI, North Campus Research Complex, 2800 Plymouth Rd Building 14, Ann Arbor, MI 48109; Department of Psychiatry, University of Michigan, Ann Arbor, MI, North Campus Research Complex, 2800 Plymouth Rd Building 10, Ann Arbor, MI 48109
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Setnik B, Roland CL, Sommerville KW, Pixton GC, Berke R, Calkins A, Goli V. A multicenter, primary care-based, open-label study to identify behaviors related to prescription opioid misuse, abuse, and diversion in opioid-experienced patients with chronic moderate-to-severe pain. J Pain Res 2015; 8:361-73. [PMID: 26185467 PMCID: PMC4501355 DOI: 10.2147/jpr.s82396] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective To compare the investigator assessment of patient risk for prescription opioid misuse, abuse, and diversion with patient self-reports of these activities in a population with chronic pain. Methods As a secondary objective of an open-label, multicenter, primary care-based clinical study to evaluate the success of converting opioid-experienced patients with chronic pain to morphine sulfate with sequestered naltrexone hydrochloride, risk for misuse, abuse, and diversion was assessed using two nonvalidated questionnaires: one was completed by the investigator and another by the patient (Self-Reported Misuse, Abuse, and Diversion [SR-MAD]). In addition, the validated Current Opioid Misuse Measure (COMM) test and urine drug test were used. Results Of the 684 patients assessed by the investigators, 537 returned the self-assessment, SR-MAD. Most patients were assigned by the investigator as low risk for misuse (84.2%), abuse (89.3%), and diversion (94.3%). Of the patients who returned SR-MAD, 60% indicated having taken more opioids than prescribed and 10.9% reported chewing or crushing their opioids in the past. Of the patients who completed COMM, 40.6% were deemed as having aberrant behaviors. COMM results correlated with the risk levels from the investigator assessment. One-third of patients (33.8%) had at least one abnormal urine drug test result. Conclusion More research is needed to better understand the gap between the investigator assessment of potential risk for misuse, abuse, and diversion and the actual extent of these behaviors among patients with chronic pain.
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Affiliation(s)
| | | | | | | | - Robert Berke
- Family Health Medical Services PLLC, Mayville, NY, USA ; Department of Social and Preventive Medicine, State University of New York at Buffalo, Buffalo, NY, USA
| | - Anne Calkins
- New York Spine & Wellness Center, Syracuse, NY, USA
| | - Veeraindar Goli
- Pfizer Inc, Durham, NC, USA ; Duke University Medical Center, Durham, NC, USA
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Abstract
Chronic pain is an international health issue of immense importance that is influenced by both physical and psychological factors. Opioids are useful in treating chronic pain but have accompanying complications. It is important for clinicians to understand the basics of opioid pharmacology, the benefits and adverse effects of opioids, and related problematic issues of tolerance, dependence, and opioid-induced hyperalgesia. In this article, the role of psychiatric comorbidity and the use of validated assessment tools to identify individuals who are at the greatest risk for opioid misuse are discussed. Additionally, interventional treatment strategies for patients with chronic pain who are at risk for opioid misuse are presented. Specific behavioral interventions designed to improve adherence with prescription opioids among persons treated for chronic pain, such as frequent monitoring, periodic urine screens, opioid therapy agreements, opioid checklists, and motivational counseling, are also reviewed. Use of state-sponsored prescription drug monitoring programs is also encouraged. Areas requiring additional investigation are identified, and the future role of abuse-deterrent opioids and innovative technology in addressing issues of opioid therapy and pain are presented.
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Affiliation(s)
- Robert N Jamison
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Jianren Mao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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125
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Wen W, Sitar S, Lynch SY, He E, Ripa SR. A multicenter, randomized, double-blind, placebo-controlled trial to assess the efficacy and safety of single-entity, once-daily hydrocodone tablets in patients with uncontrolled moderate to severe chronic low back pain. Expert Opin Pharmacother 2015; 16:1593-606. [PMID: 26111544 DOI: 10.1517/14656566.2015.1060221] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This multicenter, randomized, double-blind, placebo-controlled study with an enriched enrollment, randomized withdrawal design was conducted to evaluate the analgesic efficacy and safety of single-entity, once-daily hydrocodone 20 to 120 mg tablets (HYD) in opioid-naive and opioid-experienced patients with uncontrolled moderate to severe chronic low back pain (CLBP). RESEARCH DESIGN AND METHODS The primary endpoint was week 12 pain intensity scores (11-point scale, 0 = no pain) using a mixed effect model with repeated measures incorporating a pattern mixture model framework. Responder analysis was a secondary endpoint. Safety was assessed. RESULTS Out of 905 patients who were treated with HYD during the open-label titration period, 588 (65%) were randomized to continue to receive HYD (n = 296, 20 - 120 mg taken once daily, average daily dose 57 mg) or a matching placebo (n = 292). HYD demonstrated superior pain reduction (p = 0.0016); this result was supported by sensitivity analyses using different approaches to handling missing data. Proportions of patients achieving ≥ 30 and ≥ 50% improvement in pain from screening to week 12 also favored HYD (p = 0.0033 and 0.0225, respectively). HYD was generally well tolerated. CONCLUSIONS HYD was shown to be an efficacious treatment for CLBP in this study. There were no new or unexpected safety concerns detected.
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Affiliation(s)
- Warren Wen
- Medical Research, Purdue Pharma L.P. , One Stamford Forum, Stamford, CT 06901 , USA +1 203 588 7631 ; +1 203 588 7423 ;
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Smith SM, Paillard F, McKeown A, Burke LB, Edwards RR, Katz NP, Papadopoulos EJ, Rappaport BA, Slagle A, Strain EC, Wasan AD, Turk DC, Dworkin RH. Instruments to Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: An ACTTION Systematic Review. THE JOURNAL OF PAIN 2015; 16:389-411. [PMID: 25660826 DOI: 10.1016/j.jpain.2015.01.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/07/2015] [Accepted: 01/08/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Measurement of inappropriate medication use events (eg, abuse or misuse) in clinical trials is important in characterizing a medication's abuse potential. However, no gold standard assessment of inappropriate use events in clinical trials has been identified. In this systematic review, we examine the measurement properties (ie, content validity, cross-sectional reliability and construct validity, longitudinal construct validity, ability to detect change, and responder definitions) of instruments assessing inappropriate use of opioid and nonopioid prescription medications to identify any that meet U.S. and European regulatory agencies' rigorous standards for outcome measures in clinical trials. Sixteen published instruments were identified, most of which were not designed for the selected concept of interest and context of use. For this reason, many instruments were found to lack adequate content validity (or documentation of content validity) to evaluate current inappropriate medication use events; for example, evaluating inappropriate use across the life span rather than current use, including items that did not directly assess inappropriate use (eg, questions about anger), or failing to capture information pertinent to inappropriate use events (eg, intention and route of administration). In addition, the psychometric data across all instruments were generally limited in scope. A further limitation is the heterogeneous, nonstandardized use of inappropriate medication use terminology. These observations suggest that available instruments are not well suited for assessing current inappropriate medication use within the specific context of clinical trials. Further effort is needed to develop reliable and valid instruments to measure current inappropriate medication use events in clinical trials. PERSPECTIVE This systematic review evaluates the measurement properties of inappropriate medication use (eg, abuse or misuse) instruments to determine whether any meet regulatory standards for clinical trial outcome measures to assess abuse potential.
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Affiliation(s)
- Shannon M Smith
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York.
| | | | - Andrew McKeown
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Robert R Edwards
- Department of Anesthesiology, Brigham & Women's Hospital, Boston, Massachusetts
| | - Nathaniel P Katz
- Department of Anesthesia, Tufts University, Boston, Massachusetts; Analgesic Solutions, Natick, Massachusetts
| | | | - Bob A Rappaport
- United States Food and Drug Administration, Silver Spring, Maryland
| | - Ashley Slagle
- United States Food and Drug Administration, Silver Spring, Maryland
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ajay D Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert H Dworkin
- Departments of Anesthesiology and Neurology, and Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York
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128
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Abstract
BACKGROUND Patients frequently seek treatment for chronic nonmalignant pain in primary care settings. Compared with physicians who have completed extensive specialization (eg, fellowships) in pain management, primary care physicians receive much less formal training in managing chronic pain. While chronic pain represents a complicated condition in its own right, the recent increase in opioid prescriptions further muddles treatment. It is unknown whether patients with chronic pain seeking treatment in primary care differ from those seeking treatment in tertiary care settings. This study sought to determine whether patients with chronic pain in primary care reported less pain, fewer psychological variables related to pain, and lower risk of medication misuse/abuse compared with those in tertiary care. METHODS Data collected from patients with chronic pain in primary care settings and tertiary care settings were analyzed for significant differences using Wilcoxon rank sum tests, Fisher exact tests, and linear regression. A host of variables among populations, including demographics, self-reported pain severity, psychological variables related to pain, and risk for opioid misuse and abuse, were compared. RESULTS Findings suggest that primary care patients with chronic pain were similar to those in tertiary care on a host of indices and reported more severe pain. There were no significant group differences for risk of medication misuse or abuse. CONCLUSION It seems that primary care physicians care for a complicated group of patients with chronic pain that rivals the complexity of those seen in specialized tertiary care pain management facilities.
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129
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Abstract
With increased prescription of opioids has come increased recognition of adverse consequences, including narcotic bowel syndrome (NBS). Characterized by incompletely controlled abdominal pain despite continued or increasing doses of opioids, NBS is estimated to occur in 4.2-6.4% of patients chronically taking opioids. Patients with NBS have a high degree of comorbid psychiatric illness, catastrophizing and disability; comorbid substance abuse must also be considered among this population. NBS should be distinguished from opioid-induced bowel disorder, which results from the effects of opioids on gastrointestinal motility and secretion. By contrast, the mechanisms of NBS are probably centrally mediated and include glial cell activation, bimodal opioid modulation in the dorsal horn, descending facilitation of pain and the glutaminergic system. Few treatments have been rigorously studied. A trial of opioid detoxification resulted in complete detoxification for the vast majority of patients with reduction in pain symptoms; however, despite improvement in pain, approximately half of patients returned to opioid use within 3 months. Improved strategies are needed to identify patients who will respond to detoxification and remain off opioids. Comorbid psychiatric and substance abuse disorders are barriers to durable response after detoxification and should be actively sought out and treated accordingly. An effective patient-physician relationship is essential.
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O'Connor AB, Turk DC, Dworkin RH, Katz NP, Colucci R, Haythornthwaite JA, Klein M, O'Brien C, Posner K, Rappaport BA, Reisfield G, Adams EH, Balster RL, Bigelow GE, Burke LB, Comer SD, Cone E, Cowan P, Denisco RA, Farrar JT, Foltin RW, Haddox DJ, Hertz S, Jay GW, Junor R, Kopecky EA, Leiderman DB, McDermott MP, Palmer PP, Raja SN, Rauschkolb C, Rowbotham MC, Sampaio C, Setnik B, Smith SM, Sokolowska M, Stauffer JW, Walsh SL, Zacny JP. Abuse liability measures for use in analgesic clinical trials in patients with pain: IMMPACT recommendations. Pain 2014; 154:2324-2334. [PMID: 24148704 DOI: 10.1016/j.pain.2013.06.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 06/10/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
Assessing and mitigating the abuse liability (AL) of analgesics is an urgent clinical and societal problem. Analgesics have traditionally been assessed in randomized clinical trials (RCTs) designed to demonstrate analgesic efficacy relative to placebo or an active comparator. In these trials, rigorous, prospectively designed assessment for AL is generally not performed. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) convened a consensus meeting to review the available evidence and discuss methods for improving the assessment of the AL of analgesics in clinical trials in patients with pain. Recommendations for improved assessment include: (1) performing trials that include individuals with diverse risks of abuse; (2) improving the assessment of AL in clinical trials (eg, training study personnel in the principles of abuse and addiction behaviors, designing the trial to assess AL outcomes as primary or secondary outcome measures depending on the trial objectives); (3) performing standardized assessment of outcomes, including targeted observations by study personnel and using structured adverse events query forms that ask all subjects specifically for certain symptoms (such as euphoria and craving); and (4) collecting detailed information about events of potential concern (eg, unexpected urine drug testing results, loss of study medication, and dropping out of the trial). The authors also propose a research agenda for improving the assessment of AL in future trials.
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Affiliation(s)
- Alec B O'Connor
- Department of Medicine, University of Rochester, Rochester, NY, USA Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA Department of Anesthesiology, University of Rochester, Rochester, NY, USA Analgesic Solutions, Natick, MA, USA Department of Anesthesiology, Tufts University School of Medicine, Boston, MA, USA Colucci & Associates LLC, Newtown, CT, USA Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA United States Food and Drug Administration, Silver Spring, MD, USA Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA Center for Suicide Risk Assessment, New York State Psychiatric Institute/College of Physicians and Surgeons, Columbia University, New York, NY, USA Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA Covance, Princeton, NJ, USA Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA, USA American Chronic Pain Association, Rocklin, CA, USA National Institute on Drug Abuse, Rockville, MD, USA Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA Purdue Pharma LP, Stamford, CT, USA Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA Pfizer Inc, Ann Arbor, MI, USA Eisai Limited, Woodcliff Lake, NJ, USA Endo Pharmaceuticals Inc, Chadds Ford, PA, USA CNS Drug Consulting LLC, McLean, VA, USA Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA AcelRx Pharmaceuticals Inc, Redwood City, CA, USA Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore School of Medicine, MD, USA Johnson & Johnson Pharmaceutical Research & Development LLC, Raritan, NJ, USA California Pacific Medical Center Research Institute, San Francisco, CA, USA Clinical Pharmacology and Therapeutics Laboratory, Faculdade de Medicina de Lisboa, Lisbon, Portugal King Pharmaceuticals Inc, Cary, NC, USA Grünenthal USA Inc, Bedminster, NJ, USA Durect Corporation, Cupertino, CA, USA Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky, KY, USA Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL, USA
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131
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Barth KS, Balliet W, Pelic CM, Madan A, Malcolm R, Adams D, Morgan K, Owczarski S, Borckardt JJ. Screening for current opioid misuse and associated risk factors among patients with chronic nonalcoholic pancreatitis pain. PAIN MEDICINE 2014; 15:1359-64. [PMID: 24716629 DOI: 10.1111/pme.12403] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of this study is to assess clinical variables that may be associated with risk for opioid misuse in individuals with chronic pancreatitis. DESIGN This study utilized a descriptive, quasi-experimental, cross sectional design. SETTING AND PATIENTS Three hundred seven individuals with nonalcoholic chronic pancreatitis engaged in chronic opioid therapy for pain presented to an outpatient specialty clinic at an academic medical center. MEASURES Participants completed the Current Opioid Misuse Measure (COMM), Brief Pain Inventory (BPI), Short Form (SF)-12 Quality of Life Measure, Center for Epidemiological Studies 10-item Depression Scale (CESD), and a single item asking about current alcohol use. Mean scores on the CESD, COMM, BPI, SF-12, and factors associated with opioid misuse measures from regression analyses were the outcome measures. RESULTS Mean scores on the CESD, COMM, BPI pain-on-average item, and the SF-12 physical and psychological quality of life factors (t scores) were 11.2 (standard deviation [SD] = 6.7), 8.5 (SD = 7.3), 4.8 (SD = 2.8), 39.7 (SD = 7.0), and 45 (SD = 9.0), respectively. Descriptive analyses revealed that 55% of participants scored above the clinical cutoff for depression on the CESD, and 39% scored above the cutoff for opioid misuse concerns on the COMM. Regression analyses identified several factors associated with higher opioid misuse measure scores, including increased depressive symptoms from the CESD (β = 0.38, P < 0.0001), increased pain rating at the time of the office visit (β = 0.16, P = 0.03), impairment of psychological quality of life (β = -0.27, P = 0.001) and endorsement of alcohol use (β = 0.16, P = 0.03). These factors accounted for 37% of the variance in current opioid misuse scores. CONCLUSIONS Depression, quality of life, pain intensity and alcohol use may be good candidate variables for prospective studies to determine clinical risk factors for opioid misuse among patients with pancreatitis.
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Affiliation(s)
- Kelly S Barth
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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132
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Hartrick CT, Gatchel RJ, Conroy S. Identification and management of pain medication abuse and misuse: current state and future directions. Expert Rev Neurother 2014; 12:601-10. [DOI: 10.1586/ern.12.34] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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133
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Martel MO, Dolman AJ, Edwards RR, Jamison RN, Wasan AD. The association between negative affect and prescription opioid misuse in patients with chronic pain: the mediating role of opioid craving. THE JOURNAL OF PAIN 2014; 15:90-100. [PMID: 24295876 PMCID: PMC3877217 DOI: 10.1016/j.jpain.2013.09.014] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 07/30/2013] [Accepted: 09/26/2013] [Indexed: 01/08/2023]
Abstract
UNLABELLED Over the past decade, considerable research has accumulated showing that chronic pain patients experiencing high levels of negative affect (NA) are at increased risk for prescription opioid misuse. The primary objective of the present study was to examine the factors that underlie the association between NA and prescription opioid misuse among patients with chronic pain. In this study, 82 patients with chronic musculoskeletal pain being prescribed opioid medication completed the Current Opioid Misuse Measure, a well-validated self-report questionnaire designed to assess prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, NA, and opioid craving. A bootstrapped multiple mediation analysis was used to examine the mediating role of patients' pain intensity and opioid craving in the association between NA and prescription opioid misuse. Consistent with previous research, we found a significant association between NA and prescription opioid misuse. Interestingly, results revealed that opioid craving, but not pain intensity, mediated the association between NA and opioid misuse. The Discussion addresses the potential psychological and neurobiological factors that might contribute to the interrelationships among NA, opioid craving, and prescription opioid misuse in patients with pain. The clinical implications of our findings are also discussed. PERSPECTIVE Our study provides new insights into the factors that underlie the association between negative affect and prescription opioid misuse in patients with chronic pain. Our findings could have important clinical implications, particularly for patients being prescribed opioid medication, and for reducing rates of opioid misuse in patients with pain.
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Affiliation(s)
- Marc O Martel
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts.
| | - Andrew J Dolman
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts
| | - Robert R Edwards
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts
| | - Robert N Jamison
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ajay D Wasan
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts
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134
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Chang YP, Compton P. Management of chronic pain with chronic opioid therapy in patients with substance use disorders. Addict Sci Clin Pract 2013; 8:21. [PMID: 24341916 PMCID: PMC3904483 DOI: 10.1186/1940-0640-8-21] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 12/05/2013] [Indexed: 01/02/2023] Open
Abstract
Substance use disorders (SUDs), whether active or in remission, are often encountered in patients with chronic nonmalignant pain. Clinicians are challenged when managing chronic pain while facing substance abuse issues during the course of chronic opioid therapy (COT). Further, the interrelated behavioral symptomatology of addiction and chronic pain suggests that if one disorder is untreated, effective treatment of the other in not possible. Incomplete understanding of the overlapping presentations of the two disorders, coupled with insufficient management of both conditions, leads to undertreated pain and premature discharge of SUD patients from pain treatment. In order to achieve pain relief and optimal functionality, both conditions need to be carefully managed. This paper reviews the prevalence of SUDs in chronic pain patents; the overlapping presentation of the two disorders; risk factors and stratification for addiction; identification of addiction in the chronic pain population; and suggestions for treating patients with COT, with an emphasis on relapse prevention. With appropriate assessment and treatment, COT for chronic pain patients with a history of SUD can be successful, leading to improved functionality and quality of life.
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Affiliation(s)
- Yu-Ping Chang
- University of Buffalo School of Nursing, Buffalo, 3435 Main Street Wende Hall 201E, Buffalo, NY 14221, USA.
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135
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Butler SF, Zacharoff K, Charity S, Lawler K, Jamison RN. Electronic opioid risk assessment program for chronic pain patients: barriers and benefits of implementation. Pain Pract 2013; 14:E98-E105. [PMID: 24279713 DOI: 10.1111/papr.12141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/15/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A preliminary electronic pain assessment program known as Pain Assessment Interview Network, Clinical Advisory System (painCAS), was implemented in 2 pain centers over the course of 10 months to understand the tool's impact on opioid risk assessment documentation and clinical workflow. The program contains validated electronic versions of screeners for opioid misuse risk (SOAPP-R and Current Opioid Misuse Measure). METHODS Charts of patients with an initial and 2 follow-up visits were randomly selected for review of presence of opioid risk assessments before and after implementation of the electronic assessment program. Clinical and administrative staff members were interviewed to gain their perceptions of the impact of the program. RESULTS Significant increases were observed in the documentation of opioid risk assessments between the baseline patient chart reviews before implementation of the program (n = 66) and the postintervention patient chart reviews after the implementation of the program (n = 39), for both initial and follow-up clinic visits (P < 0.001). Specific benefits of the program identified by 7 clinicians and 8 administrators included ease of use, reduced paperwork, completion of the assessment before the clinic visit, and incorporation of information directly into an electronic medical record (EMR). Perceived barriers to implementation included poor patient compliance, changes in administration workflow, and difficulties associated with patients with no email addresses, and limited computer skills. CONCLUSIONS Implementation of an opioid risk electronic pain assessment program significantly increased the likelihood that a risk assessment would be included in the medical record, which has implications for improvement of quality of care.
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136
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Finkelman MD, Kulich RJ, Zoukhri D, Smits N, Butler SF. Shortening the Current Opioid Misuse Measure via computer-based testing: a retrospective proof-of-concept study. BMC Med Res Methodol 2013; 13:126. [PMID: 24138225 PMCID: PMC4016584 DOI: 10.1186/1471-2288-13-126] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/15/2013] [Indexed: 11/30/2022] Open
Abstract
Background The Current Opioid Misuse Measure (COMM) is a self-report questionnaire designed to help identify aberrant drug-related behavior in respondents who have been prescribed opioids for chronic pain. The full-length form of the COMM consists of 17 items. Some individuals, especially compromised individuals, may be deterred from taking the full questionnaire due to its length. This study examined the use of curtailment and stochastic curtailment, two computer-based testing approaches that sequentially determine the test length for each individual, to reduce the respondent burden of the COMM without compromising sensitivity and specificity. Methods Existing data from n = 415 participants, all of whom had taken the full-length COMM and had been classified via the Aberrant Drug Behavior Index (ADBI), were divided into training (n = 214) and test (n = 201) sets. Post-hoc analysis of the test set was performed to evaluate the screening results and test lengths that would have been obtained, if curtailment or stochastic curtailment had been used. Sensitivity, specificity, and average test length were calculated for each method and compared with the corresponding values of the full-length test. Results The full-length COMM had a sensitivity of 0.703 and a specificity of 0.701 for predicting the ADBI. Curtailment reduced the average test length by 22% while maintaining the same sensitivity and specificity as the full-length COMM. Stochastic curtailment reduced the average test length by as much as 59% while always obtaining a sensitivity of at least 0.688 and a specificity of at least 0.701 for predicting the ADBI. Conclusions Curtailment and stochastic curtailment have the potential to achieve substantial reductions in respondent burden without compromising sensitivity and specificity. The two sequential methods should be considered for future computer-based administrations of the COMM.
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Affiliation(s)
- Matthew D Finkelman
- Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA 02111, USA.
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137
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Abstract
Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed.
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Affiliation(s)
- Michael R Von Korff
- Group Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA.
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138
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Kissin I. Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety? J Pain Res 2013; 6:513-29. [PMID: 23874119 PMCID: PMC3712997 DOI: 10.2147/jpr.s47182] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND For the past 30 years, opioids have been used to treat chronic nonmalignant pain. This study tests the following hypotheses: (1) there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective; and (2) the main problem associated with the safety of such treatment - assessment of the risk of addiction - has been neglected. METHODS Scientometric analysis of the articles representing clinical research in this area was performed to assess (1) the quality of presented evidence (type of study); and (2) the duration of the treatment phase. The sufficiency of representation of addiction was assessed by counting the number of articles that represent (1) editorials; (2) articles in the top specialty journals; and (3) articles with titles clearly indicating that the addiction-related safety is involved (topic-in-title articles). RESULTS Not a single randomized controlled trial with opioid treatment lasting >3 months was found. All studies with a duration of opioid treatment ≥6 months (n = 16) were conducted without a proper control group. Such studies cannot provide the consistent good-quality evidence necessary for a strong clinical recommendation. There were profound differences in the number of addiction articles related specifically to chronic nonmalignant pain patients and to opioid addiction in general. An inadequate number of chronic pain-related publications were observed with all three types of counted articles: editorials, articles in the top specialty journals, and topic-in-title articles. CONCLUSION There is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective. The above identified signs indicating neglect of addiction associated with the opioid treatment of chronic nonmalignant pain were present.
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Affiliation(s)
- Igor Kissin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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139
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Bonar EE, Ilgen MA, Walton M, Bohnert ASB. Associations among pain, non-medical prescription opioid use, and drug overdose history. Am J Addict 2013; 23:41-7. [PMID: 24313240 DOI: 10.1111/j.1521-0391.2013.12055.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 12/17/2012] [Accepted: 01/17/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Recently, use of prescription opioids (POs) has increased; non-medical PO (NMPO) use is linked to overdose. NMPO use is common among individuals prescribed opioids for pain, and those in substance use disorder (SUD) treatment with pain could be at increased risk for unintentional overdose due to NMPO use. We examined associations between pain, NMPO use, and overdose among SUD treatment patients. METHODS Among 342 patients at a residential SUD treatment center, logistic regression examined the association of overdose with pain, adjusting for substance use, suicide attempts, and demographics. RESULTS Pain was positively related to NMPO use. Heroin use, suicide attempts, pain, and NMPO use were positively associated with overdose; but NMPO use attenuated the pain-overdose relationship. CONCLUSIONS The relationship between pain and overdose among substance users may be, in part, explained by the association between pain and heavy NMPO use.
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Affiliation(s)
- Erin E Bonar
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
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140
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Marino EN, Rosen KD, Gutierrez A, Eckmann M, Ramamurthy S, Potter JS. Impulsivity but not sensation seeking is associated with opioid analgesic misuse risk in patients with chronic pain. Addict Behav 2013; 38:2154-7. [PMID: 23454878 DOI: 10.1016/j.addbeh.2013.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 12/21/2012] [Accepted: 01/29/2013] [Indexed: 02/02/2023]
Abstract
Impulsivity and sensation seeking have been associated with substance use disorders, including opioid use disorders. This pilot study sought to examine whether impulsivity and sensation seeking, as measured by the Barratt Impulsiveness Scale (BIS) and Sensation Seeking Scale (SSS), were associated with opioid analgesic misuse risk in chronic, low-back pain patients prescribed opioid analgesics. Participants were 42 chronic, low-back pain patients enrolled in a larger study examining problematic opioid analgesic use. Impulsivity was assessed using the BIS, sensation seeking was measured using the SSS, and opioid analgesic misuse risk was assessed using the Current Opioid Misuse Measure (COMM). Significant bivariate associations were found between the COMM and the following predictor variables: age and the three BIS subscales: Attentional Impulsiveness, Non-planning Impulsiveness, and Motor Impulsiveness. Using a multivariate linear regression, after controlling for age, the BIS subscales accounted for 29.0% of the variance in the COMM. Attentional Impulsiveness was the only significant BIS subscale. These results suggest a potential relationship between impulsivity, but not sensation seeking, and risk for opioid analgesic misuse. Impulsivity is not a prominent trait observed in chronic pain patients; however, it may be an important risk factor for opioid analgesic misuse for a subset of individuals with chronic pain. As such, these findings suggest that additional exploration of this potential risk factor is warranted.
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141
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Becker WC, Fraenkel L, Edelman EJ, Holt SR, Glover J, Kerns RD, Fiellin DA. Instruments to assess patient-reported safety, efficacy, or misuse of current opioid therapy for chronic pain: a systematic review. Pain 2013; 154:905-16. [PMID: 23601625 DOI: 10.1016/j.pain.2013.02.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 02/04/2013] [Accepted: 02/26/2013] [Indexed: 12/19/2022]
Abstract
The purpose of this systematic review was to summarize and critically appraise research developing or validating instruments to assess patient-reported safety, efficacy, and/or misuse in ongoing opioid therapy for chronic pain. Our search included the following datasets: OvidSP MEDLINE (1946-August 2012), OvidSP PsycINFO (1967-August 2012), Elsevier Scopus (1947-August 2012), OvidSP HaPI (1985-August 2012), and EBSCO CINAHL (1981-August 2012). Eligible studies were published in English and pertained to adult, nonsurgical/interventional populations. Two authors independently assessed inclusion criteria. Each study was evaluated by 2 authors to assess the sources and content of items, types of psychometric tests, their results, and quality of diagnostic accuracy testing, when applicable. Of 1874 citations found in the initial search, we identified 14 studies meeting our inclusion criteria, describing 9 different instruments. Individual items were derived from surveys of content experts, literature reviews, and adapted non-patient-reported items. Misuse-related items were most prevalent (60/144; 42%), followed by safety (47/144; 33%), with efficacy having the fewest items (17/144; 12%). The studies employed a wide variety of psychometric tests, with most demonstrating statistical significance, but several potential sources of bias and generalizability limitations were identified. Lack of testing in clinical practice limited assessment of feasibility. The dearth of safety and efficacy items and lack of testing in clinical practice demonstrates areas for further research.
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142
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Abstract
There is much evidence to suggest that psychological and social issues are predictive of pain severity, emotional distress, work disability, and response to medical treatments among persons with chronic pain. Psychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management, leading to a greater likelihood of treatment success. The assessment of different domains using semi-structured clinical interviews and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral and social issues in order to facilitate treatment planning. In this paper, we briefly describe measures to assess constructs related to pain and intervention strategies for the behavioral treatment of chronic pain and discuss related psychiatric and substance abuse issues. Finally, we offer a future look at the role of integrating pain management in clinical practice in the psychological assessment and treatment for persons with chronic pain.
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143
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Garland EL, Froeliger BE, Passik SD, Howard MO. Attentional bias for prescription opioid cues among opioid dependent chronic pain patients. J Behav Med 2012; 36:611-20. [PMID: 22968666 DOI: 10.1007/s10865-012-9455-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 08/31/2012] [Indexed: 12/15/2022]
Abstract
Recurrent use of prescription opioid analgesics by chronic pain patients may result in opioid dependence, which involves implicit neurocognitive operations that organize and impel craving states and compulsive drug taking behavior. Prior studies have identified an attentional bias (AB) towards heroin among heroin dependent individuals. The aim of this study was to determine whether opioid-dependent chronic pain patients exhibit an AB towards prescription opioid-related cues. Opioid-dependent chronic pain patients (n = 32) and a comparison group of non-dependent opioid users with chronic pain (n = 33) completed a dot probe task designed to measure opioid AB. Participants also rated their opioid craving and self-reported arousal associated with opioid-related and neutral images, pain severity, and relief from pain treatments. Repeated-measures ANOVA revealed a significant group (opioid-dependent vs. non-dependent opioid user) × presentation duration (200. vs. 2,000 ms.) interaction, such that opioid-dependent individuals evidenced a significant AB towards opioid cues presented for 200 ms but not for cues presented for 2,000 ms, whereas non-dependent opioid users did not exhibit a significant mean AB at either stimulus duration. Among opioid-dependent individuals, 200 ms opioid AB was significantly associated with opioid craving, while among non-dependent opioid users, 200 ms opioid AB was significantly associated with relief from pain treatments. Furthermore, dependent and non-dependent opioid users experienced opioid cues as significantly more arousing than neutral cues. Opioid dependence among chronic pain patients appears to involve an automatic AB towards opioid-related cues. When coupled with chronic pain, attentional fixation on opioid cues may promote compulsive drug use and addictive behavior.
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Affiliation(s)
- Eric L Garland
- Trinity Institute for the Addictions, College of Social Work, Florida State University, University Center, Building C, Tallahassee, FL, 32306-2570, USA,
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144
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Jamison RN, Edwards RR. Risk factor assessment for problematic use of opioids for chronic pain. Clin Neuropsychol 2012; 27:60-80. [PMID: 22935011 DOI: 10.1080/13854046.2012.715204] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Opioid analgesics provide effective treatment for noncancer pain, but many health providers have concerns about cognitive effects, tolerance, dependence, and addiction. Misuse of opioids is prominent in patients with chronic pain and early recognition of misuse risk could help providers offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. Many persons with chronic pain also have significant medical and psychiatric comorbidities that affect treatment decisions. Neuropsychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management. The assessment of different domains using semi-structured interviews, sensory and neuropsychological testing, and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral, and social issues in order to facilitate treatment planning. In this review we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic pain, and present an overview of assessment and treatment strategies that can be effective in improving outcomes associated with the use of prescription opioids for pain. Finally we briefly discuss the effect of opiate analgesics on cognition and review some intervention strategies for chronic pain patients.
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Affiliation(s)
- Robert N Jamison
- Pain Management Center, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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145
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Parhami I, Hyman M, Siani A, Lin S, Collard M, Garcia J, Casaus L, Tsuang J, Fong TW. Screening for addictive disorders within a workers' compensation clinic: an exploratory study. Subst Use Misuse 2012; 47:99-107. [PMID: 22066751 PMCID: PMC3281509 DOI: 10.3109/10826084.2011.629705] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We conducted a cross-sectional study investigating the extent of addictive disorders within a workers' compensation (WC) clinic. We also examined the feasibility of substance abuse screening within the same clinic. In 2009 , 100 patients were asked to complete the World Health Organization's Alcohol, Smoking, Substance Involvement Screening Test (WHO-ASSIST) and the Current Opioid Misuse Measure (COMM). According to the WHO-ASSIST, we found that 46% of WC patients required intervention for at least one substance-related disorder (25% tobacco, 23% sedatives, 8% opioids), and according to the COMM, 46% screened positive for prescription opioid misuse. Importantly, the addition of this screening was brief, economical, and well accepted by patients. Further research should analyze the costs and benefits of detection and intervention of substance-related disorders in this setting.
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Affiliation(s)
- Iman Parhami
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, California 90095, USA.
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Jamison RN, Serraillier J, Michna E. Assessment and treatment of abuse risk in opioid prescribing for chronic pain. PAIN RESEARCH AND TREATMENT 2011; 2011:941808. [PMID: 22110936 PMCID: PMC3200070 DOI: 10.1155/2011/941808] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 07/29/2011] [Indexed: 11/23/2022]
Abstract
Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of opioids is prominent in patients with chronic back pain and early recognition of misuse risk could help physicians offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. In this review, we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic back pain and present an overview of assessment and treatment strategies that can be effective in improving compliance with the use of prescription opioids for pain. Many persons with chronic back pain have significant medical, psychiatric and substance use comorbidities that affect treatment decisions and a comprehensive evaluation that includes a detailed history, physical, and mental health evaluation is essential. Although there is no "gold standard" for opioid misuse risk assessment, several validated measures have been shown to be useful. Controlled substance agreements, regular urine drug screens, and interventions such as motivational counseling have been shown to help improve patient compliance with opioids and to minimize aberrant drug-related behavior. Finally, we discuss the future of abuse-deterrent opioids and other potential strategies for back pain management.
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Affiliation(s)
- Robert N. Jamison
- Pain Management Center, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 850 Boylston Street, Chestnut Hill, MA 02467, USA
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Passik SD, Lowery A. Psychological variables potentially implicated in opioid-related mortality as observed in clinical practice. PAIN MEDICINE 2011; 12 Suppl 2:S36-42. [PMID: 21668755 DOI: 10.1111/j.1526-4637.2011.01130.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Opioid-related deaths in the United States have become a public health problem, with accidental and unintended overdoses being especially troubling. Screening for psychological risk factors is an important first step in safeguarding against nonadherence practices and identifying patients who may be vulnerable to the risks associated with opioid therapy. Validated screening instruments can aid in this attempt as a complementary tool to clinicians' assessments. A structured screening is imperative as part of an assessment, as clinician judgment is not the most reliable method of identifying nonadherence. As a complement to formal screening, we present for discussion and possible future study certain psychological variables observed during years of clinical practice that may be linked to medication nonadherence and accidental overdose. These variables include catastrophizing, fear, impulsivity, attention deficit disorders, existential distress, and certain personality disorders. In our experience, chronic pain patients with dual diagnoses may become "chemical copers" as a way of coping with their negative emotion. For these patients, times of stress could lead to accidental overdose. Behavioral, cognitive-behavioral (acceptance and commitment, dialectical behavior), existential (meaning-centered, dignity), and psychotropic therapies have been effective in treating these high-risk comorbidities, while managing expectations of pain relief appears key to preventing accidental overdose.
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Affiliation(s)
- Steven D Passik
- Department of Psychiatry and Anesthesiology, Vanderbilt University Medical Center, Psychosomatic Medicine, Nashville, Tennessee 37232, USA.
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